Perioperative Morbidity in Patients Randomized to Epidural or General Anesthesia for Lower Extremity Vascular Surgery

Christopherson, Rose; Beattie, Charles; Frank, Steven M.; Norris, Edward J.; Meinert, Curtis L.; Gottlieb, Sidney O.; Yates, Helen; Rock, Peter; Parker, Stephen; Perler, Bruce A.; Willams, G Melville

doi:10.1097/00000542-199309000-00004

Cited by 510 publications

(160 citation statements)

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“…Glucose level was better suppressed in Groups I and II relative to Group III. The trials detected that the cortisol levels increased starting from the skin incision in cases undergoing general anesthesia + epidural analgesia; however, the blood cortisol levels were suppressed relative to the group receiving general anesthesia (19,20). In another trial (21), epidural + general anesthesia and postoperative morphine administration were claimed to provide a better suppression of the blood cortisol level relative to the general anesthesia + postoperative iv morphine administration.…”

Section: Discussionmentioning

confidence: 99%

The Effect of General Anesthesia and General Anesthesia Plus Epidural Levobupivacaine or Bupivacaine on Hemodynami Stress Response and Postoperative Pain

Calimli¹,

Topal²,

Erol³

et al. 2012

Pain Management - Current Issues and Opinions

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Section: Discussionmentioning

confidence: 99%

The Effect of General Anesthesia and General Anesthesia Plus Epidural Levobupivacaine or Bupivacaine on Hemodynami Stress Response and Postoperative Pain

Calimli¹,

Topal²,

Erol³

et al. 2012

Pain Management - Current Issues and Opinions

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“…Epidural anesthesia is desirable in elderly patients because it attenuates the stress response to surgery, reduces the incidence of deep vein thrombosis, increases vascular graft blood flow, and reduces the incidence of reoperation for inadequate tissue perfusion when compared to general anesthesia (2,3). Peripheral vascular surgery may be lengthy, and rather large amounts of local anesthetic may be required during its course by continuous epidural infusion or by intermittent boluses.…”

Section: Introductionmentioning

confidence: 99%

A Population Pharmacokinetic Model of Epidural Lidocaine in Geriatric Patients: Effects of Low-Dose Dopamine

Kwa¹,

Šprung²,

Guilder³

et al. 2008

Therapeutic Drug Monitoring

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Purpose-To develop a population pharmacokinetic (PK) model of epidural lidocaine in geriatric patients, to search for any difference in the PK behavior of epidural lidocaine when dopamine is given concurrently, and to develop a descriptive PK model from which to calculate dosage and infusion regimens of epidural lidocaine to define and achieve desired target goals in either the epidural or the serum compartment. Methods-Twenty patients over age 65, undergoing peripheral vascular surgery using continuous epidural lidocaine anesthesia, were studied. Ten patients also received an intravenous (IV) infusion of placebo (normal saline), while ten other patients received an IV infusion of dopamine at 2 μg/kg/ min. Total plasma lidocaine concentrations (gas-chromatographic assay) were measured from arterial samples just before injecting the first epidural dose (baseline) and then at 5, 15, 30, 60, 90, 120 min and hourly thereafter. Samples were also taken when the lidocaine infusion was stopped at the end of the surgery, and at 30min, 60min, 90min, 2h, 3h, 4h, and 5h after surgery. The nonparametric adaptive grid (BigNPAG) computer program in the MM-USCPACK collection was utilized for population PK modeling to obtain the entire discrete maximum likelihood joint parameter distribution. The assay error polynomial was determined to be 0.2 + 0.05*C. The structural population PK model was linear, and had 3 compartments, each with first order transfer kinetics.Results-Lidocaine had a very fast transfer rate constant (Ka part + K20) from the epidural space to the serum compartment. This rate was slowed, by over 41%, by dopamine. The mean rate constant of elimination from the serum compartment (K20) was increased by 9.7 % by dopamine. The mean rate constant for drug movement from central to peripheral compartment (K23) was increased by 47% in the dopamine patients. The mean rate constant back from the peripheral to the central compartment (K32) was slowed by 46% by dopamine. There was no obvious difference in the apparent volume of distribution of the central compartment between the placebo and the dopamine patients. In this model, there was no specific compartment for Lidocaine in the cerebrospinal fluid (CSF). CSF is probably one of the components of the overall peripheral, nonserum, compartment in our model. Conclusions-In this first population model of epidural lidocaine using a statistically consistent method, low-dose dopamine appears to decrease the rate of transfer of lidocaine from the epidural to the serum compartment, and to increase both the rate of elimination of lidocaine as well as its transfer between the central (serum) and peripheral compartment, presumably by increasing tissue perfusion. Serum lidocaine concentrations were slightly less in the dopamine patients. Dosage requirements (overall hourly weight-adjusted infusion rates) were slightly less for the dopamine patients, consistent with the slower removal of lidocaine from the epidural compartment. This model should be useful to design more optimal ...

