Cervical epidural analgesia combined with general anesthesia for head and neck cancer surgery: A randomized study

Abstract

Background and Aims: The role of cervical epidural analgesia in head and neck cancer surgery is not fully explored. The aim of this study was to evaluate cervical epidural analgesia in terms of opioid and anesthetic requirements and stress response in patients undergoing head and neck cancer surgery. Material and Methods: After institutional ethical committee approval and written informed consent, 30 patients undergoing elective head and neck cancer surgery were randomized into two groups: Group E (cervical epidural analgesia with general anesthesia), and group G (general anesthesia alone). In group E, an 18 gauge epidural catheter was placed at cervical (C) 6 – thoracic (T) 1 level. After test dose, a bolus of 10 ml of 0.2% ropivacaine was given followed by continuous infusion. Technique of general anesthesia and post-operative management was standardized in both the groups. Opioid and anesthetic drug requirement was observed. Blood glucose and serum cortisol levels were measured at baseline; post-incision and after surgery. Results: There was significant reduction in the requirement of morphine ( P < 0.001), isoflurane ( P = 0.004) and vecuronium ( P = 0.001) in group E. Post-operative, blood glucose and serum cortisol levels were significantly reduced ( P = 0.0153 and 0.0074, respectively). Early post-operative pain was reduced with the lesser requirement of post-operative morphine. Conclusions: The use of combined cervical epidural analgesia with general anesthesia reduces opioid, anesthetic drug requirement and stress response as compared to general anesthesia alone in patients undergoing head and neck cancer surgery.

Understanding data and its analysis for interpretation – Correct interpretation and safety matters!

“…The reported morphine consumption is 8.9 ± 0.95 and 7.1 ± 1.02 in the two groups with P value <0.0001. [ 4 ] Though the difference is statistically significant, the difference may not be clinically relevant due to lesser consumption of the drug in either group.…”

“…This issue is accompanied by an original article titled, “ Cervical epidural analgesia combined with general anesthesia for head and neck cancer surgery: a randomized study “. [ 4 ] In this small study on 30 patients undergoing oral, hypo-pharyngeal and laryngeal cancers surgeries, the authors hypothesized that cervical epidural analgesia (cervical epidural catheter placed at C 6 – T1 level in sitting position using loss of resistance to air technique without use of ultrasound or fluoroscope) may reduce opioid, anesthetic requirements and stress response. [ 4 ] The authors have administered 0.2% ropivacaine via epidural catheter as bolus followed by infusion.…”

“…Authors reported that, “there was significantly lower consumption of morphine ( P < 0.0001), isoflurane (P-0.004) and vecuronium (P-0.001) in cervical epidural group along with general anesthesia compared with the control group (received only general anesthesia)”. [ 4 ]…”

“…The authors reported that three patients (20%) in cervical epidural group to have hemodynamic compromise as compared to none in control group. [ 4 ] In view of availability of other analgesic techniques (probably more safer), the comparison of adverse events becomes essential. The technique of cervical epidural placement should be undertaken in experienced hand and probably under image guidance.…”

“…Clinical studies are conducted to test the superiority usually (inferiority and equivalence trials are also conducted) of an intervention over a control (cervical epidural along with general anesthesia vs. general anesthesia alone in this study). [ 4 5 6 7 ] The outcomes of such studies are evaluated based on two aspects– statistical (result-based merit) and clinical relevance of the outcome (process-based merit or non-statistics merits). [5-8] Both need to be considered in a study for making a meaningful conclusion.…”