Effect of Segmental Thoracic Epidural Block on Pancreatitis Induced Organ Dysfunction: A Preliminary Study

Abstract

Background This preliminary randomized controlled study evaluated effect of thoracic epidural block (TEB) on progression of acute pancreatitis induced organ dysfunction/failure. Materials and Methods Patients with predicted severe acute pancreatitis, without contraindication to TEB were randomized to receive (group TE) or not receive a TEB (group NTE) (n = 16 each). For group TE, TEB was performed at T8-9 or T9-10 vertebral level, with infusion of ropivacaine (0.2%) along with fentanyl 2 µg/mL; in group NTE, intravenous morphine was used instead, both interventions titrated to NRS of <4. SOFA score was assessed daily till discharge from ICU, and aggregate SOFA calculated by summing worst scores for each of organ system during ICU stay as primary outcome measure. Other surrogate measures of patient outcome were recorded as secondary objectives. Results Aggregate SOFA score was statistically similar between both groups (group NTE: 3 [2 - 4]; group TE: 5 [2 - 6]) ( P = 0.379); but there was trend of improvement in SOFA score in group TE versus a worsening in group NTE. Duration of hospital stay, and number of patients requiring mechanical ventilation were statistically similar; mortality was insignificantly lesser for group TE (12.5% versus 6.6%; p = 1.000). Fall in serum procalcitonin was significantly greater for group TE. Conclusion Thoracic epidural was associated with insignificant clinical trend towards better organ functions and lesser mortality; along with significantly greater fall in serum procalcitonin. These are encouraging results that could guide future use of thoracic epidural in acute pancreatitis for its non-analgesic benefits. How to cite this article Tyagi A, Gupta YR et al. Effect of Segmental Thoracic Epidural Block on Pancreatitis Induced Organ Dysfunction: A Preliminary Study. Indian J of Crit Care Med 2019;23(2):89-94.

Thoracic Epidural Analgesia in Acute Pancreatitis

“…Thoracic epidural analgesia was associated with improvement of serum procalcitonin, 4 lower incidences of acute mesenteric ischemia, 10 and lower incidences of acute kidney injury 10 . However, TEA had no impact on locoregional complications or septic complications 3,10 .…”

“…The 2 clinical trials both showed high risk of bias, particularly in outcome measurement 3,4 . Among the nonrandomized studies, 1 had moderate risk of bias, 10 whereas 5 had high risk of bias.…”

“…Regarding safety outcomes, 5 studies reported incidences of epidural-related hypotension, which ranged from 0% to 37.5%. All episodes of epidural-related hypotension were successfully managed by intravenous fluids or vasopressors 3–5,7,8 . No incidences of postprocedural epidural hematoma or abscess were reported.…”

“…Regarding clinical outcomes of AP, 4 studies reported the median hospital stay to range from 8 to 26 days 3,4,7,9 . Mortality was reported in 7 studies, with in-hospital mortality ranging from 0% to 25.0% 3–5,7–10 .…”

“…Regarding clinical outcomes of AP, 4 studies reported the median hospital stay to range from 8 to 26 days 3,4,7,9 . Mortality was reported in 7 studies, with in-hospital mortality ranging from 0% to 25.0% 3–5,7–10 . A 2018 cohort study reported that TEA was independently associated with reduced mortality by more than 5-fold (4% in the TEA group vs 22% in the control group) 10 ; however, this significant improvement in mortality was not repeatable in 2 other clinical trials 3,4 …”