Non-analgesic effects of thoracic epidural anesthesia

Torakal epidural anestezi postoperatif ağrı kontrolünde etkin bir yöntemdir; ayrıca lokal anesteziklerin epidural mesafeye verilmesi ile segmenter sempatik blok meydana gelir. Bu geçici sempatik blokajın kardiyovasküler, solunum ve diğer sistemler üzerine etkileri, postoperatif morbidite ve mortalite üzerine etkileri nedeniyle, araştırılmaya değer gözükmektedir. Torakal epidural anestezi kalp, akciğer ve büyük batın cerrahilerinde başarı ile kullanılmaktadır. Hareket halinde de etkinliği süren bir analjezi ile birlikte erken mobilizasyon, stres yanıtın baskılanması, erken ekstübasyon ve akciğere ait kompllikasyonlarda azalma ve bağarsak işlevinde hızlı derlenme sağlamaktadır. Torakal sempatik blokun en fazla yararlı olacağı düşünülen yer kalp cerrahisidir, ancak yayınlarda morbidite ve mortalite arasında fark saptanmamıştır. Ağrı kontrolündeki başarısına rağmen, torakal epidural anestezinin meta-analizlerde hasta prognozu açısından etkinliği gösterilememiştir. Öte yandan, farklı organ sistemleri üzerine yapılan yakın tarihli çalışmalar halen olumlu etkilerinden söz etmektedir. Torakal epidural anestezi yakın gelecekte daha fazla kullanım alanı bulacak ve tartışmalarla birlikte, üzerinde daha çok çalışılacak gibi durmaktadır.

Anahtar Kelimeler:

Stres, fizyolojik, Analjezi, epidural, Ağrı, ameliyat sonrası

Torakal epidural anestezinin non-analjezik etkileri

Thoracic epidural anaesthesia is selected usually to provide adequate postoperative analgesia; however with administration of local anaesthetics to epidural space selective sympatolysis ensues. The effects of this transient sympathectomy on cardivascular, respiratory and other systems deserve certainly some interest as it may influence postoperative morbidity or mortality. Thoracic epidural anaesthesia has succesfully been used in cardiac, thoracic and major abdominal surgery. It provides dynamic analgesia, rapid mobilization, blunted stress response, early extubation with reduced pulmonary complications and also rapid recovery of bowel function. In cardiac surgery where thoracic sympathetic blockade is expected to be most useful, there is no difference in morbidity and mortality. Despite the superior quality of pain control, the beneficial aspect of thoracic epidural anaesthesia is not reflected on outcome in meta-analysis. Recent papers has still demonstrated positive effects on each system. So thoracic epidural anaesthesia is increasingly used and it seems that it will be discussed more in near future.

Keywords:

