in the treatment of post-thoracotomy pain

Transcription

1 Role of thoracic epidural anesthesia/analgesia in the treatment of post-thoracotomy pain 26th International Winter Symposium Update in Cardiothoracic Anesthesia January 7th - 8th, 2011, Leuven, Belgium Norbert Rolf, Marienkrankenhaus Hamburg

2 Role of TEA in terms of: Analgesia Pulmonary Complications Cardiovascular Effects Gastrointestinal Effects Metabolic Effects Oncological Aspects versus Systemic Analgesia Paravertebral Block

3 Role of TEA in terms of: Analgesia Pulmonary Complications Cardiovascular Effects Gastrointestinal Effects Metabolic Effects Oncological Aspects

4 T-PCEA is better than ivpca 10 8 * * * TIVA group TEA group VAS [cm] Tage post-op. von Dossow V et al. Anesth thanalg ;92:848-54

5 Efficacy of Postoperative Analgesia: A Meta-analysis Block BM et al., JAMA 290: , 2003

6 TEA (Ropi 0,2% + Fenta 2 ug/ml) vs. PCIA (Morphin) after repair of funnel chest Pain N=20/Gr Random. Well-being Bauer T et al., J Thor Cardiovasc Surg 134: 865, 2007

7 TEA vs. i.v. Morphine for PCA after Lobectomy Quality of Analgesia (VAS) at rest p.o.- Tag OR cough i.v. better TEA better Bauer C et al., Anesth Analg 105: , 2007

8 Quality of Analgesia after Thoracotomy Survey of consecutive patients between 1998 and 2006 n=1145 n=110 Pöpping DM, Van Aken H et al.; Br J Anaesth 101: ,

9 Analgesia and Quality of Life: TEA vs. iv-pca VAS Quality of Life Ali M et al.: Br J Anaesth 104: , 2010

10 TEA vs. Paravertebral Block after Thoracotomy Joshi GP et al., Anesth Analg 107:1026, 2008

11 Role of TEA in terms of: Analgesia Pulmonary Complications Cardiovascular Effects Gastrointestinal Effects Metabolic Effects Oncological Aspects

12 TEA improves breathing capacity after major abdominal surgery 35 Incidence of Resp. Insuff. (%) p< Control Epidural Rigg JRA et al. Lancet 2002;359: Prolonged P l d Intubation ti Reintubation PaO 2 < 50 mmhg PaCO 2 > 50 mmhg

13 Protective Effects of Epidural Analgesia on Pulmonary Complications After Abdominal and Thoracic Surgery Postoperative Pneumonia Epidural analgesia protects against pneumonia..., although this benefit has lessened over the past 35 years due to a decrease in baseline risk Pöpping D et al., Arch Surg 143: , 2008

14 Strategies to reduce risk of postoperative pulmonary complications Smetana GW, Clevel Clin J Med 76: S60, 2009

15 Thoracic epidural analgesia after abdominal aortic surgery The Cochrane Collaboration, Intervention Review 2010 Acute Respiratory Failure Nishimori i M et al., 2010

16 Role of TEA in terms of: Analgesia Pulmonary Complications Cardiovascular Effects/Mortality Gastrointestinal Effects Metabolic Effects Oncological Aspects

17 Risikofaktoren für eine erhöhte Morbidität und Mortalität nach Pneumonektomien KHK Alter > 70 Jahre Fortgeschrittenes Tumorstadium Ki Keine Epiduralanalgesie Eid l i Licker et al., Chest 121: ,

18 Effect of TEA on Myocardial Stunning Aorta LVP WT OclusionLAD FlowLAD Control LAP FlowCx Wal thickeningcx LVP Wal thickeninglad 10 ischem. 1 ischem. WTF (% of BL) dp/dt BJ J with TEA J J without TEA B J J J J * B J J * * * B BB BB BBJ BBB J BL TEA B h 3h 6h 12h 24h 48h J Reperfusion Ischemia Rolf N, Van de Velde M, Wouters P, Van Aken H et al.; Anesth Analg 83: 935, 1996

19 TEA increases effective refractoriness period in dogs ER RP (msec) Reihe1 TEA Reihe2 Kontrolle Zykluslänge (msec) Meissner A, Rolf N et al., Anesthesiology 2001; 95: 132-8

