Abstract
Purpose
To compare thoracic epidural analgesia (TEA) using a bupivacaine/fentanyl mixture and lumbar epidural analgesia (LEA) with morphine, in respect to the time to extubation and the quality of post-operative analgesia, in patients having thoracoabdominal esophagectomy.
Methods
Twenty two patients scheduled for elective thoracoabdominal esophagectomy were randomized to TEA or LEA. Postoperatively, the TEA group received Patient Controlled Epidural Analgesia (PCEA) with bupivacaine 0.125% and 5 μg·mlB1 fentanyl, and the LEA group received PCEA with 0.2 μg·mlB1 morphine. A blinded observer assessed criteria for tracheal extubation and the time of tracheal extubation was recorded. Early extubation was defined as tracheal extubation within four hours postoperatively. Visual analogue pain scores at rest (Static Visual Analogue Pain Scores, SVAPS) and with movement (Dynamic Visual Analogue Pain Scores, DVAPS) were recorded at 1, 6, 12, 18 and 24 hr post-extubation. Failure of the epidural protocol (FEP) was defined as a request for additional analgesia.
Results
Tracheal extubation was achieved in 70% of the LEA and 100% of the TEA at four hours postoperatively (P=NS). However, the TEA group achieved earlier extubation times when assessed with log rank testing (P = 0.01). By six hours post-extubation FEP had occurred in 50% of the LEA group but in none of the TEA group (P = 0.01). Mean SVAPS and DVAPS were lower in the TEA than in the LEA group at all measured times (P < 0.01).
Conclusion
This study has demonstrated superior pain control in patients undergoing thoraco-abdominal esophagectomy treated with TEA than with LEA, particularly for pain with movement. Tracheal extubation occurred earlier in the TEA group, but this difference was not significant at four hours postoperatively.
Résumé
Objectif
Comparer l’analgésie péridurale thoracique (APT), à base d’un mélange de bupivacàïne/fentanyl, avec l’analgésie péridurale lombaire (APL) à la morphine, en regard du moment de l’extubation et de la qualité de l’analgésie postopératoire, chez des patients qui subissent une œsophagectomie thoraco-abdominale.
Méthode
Vingt-deux patients devant subir une œsophagectomie thoraco-abdominale élective, ont été répartis en deux groupes : APT et APL. Après l’intervention, le groupe APT a reçu une analgésie péridurale contrôlée par le patient (APCP) avec de la bupivacaïne 0,125 % et 5 μg·ml−1 de fentanyl, et le groupe APL a reçu une APCP avec 0,2 μg·ml−1 de morphine. Un observateur impartial a évalué les critères de l’extubation et a noté le moment de l’extubation endotrachéale. Lextubation était jugée précoce si elle avait lieu en moins de quatre heures après l’opération. Les scores de douleurs au repos à l’échelle visuelle analogue (scores de douleurs statiques de l’échelle visuelle analogue SDSEVA) et lors de mouvements (scores de douleurs dynamiques de l’échelle visuelle analogue SDDEVA) ont été enregistrés à 1, 6, 12, 18 et 24 h après l’extubation. L’échec du protocole péridural (EPP) était defini comme des besoins d’analgésie supplémentaire.
Résultats
Lextubation était réalisée chez 70 % des patients du groupe APL et 100 % de ceux du groupe APT quatre heures après l’intervention (P = NS). Cependant, le groupe d’APT a affiché des temps d’extubation plus précoces d’après une évaluation avec le test de rang logarithmique (P = 0,01). Six heures après l’extubation, l’EPP s’etait produit chez 50 % des cas du groupe d’APL mais chez aucun du groupe d’APT (P = 0,01). Les SDSEVA et SDDEVA moyens etaient plus bas dans le groupe d’APT que dans le groupe d’APL pour toutes les mesures de temps (P < 0,01).
Conclusion
Cette étude a fait la preuve d’un contrôle supérieur de la douleur chez les patients subissant une cesophagectomie thoraco-abdominale avec un traitement d’APT plutôt qu’avec une APL, surtout quant il s’agissait de douleur lors de mouvement. Lextubation trachéale a eu lieu plus tôt dans le groupe APT mais cette différence n’était pas significative 4 h après l’intervention.
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Kahn, L., Baxter, F.J., Dauphin, A. et al. A comparison of thoracic and lumbar epidural techniques for post-thoracoabdominal esophagectomy analgesia. Can J Anesth 46, 415–422 (1999). https://doi.org/10.1007/BF03012939
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DOI: https://doi.org/10.1007/BF03012939