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A multimodal approach to control postoperative pathophysiology and rehabilitation
in patients undergoing abdominothoracic esophagectomy.
Brodner G, Pogattzki E, Van Aken H, Buerkle H; Goeters C; Schulzki
C; Nottberg H; Mertes N. Anesthesia and Analgesia 1998; 86:228-34
[ see abstract below ]
Over the last decade the advent of managed care has created enormous pressure
to discharge patients from hospital earlier, thereby saving thousands of
dollars in medical costs. One approach to this issue is the use of epidural
catheters to create "preemptive analgesia" - i.e. prevention of transmission
of nociceptive impulses at the spinal levels involved in the generation
of the pain response. This can result in earlier extubation, shortened ICU
stay, earlier return of gastrointestinal tract function, earlier ambulation
and earlier discharge. An aggressive postoperative "care map" utilizing
epidural anesthesia and analgesia has come to be known as a "multimodal"
approach.
In the March issue of Anesthesia and Analgesia, Brodner et al. report from
the Clinic and Polyclinic for Anesthesiology and Intensive Care in M�nster,
Germany, on their experience in using such a multimodal approach in patients
undergoing abdominothoracic esophagectomy, an invasive procedure with a
formidable incidence of morbidity, especially respiratory problems. Unfortunately
the major drawback in this study is that it relies on a set of historic
controls for comparison. Nonetheless, it does demonstrate the significant
advantages of preemptive analgesia.
The historical controls (Group 1, n = 42), collected over an eight month
period, had an epidural catheter placed at the T6-9 thoracic level prior
to the induction of general anesthesia. For postoperative pain relief, a
mixture of bupivacaine 1.25 mg/mL and sufentanil 1 mcg/mL was infused for
five days without titration to the quality of analgesia. The study patients
(Group 2, n = 42) received a preoperative bolus of 10-15 mL bupivacaine
2.5 mg/mL plus 20-30 mcg sufentanil. After sensory block to T4 was confirmed,
general anesthesia was induced. An infusion of bupivacaine 1.75 mg/mL and
sufentanil 1 mcg/mL was given intraoperatively at 5 mL/hr. Postoperatively,
a PCEA (patient controlled epidural analgesia) setup allowed patients to
self-administer 2 mL of the mixture, with a lock-out period of 20 min. Early
tracheal extubation and forced ambulation were pursued to drive recovery.
Group 2 patients (i.e. with preemptive pain control, titrated to effect),
were tracheally extubated, ambulated earlier and had shorter ICU stays that
the patients in the study group:
| |
Group1 (control) |
Group 2 (multimodal) |
| extubation (hr) |
25.1 |
6.7 |
| mobilization (days) |
2.0 |
1.2 |
| ICU discharge (days) |
4.0 |
1.7 |
| IICU discharge (days) |
6.4 |
4.9 |
ICU =
intensive care unit; IICU = intermediate intensive care unit
Potential benefits claimed for preemptive epidural analgesia include reversal
of diaphragmatic dysfunction, improved myocardial oxygen balance, more
rapid recovery of GI function, and decreased risk of postoperative thrombosis
or embolism.
Brodner et al. emphasized that these benefits could be realized only if
certain "rules" were applied and followed. These include:
(1) confirmation of an adequate level of epidural blockade through the
perioperative period;
(2) continuous assessment of the adequacy of the level of analgesia, preferably
by a dedicated Acute Pain Service;
(3) continuous use of epidural analgesia with other interventions, e.g.
physiotherapy; and
(4) continuous evaluation of the possible adverse effects of epidural
anesthesia and analgesia.
Obviously this kind of care requires dedicated and continuous care by
a closely knit group of anesthesiologists. The potential benefits to the
patient are obvious. Another unmistakeable benefit is that our surgical
colleagues and hospital administrators perceive this as a contribution
of tangible value - and that doesn't hurt at all!
Return to the Current Literature Review Front
Page , or read the abstract:
ABSTRACT
This two-armed
study was designed to determine whether recovery after esophageal resection
may be improved by introducing a new multimodal approach. For 8 mo after
the new approach was introduced, all patients undergoing abdominothoracic
esophageal resection were studied (Group 2; n = 42). For comparison, a retrospective
analysis was also conducted using the data of all patients who had undergone
this operation in the 8 mo before the introduction of the new regimen, when
the traditional therapy was still in use (Group 1; n = 49).
All patients received an epidural catheter at the level of T6-9 before the
induction of general analgesia. Afterward, Group 1 patients were operated
under general anesthesia. For postoperative pain relief, a mixture of bupivacaine
1.25 mg/mL and sufentanil 1 microg/mL was administered during 5 days without
titration of the quality of analgesia. Patients in Group 2 received a preoperative
bolus of 10-15 mL bupivacaine 2.5 mg/mL and 20-30 microg sufentanil. After
sensory block up to T4 was confirmed, general anesthesia was introduced
and intraoperatively combined with a continuous infusion of 5 mL/h of a
solution containing bupivacaine 1.75 mg/mL and sufentanil 1 microg/mL.
Postoperatively, the epidural infusion rate was adJusted to the need of
the individual patients, who were able to administer themselves additional
bolus doses of 2 mL with a lockout time of 20 min. Early tracheal extubation
and forced mobilization were pursued to improve recovery. Demographic data
of both groups were comparable.
The pain relief of Group 2 patients was superior to that of patients in
Group 1. The nitrogen balance of a subgroup of nine matched pairs of patients
with comparable nutritional status was less negative in Group 2 patients
on Postoperative Days 1 and 2. Patients in Group 2 were tracheally extubated
earlier (mean 6.7 vs 25.1 h after admission to the intensive care unit [ICU
), mobilized earlier (mean 1.2 vs 2.0 days after surgery), discharged from
the ICU earlier (mean 1.7 vs 4.0 days), and fulfilled criteria for discharge
from the ICU (mean 1.8 vs 4.1 days) and from the intermediate care unit
earlier (4.9 vs 6.4 days).
We conclude that the multimodal approach may improve recovery and thus reduce
costs after abdominothoracic esophageal resection. Implications: Analgesia
and blockade of the perioperative stress response, combined with other aspects
of postoperative therapy, may improve recovery after surgery. The intensive
care unit stay after esophageal resection was reduced by a new regimen (thoracic
epidural analgesia, early tracheal extubation, forced mobilization). This
approach may influence the cost of maJor surgery.
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