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Neuraxial block and postoperative epidural analgesia: effects on outcomes in the POISE-2 trial†.

ABSTRACT: We assessed associations between intraoperative neuraxial block and postoperative epidural analgesia, and a composite primary outcome of death or non-fatal myocardial infarction, at 30 days post-randomization in POISE-2 Trial subjects.10 010 high-risk noncardiac surgical patients were randomized aspirin or placebo and clonidine or placebo. Neuraxial block was defined as intraoperative spinal anaesthesia, or thoracic or lumbar epidural anaesthesia. Postoperative epidural analgesia was defined as postoperative epidural local anaesthetic and/or opioid administration. We used logistic regression with weighting using estimated propensity scores.Neuraxial block was not associated with the primary outcome [7.5% vs 6.5%; odds ratio (OR), 0.89; 95% CI (confidence interval), 0.73-1.08; P=0.24], death (1.0% vs 1.4%; OR, 0.84; 95% CI, 0.53-1.35; P=0.48), myocardial infarction (6.9% vs 5.5%; OR, 0.91; 95% CI, 0.74-1.12; P=0.36) or stroke (0.3% vs 0.4%; OR, 1.05; 95% CI, 0.44-2.49; P=0.91). Neuraxial block was associated with less clinically important hypotension (39% vs 46%; OR, 0.90; 95% CI, 0.81-1.00; P=0.04). Postoperative epidural analgesia was not associated with the primary outcome (11.8% vs 6.2%; OR, 1.48; 95% CI, 0.89-2.48; P=0.13), death (1.3% vs 0.8%; OR, 0.84; 95% CI, 0.35-1.99; P=0.68], myocardial infarction (11.0% vs 5.7%; OR, 1.53; 95% CI, 0.90-2.61; P=0.11], stroke (0.4% vs 0.4%; OR, 0.65; 95% CI, 0.18-2.32; P=0.50] or clinically important hypotension (63% vs 36%; OR, 1.40; 95% CI, 0.95-2.09; P=0.09).Neuraxial block and postoperative epidural analgesia were not associated with adverse cardiovascular outcomes among POISE-2 subjects.

SUBMITTER: Leslie K

PROVIDER: S-EPMC4681616 | biostudies-literature | 2016 Jan

REPOSITORIES: biostudies-literature

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Neuraxial block and postoperative epidural analgesia: effects on outcomes in the POISE-2 trial†.

Leslie K K McIlroy D D Kasza J J Forbes A A Kurz A A Khan J J Meyhoff C S CS Allard R R Landoni G G Jara X X Lurati Buse G G Candiotti K K Lee H-S HS Gupta R R VanHelder T T Purayil W W De Hert S S Treschan T T Devereaux P J PJ

British journal of anaesthesia 20150725 1

<h4>Background</h4>We assessed associations between intraoperative neuraxial block and postoperative epidural analgesia, and a composite primary outcome of death or non-fatal myocardial infarction, at 30 days post-randomization in POISE-2 Trial subjects.<h4>Methods</h4>10 010 high-risk noncardiac surgical patients were randomized aspirin or placebo and clonidine or placebo. Neuraxial block was defined as intraoperative spinal anaesthesia, or thoracic or lumbar epidural anaesthesia. Postoperative ...[more]

PMID: 26209855

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Project description:Background:Postoperative pain management is important for the early recovery of the living donor patient. Patient-controlled opioid analgesia, epidural analgesia, or a combination of both is the preferred pain management after abdominal surgery although these approaches have serious side effects. The transversus abdominis plane (TAP) block has been increasingly used for postoperative pain management and the addition of dexamethasone to local anesthetic can prolong the duration of action. Objectives:This study evaluated the efficacy of ultrasound-guided three-quadrant TAP block analgesia with the addition of dexamethasone, compared to the continuous epidural analgesia in postoperative cumulative opioid consumption and pain scale in the first 24 hours following transperitoneal laparoscopic living donor nephrectomy. Methods:A prospective randomized control study was conducted on 50 patients with ASA I-II, 18 - 65 years old, BMI 18 - 30, and undergoing transperitoneal laparoscopic donor nephrectomy under general anesthesia. The patients were randomly assigned into either a three-quadrant TAP block group (n = 25) with 20 mL of 0.25% bupivacaine plus dexamethasone 8 mg or a continuous epidural group (n = 25) using 0.125% bupivacaine postoperatively. The morphine consumption and the numerical rating scale (NRS) at rest and movement were evaluated at 2, 6, 12, and 24 hours postoperatively. The postoperative first-time mobilization and duration of urinary catheter usage were recorded. Results:Patients demographic characteristics were similar in the two groups. During 24 hours after the surgery, cumulative morphine consumption (P = 0.232), the NRS at rest and movement (P > 0.05), and the first-time mobilization (P = 0.075) were not significantly different between the groups, except that the NRS during movement at 12 hours was significantly lower in the TAP block group (P = 0.004). The duration of urinary catheterization was significantly longer as a side effect in the continuous epidural group (P < 0.001). Conclusions:The three-quadrant TAP block with the addition of dexamethasone showed comparable analgesic effects as the continuous epidural analgesia in cumulative opioid consumption and pain scale in the first 24 hours following transperitoneal laparoscopic donor nephrectomy.