Stress, Physiological, Analgesia, Epidural, Pain, Postoperative,

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Ballantyne JR, Carr DB, de Ferranti S: The comparative effects of postoperative analgesic therapies on pulmonary outcome.Anesth Analg 1998, 86: 598: 612.
Beilin B, Shavit Y, Trabekin E et al.: The effects of postoperative pain management on immune response to surgery. Anesth Analg 2003; 97: 822-827.
Berendes E, Schmidt C, Van Aken H: Reversible cardiac sympathectomy by high thoracic epidural anesthesia improves regional left ventricular fuction in patients undergoing coronary bypass grafting. Arc Surg 2003; 138: 1283-1290.
Borg T, Modig J: Potential antithrombotic effects of local anaesthetics by there inhibition of platelet aggregation. Acta Anaesthesiol Scand.1985;29:739-742.
Bredbacka S, Blomback M, Hagnevik K et al.: Pre- and postoperative changes in coagulation and fibrinolytic variables during abdominal hysterectomy under epidural or general anesthesia. Acta Anaesthesiol Scand. 1986; 30: 204-210.
Blomberg S, Emanuelsson H, Kvist H et al.: Effects of thoracic epidural anesthesia on coronary arteries and arterioles in patients with coronary artery disease. Anesthesiology 1990; 73: 840-847.
Buggy D, Warren L, Heart E, Pallet E: Postoperative wound oxygen tension with epidural or intravenous analgesia. Anesthesiology 2002, 97: 952-958.
Carli F, Mayo N, Klubien K: Epidural analgesia enhances functional exercise capacity and health-related quality of life after colonic surgery: results of a randomized trial. Anesthesiology 2002; 97:540-549.
Casalino S, Mangia F, Stelian E, Novelli E, Diena E: High thoracic epidural anesthesia in cardiac surgery. Tex Heart Inst J 2006; 33: 148-153.
Crawford OB, Brasher C, Buckingham WW: Peridural anesthesia for thoracic surgery. Anesthesiology 27: 241, 1957.
de Leon-Casasola OA: Immunomodulation and epidural anesthesia and analgesia. Reg Anesth. 1996; 21(6S): 24-25.
Griffiths DPG, Diamon AW, Cameron JD: Postoperative extradural analgesia following thoracic surgery. Br J Anaesth 47: 48, 1975.
Groban L, Zvara DA, Deal DD, Vernon JC, Carpenter RL: Thoracic epidural anesthesia reduces infarct size in a canine model of myocardial ischemia and reperfusion injury. J Cardiothorac Vasc Anesth. 1999 Oct; 13(5): 579-585.
Groeben H: Effects of thoracic epidural anesthesia and local anesthetics on bronchial hyperreactivity. J Clin Monit 2000, 16: 457-463.
Groeben H: Epidural anesthesia and pulmonary funtion. J Anesth 2006,20: 290-299.
Gruber EM, Tshernko EM, Kritzinger M, Deviatko E: The effects of thoracic analgesia with bupivacaine % 0.25 on ventilatory mechanics in patients with severe chronic obstructive pulmonary disease. Anesth Analg 2001, 92: 1015-1019.
Guay J: The benefits of adding epidural analgesia to general anesthesia:a metaanalysis. J Anesth 2006; 20: 335-340.
Hachenberg T, Pfeiffer B: Use of thoracal epidural anesthesia for thoracic surgery and its effect on pulmonary function. In: Van Aken H and Rolf N, editors. Thoracic Epidural Anesthesia. Best Practice and Research Clinical Anesthesiology. Vol 13. Baillere’s Harcourt, 1999; 57-72.
Holte K, Kehlet H: Epidural analgesia and anesthesia: effects on stress surgical responses and implications for postoperative nutrition. Clinical Nutrition 2002, 21: 199-206.
Kabon K, Fleischman E, Treschan T: Thoracic epidural anesthesia increases tissue oxygenation during major abdominal surgery.Anesth Analg 2003, 97: 1812-1817.
Kehlet H, Holte K. Effect of postoperative analgesia on surgical outcome. Br J Anaesth 2001, 87: 62-72.
Kozian A, Schilling T, Hachenberg H: Nonanalgesic effects of thoracic epidural anesthesia. Current Opininon in Anesthesiology 2005, 18: 29-34.
Latterman R, Carli F, Schriker T: Epidural blockade suppressess lipolysis during major abdominal surgery. Reg Anesth Pain Med. 200,27: 469-475.
Loick H.M, C. Schmidt and Van Aken H, Junker R, Erren M,Berendes E, Rolf N, Meissner A, Schmid C, Scheld HH, Mollhoff T: High thoracic epidural anesthesia, but not clonidine, attenuates the perioperative stress response via sympatholysis and reduces the release of troponin T in patients undergoing coronary artery bypass grafting. Anesth Analg 1999; 88: 701–709.
Liu SS, Wu CL: Effect of postoperative analgesia on major postoperative complications: a systematic update of the evidence. Anesth Analg. 2007 Mar; 104: 689-702.
Liu SS, Block BM, Wu CL: Effects of central neuroaxial analgesia on outcome on coronary artery bypass surgery: a metaanalysis.Anesthesiology 2004; 101: 153-161.
Modig J, Borg T, Bagge L et al.: Role of extradural and of general anesthesia on fibrinolysis and coagulation after total hip replacement. Br J Anaesth. 1983; 55: 625-629.
Moon MR, Luchette FA, Gibson SW Crews J, Sudarshan G, Hurst JM,Davis K Jr, Johannigman JA, Frame SB, Fischer JE: Prospective,randomized comparison of epidural versus parenteral opioid analgesia in thoracic trauma. Ann Surg 1999; 229: 684-691.
Moraca RJ, Sheldon DG, Thirlby RC: The Role of Epidural Anesthesia and Analgesia in Surgical Practice. Ann Surg 2003, 238: 663-673.
Neal JM, Wilcox RT, Allen HW, Low DE: Near-total esophasectomy:influence of standardized multimodal management and intraoperative fluid restriction. Reg Anesth and Pain 2003, 28: 328-334.
Oka T, Ozawa Y, Okhubo Y: Thoracic epidural bupivacaine attenuates supraventricular tachyarrhytmias after pulmonary resection.Anesth Analg 2001; 93: 253-259.
Olausson K, Magnusdottir H, Lurje L: Anti-ischemic and anti-anginal effects of thoracic epidural anesthesia versus those of conventional medical therapy in the treatment of severe refractory unstable angina pectoris, Circulation 1997, 96: 2178-2182.
Ozcan PE, Senturk M, Ulke ZS, Toker A, Dilege S, Ozden E, Camci E: effects of thoracic epidural anaesthesia on pulmonary venous admixture and oxygenation during one-lung ventilation.Accepted for publication in Acta Scan Anesth.
Rodgers A, Walker N, Schug S, McKee A, Kehlet H, van Zundert A,Sage D. Futter M, Saville G, Clark T, MacMahon S: Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomized trials. Br Med J. 2000; 321: 1493–1497.
Segawa H, Mori K, Kasai K, Fukata J, Nakao K: The role of the phrenic nerves in stress response in upper abdominal surgery.Anesth.Analg. 1996; 82: 1215-1224
Volk T, Schenk M, Vogt K et al.: Postoperative epidural anesthesia preserves lymphocyte, but monocyte, immune function after major spine surgery. Anesth Analg 2004; 98: 1086-1092.
Waurick R, Van Aken H: Update in thoracic epidural analgesia. Best Pract Res Clin Anaesthesiol. 2005 Jun; 19(2): 201-213.
Warner DO, Warner MA, Ritman, EL: Human Chest Wall Function during Epidural Anesthesia. Anesthesiology 1996, 85: 761-773.
Williams JP, Sullivan EA, Ramakrishna: Effects of thoracal epidural anesthesia for thoracic surgery and its effect on the coagulation system. In: Van Aken H and Rolf N, editors. Thoracic Epidural Anesthesia. Best Practice and Research Clinical Anesthesiology. Vol 13. Baillere’s Harcourt, 1999; 31-56.