Multimodal Perioperative Management—Combining Thoracic Epidural Analgesia, Forced Mobilization, and Oral Nutrition—Reduces Hormonal and Metabolic Stress and Improves Convalescence After Major Urologic Surgery

Abstract

We sought in this prospective study to use a multimodal approach to reduce stress and improve recovery in patients undergoing major surgery. During an initial study period, 30 patients were randomly allocated to receive general anesthesia (GA; Group 1) or a combination of GA and intraoperative thoracic epidural analgesia (TEA; Group 2) when undergoing radical cystectomy. Parenteral nutrition was provided for 5 days after surgery. During the second period, 15 patients were treated with a multimodal approach (Group 3) consisting of intraoperative GA and TEA, postoperative patient-controlled TEA, early oral nutrition, and enforced mobilization. Data for plasma and urine catecholamines, plasma cortisol, the nitrogen balance, the postoperative inflammatory nutrition index, pain relief, fatigue, sleep, overnight recovery, recovery of bowel function, and mobilization were recorded up to the fifth postoperative day. Plasma concentrations of catecholamines and cortisol were comparable in all patients, but those in Group 3 had lower levels of urinary catecholamine excretion. Protein intake was more effective with parenteral nutrition. Nitrogen balances were less negative, and the postoperative inflammatory nutrition index score increased significantly in the traditional groups but not in Group 3. Multimodally treated patients reported less fatigue and better overnight recovery. Along with improved pain relief, recovery of bowel function, and ambulation, there were no differences in the postoperative complication rates among the three groups. The multimodal approach reduced stress and improved metabolism and recovery after radical cystectomy.

The Effect of General Anesthesia and Thoracic Epidural Analgesia on Stress Response and Homocysteine Levels in Major Upper Abdominal Surgery: A Prospective Randomised Study

“…Cortisol levels increased with surgery, but they determined no difference between groups. 15 Tutaş et al reported significantly high 6-h glucose values in patients undergoing laparoscopic hiatal hernia surgery and receiving EA , while there was no significant difference between the groups in terms of cortisol levels. 16 Ersoy et al reported that lumbar EA combined with GA in major abdominal surgery established hemodynamic stability and reduced stress response and sevoflurane requirements.…”

Safety of opioid patch initiation in Australian residential aged care

“…NsNSAIDs are integral components of multimodal analgesia (Kehlet, 1997;Brodner et al, 2001;Barratt et al, 2002 ). There was no effect on pruritus, urinary retention and respiratory depression (Marret et al, 2005 Level I 5 ).…”

Comparative Assessment of Thoracic Epidural and General Anaesthesia in Modified Radical Mastectomy

“…[8,9] Beyond its analgesic properties, TEA's effects on the postoperative neurohumoural stress response, cardiovascular pathophysiology, and intestinal dysfunction have been in the focus of both clinical and experimental investigations for years. [10][11][12][13][14] However, the use of TEA is related to specific complications and contraindications. Thoracic epidural allows utilization of incremental doses of local anesthetic agent which offers preservation of the respiratory function.…”