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“…Dans le premier article portant sur 100 patients, Christopherson note que des thromboses de greffons se produisent chez 13 d'entre eux; la majorité (11) survenant chez les patients opérés sous AG contre deux dans le groupe PÉRI (P 0,01). 6 Les membres du groupe PIRAT proposent une explication à cette situation dans le second article. 7 Ils constatent en effet, chez les malades opérés sous AG, que l'inhibiteur de l'activation du plasminogène de type 1 (PAI-1) augmente de 48% 24 hr après la chirurgie pour ne retourner au niveau de base qu'après trois jours.…”

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“…Peu d'hôpitaux sont actuellement en mesure d'assurer de tels soins pour l'ensemble des malades subissant une revascularisation périphérique. Il est donc plausible qu'une surveillance serrée de l'état hémodynamique du malade, menant à des corrections rapides telles qu'on peut en effectuer dans le contexte d'une unité de soins intensifs, puisse permettre à l'AG de procurer des résultats jusque là obtenus uniquement avec l'ALR-N. 5,6 L'utilisation de l'ALR-N, qui assure un contrôle efficace du stress péri-opératoire à moindre coût, ne représente-t-elle pas une approche coût-bénéfice plus intéressante? L'utilisation de l'ALR-N peut-elle influencer le pronostic cardio-vasculaire des malades subissant une intervention de nature vasculaire, qu'elle soit pratiquée au niveau aortique ou infrainguinal?…”

unclassified

L’anesthésie locorégionale neuraxiale et la chirurgie vasculaire: les bénéfices

Drolet

Girard

2001

Can J Anesth/J Can Anesth

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Objectif : Cette revue vise à définir les avantages de l'anesthésie loco-régionale neuraxiale (ALR-N) dans le cadre de la chirurgie vasculaire et de les confronter au risque d'hématome périmédullaire.Constatations principales : L'utilisation de l'ALR-N favorise la perméabilité des pontages infrainguinaux. Cet effet est attribué à la réduction de l'hypercoagulabilité périopératoire et des résistances au niveau des greffons ainsi qu'à l'augmentation du flot sanguin. Concernant les malades sous anesthésie générale, seuls les auteurs qui rapportent une prise en charge agressive (cathéters pulmonaires et radiaux, soins intensifs postopératoires) obtiennent des résultats comparables à l'ALR-N quant à la perméabilité des greffons. L'ALR-N atténue et facilite le contrôle des réponses neuro-hormonale et hémodynamique dans la période péri-opératoire. Elle procure de plus une analgésie postopératoire supérieure. L'impact de l'ALR-N sur la morbidité cardiaque, dans le cadre de la chirurgie de reconstruction aortique, demeure cependant incertain. Les cas d'hématomes épiduraux associés aux blocs neuraxiaux en chirurgie vasculaire sont exceptionnels. Ils sont décrits chez des patients recevant des médicaments à action fibrinolytique ou soumis à une anticoagulation prolongée. Il est possible que les héparines de bas poids moléculaire augmentent le risque d'hématome épidural et il faudrait réévaluer les indications d'ALR-N si leur usage devenait plus courant durant la chirurgie vasculaire.Conclusion : L'utilisation de l'ALR-N en chirurgie vasculaire est sans danger et présente des avantages théoriques et démontrés pour le patient. Elle est particulièrement efficace et économique pour la revascularisation infrainguinale. Les blocs neuraxiaux ne doivent cependant être entrepris qu'avec grande prudence si l'administration de produit à action fibrinolytique ou si une anticoagulation prolongée est prévue.Purpose: To assess the advantages of neuraxial blockade (NB) during and after vascular surgery and to confront them with the risk of epidural or spinal hematoma.Main findings: NB may reduce the risk of thrombotic occlusion following lower extremity vascular reconstruction. This effect of NB may be attributed to reduced hypercoagulability, decreased peripheral resistance and increased graft flow. In patients under general anesthesia, only those authors using an aggressive perioperative management (pulmonary artery catheter monitoring, intensive care unit admission) were able to report grafts patency rates similar to those obtained with NB. NB facilitates the modulation of the hemodynamic and hormonal stress responses during the perioperative period. It also produces superior postoperative analgesia. Still, the impact of NB on cardiac morbidity following aortic reconstructive surgery remains open to debate. Only very few cases of epidural hematomas associated to NB following vascular surgery have been reported. They implicated patients who received either fibrinolytic medication, continuous heparin infusion, or both. Low molecular weig...

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Perioperative Morbidity in Patients Randomized to Epidural or General Anesthesia for Lower Extremity Vascular Surgery

Cited by 510 publications

References 0 publications

The Effect of General Anesthesia and General Anesthesia Plus Epidural Levobupivacaine or Bupivacaine on Hemodynami Stress Response and Postoperative Pain

The Effect of General Anesthesia and General Anesthesia Plus Epidural Levobupivacaine or Bupivacaine on Hemodynami Stress Response and Postoperative Pain

A Population Pharmacokinetic Model of Epidural Lidocaine in Geriatric Patients: Effects of Low-Dose Dopamine

L’anesthésie locorégionale neuraxiale et la chirurgie vasculaire: les bénéfices

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