Project description:BackgroundAdequate pain control after video-assisted thoracoscopic surgery (VATS) for lung resection is important to improve postoperative mobilisation, recovery, and to prevent pulmonary complications. So far, no consensus exists on optimal postoperative pain management after VATS anatomic lung resection. Thoracic epidural analgesia (TEA) is the reference standard for postoperative pain management following VATS. Although the analgesic effect of TEA is clear, it is associated with patient immobilisation, bladder dysfunction and hypotension which may result in delayed recovery and longer hospitalisation. These disadvantages of TEA initiated the development of unilateral regional techniques for pain management. The most frequently used techniques are continuous paravertebral block (PVB) and single-shot intercostal nerve block (ICNB). We hypothesize that using either PVB or ICNB is non-inferior to TEA regarding postoperative pain and superior regarding quality of recovery (QoR). Signifying faster postoperative mobilisation, reduced morbidity and shorter hospitalisation, these techniques may therefore reduce health care costs and improve patient satisfaction.MethodsThis multi-centre randomised study is a three-arm clinical trial comparing PVB, ICNB and TEA in a 1:1:1 ratio for pain (non-inferiority) and QoR (superiority) in 450 adult patients undergoing VATS anatomic lung resection. Patients will not be eligible for inclusion in case of contraindications for TEA, PVB or ICNB, chronic opioid use or if the lung surgeon estimates a high probability that the operation will be performed by thoracotomy.Primary outcomes(1) the proportion of pain scores ≥ 4 as assessed by the numerical rating scale (NRS) measured during postoperative days (POD) 0-2; and (2) the QoR measured with the QoR-15 questionnaire on POD 1 and 2. Secondary outcome measures are cumulative use of opioids and analgesics, postoperative complications, hospitalisation, patient satisfaction and degree of mobility.DiscussionThe results of this trial will impact international guidelines with respect to perioperative care optimization after anatomic lung resection performed through VATS, and will determine the most cost-effective pain strategy and may reduce variability in postoperative pain management. Trial registration The trial is registered at the Netherlands Trial Register (NTR) on February 1st, 2021 (NL9243). The NTR is no longer available since June 24th, 2022 and therefore a revised protocol has been registered at ClinicalTrials.gov on August 5th, 2022 (NCT05491239).Protocol versionversion 3 (date 06-05-2022), ethical approval through an amendment (see ethical proof in the Study protocol proof).

Project description:BackgroundRecently, robot-assisted thoracic surgery has been increasingly performed for mediastinal disease. However, appropriate postoperative analgesic methods have not been evaluated.MethodsWe retrospectively studied patients who underwent robot-assisted thoracic surgery for mediastinal disease at a single university hospital between January 2019 and December 2021. Patients were performed either general anesthesia alone, general anesthesia combined with thoracic epidural anesthesia, or general anesthesia combined with ultrasound-guided thoracic block. Patients were divided into three groups [non-block (NB), thoracic epidural analgesia (TEA), and thoracic paraspinal block (TB)] according to postoperative analgesic methods, and they compared with terms of postoperative pain scores by using numerical rating scale (NRS) at 0, 3, 6, 12, 18, 24, and 48 h. Additionally, rescue supplemental analgesic within 24 h, side effects of anesthesia such as respiratory depression, hypotension, postoperative nausea and vomiting, pruritus and urinary retention, time to ambulation after surgery, and hospital stay after surgery were also compared among the three groups.ResultsData from 169 patients (Group NB: 25, Group TEA: 102, and Group TB: 42) were progressed to the analysis. Postoperative pain scale at 6 and 12 h was significantly lower in Group TEA than NB (1.2±1.6 vs. 2.4±1.8, P<0.01; and 1.2±1.5 vs. 2.2±1.7, P=0.018, respectively). There were no differences in pain scores between Groups TB and TEA at any point. The incidence of patients using rescue analgesics within 24 h was significantly different between groups [Group NB: 15/25 (60%), Group TEA: 30/102 (29.4%), Group TB: 25/42 (59.5%), P=0.01]. For postoperative side effects, only the number of patients complaining of postoperative nausea and vomiting for 24 h after surgery differed significantly between groups [Group NB: 7/25 (28%), Group TEA: 19/102 (18.6%), Group TB: 1/42 (2.4%), P=0.01].ConclusionsTEA provided better analgesia after robot-assisted thoracic surgery for mediastinal disease than NB as indicated by lower pain scores and fewer rescue analgesic requirements. However, the frequency of postoperative nausea and vomiting was lowest in Group TB of all the groups. Thus, TBs might also provide adequate postoperative analgesia following robot-assisted thoracic surgery for mediastinal disease.

Dataset Information

Neuraxial block and postoperative epidural analgesia: effects on outcomes in the POISE-2 trial†.

Publications

Neuraxial block and postoperative epidural analgesia: effects on outcomes in the POISE-2 trial†.

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