20 Anti-ischemic and anti-anginal effects of TEA in severe refractory unstable angina pectoris 4 mm 3 Control TEA n 70 Control 60 TEA stenot. * normal segments Ischemic Pts c. Episodes episodes ischemia per pt. Blomberg S et al., Eur Heart J 10: , 1989 Olausson K et al., Circulation 96: , 1997

21 TEA in patients with coronary artery disease Myocardial Performance Index 10 1,0 n = 37,8 *,6,4,2 * p < 0,0001 0,0 vor TEA nach TEA Schmidt C, Van Aken H et al., Anesth Analg 100: 1561, 2005

22 TEA improves regional LV-function in CABG-patients GA only TEA/GA GA only TEA/GA Berendes E et al; Arch Surg 138: 1283, 2003

23 Cardioprotective effects of TEA are induced by the expression of VEGF and inos in CABG 4 CI after CPB 60 VF (%) after CPB 50 3, , TEA+GA GA TEA+GA GA Gonca S et al., J Cardiovasc Surg 48: 93, 2007

24 Regional anaesthesia reduces postop. mortality Rodgers A et al., Br Med J 321: 2000 RA better GAbetter

25 Regional anaesthesia reduces postop. mortality Rodgers A et al., Br Med J 321: 2000

26 Thoracic epidural anesthesia reduces postoperative mortality after thoracic surgery Population-based cohort study, pts., , Ontario Wijeysundera D et al., Lancet 372: 562, 2008

27 Thoracic epidural analgesia after abdominal aortic surgery The Cochrane Collaboration, Intervention Review 2010 Myocardial Infarction Nishimori i M et al., 2010

28 Thoracic epidural analgesia after abdominal aortic surgery The Cochrane Collaboration, Intervention Review 2010 Mortality Nishimori i M et al., 2010

29 Role of TEA in terms of: Analgesia Pulmonary Complications Cardiovascular Effects/Mortality Gastrointestinal Effects Metabolic Effects Oncological Aspects

30 TEA increases mucosal perfusion in ileum of rats prior to TEA µm/s µm 2 Control TEA during TEA RBC vel ICA cont Sielenkämper A, Van Aken H et al., Anesthesiology 93: 844, 2000

31 Thoracic epidural anesthesia increases tissue oxygenation during major abdominal surgery PsqO 2 (mmhg) GA / TEA GA alone Minutes Kabon B et al., Anesth Analg 97: 1812, 2003

32 Thoracic epidural analgesia after abdominal aortic surgery The Cochrane Collaboration, Intervention Review 2010 Gastrointestinal Complication Nishimori i M et al., 2010

33 Role of TEA in terms of: Analgesia Pulmonary Complications Cardiovascular Effects/Mortality Gastrointestinal Effects Metabolic Effects Oncological Aspects

34 Epidural analgesia enhances postoperative anabolic effect of amino acids in DM II patients Kopp Lugli A et al.; Anesthesiology 108: 1092, 2008

35 Role of TEA in terms of: Analgesia Pulmonary Complications Cardiovascular Effects/Mortality Gastrointestinal Effects Metabolic Effects Oncological Aspects

36 Intraoperatie TEA attenuates stress-induced immunosuppression in major abdominal surgery Ahlers O et al.; Br J Anaesth 101: 781, 2008 Baseline Surg. Day 1 Day 2

37 Surgery as a risk factor for breast cancer recurrence and metastasis 129 consecutive pts; mastectomy for breast Cx; 50 paravertebr., 79 general Paravertebr. Recurren nce free (% %( General Months Exadaktylos A et al.; Anesthesiology 105: 660, 2006

38 Epidural analgesia after prostatectomy affects cancer recurrence Retrospective analysis Biki B et al.; Anesthesiology 109: 180, 2008

39 Summary & Conclusions Thoracic Epidural Anesthesia / Analgesia in Thoracic Surgery: - provides superior analgesia vs. PCIA (and PVB) - reduces the incidence of pulmonary complications - has favourable effects on myocardial perfusion / function - improves gastrointestinal function - improves protein metabolism - allows fast-track postop. Care - leads to better quality of life -scores and may - reduce perioperative mortality - reduce the recurrence rate of cancer

40 TEA/GA vs. GA in CABG Liu S et al., Anesthesiology 101: 153, 2004