Effect of epidural blockade on indicators of splanchnic perfusion and gut function in critically ill patients with peritonitis: a randomised comparison of epidural bupivacaine with systemic morphine

Abstract

Epidural analgesia resulted in improvements in gastric mucosal perfusion and the ultrasound appearance of the small bowel, indicating potential clinical benefit in a group of patients in whom epidural catheterisation is traditionally contraindicated.

Thoracic epidural anesthesia: Effects on splanchnic circulation and implications in Anesthesia and Intensive care

“…This is the rationale for ongoing experimental therapies using vasodilators or oxygen carrying solutions to support dysoxic weak units [33] . Thoracic epidural blockade applied to animal [3,9,14] and human [26] models of sepsis appeared to be effective in fostering microvascular circulation or at least modify its distribution [11] . Regional sympathetic blockade could counteract the above mentioned mechanisms of heterogeneous flow distribution, restoring oxygenation to weak units, and thus contributing to the survival of the intestinal barrier [9,34] .…”

“…The six studies using surrogate hemodynamic parameters had conflicting results. Tanaka et al [23] used PDRicg as indirect measure of hepatic blood [7] Hogan et al [8] Sielenkämper et al [10] Adolphs et al [12] Adolphs et al [11] Schwarte et al [15] Kosugi et al [9] Freise et al [13] Daudel et al [14] Bachmann et al [16] Tanaka et al [23] Väisänen et al [25] Spackman et al [26] Gould et al [20] Michelet et al [22] Kortgen et al [27] Meierhenrich et al [21] Trepenaitis et al [24] Treatment Meissner et al [4] Ai et al [6] Vagts et al [5] Shäper et al [3] Freise et al [17] Freise et al [18] Treatment allocation Siniscalchi A et al . Thoracic epidural anesthesia flow, finding that TEA reduced blood flow to the liver, fluid resuscitation alone could not reverse this effect but had to be associated with dopamine infusion.…”

“…Väisänen et al [25] found no influence of TEA on gastric and sigmoidal PCO2 gap in patients undergoing elective abdominal aortic surgery. Spackman et al [26] evaluated the effects of TEA on a group of critically ill patients with surgically treated peritonitis, they found better pHi and PCO2 gap in patients treated with epidural infusion of bupivacaine. Kortgen et al [27] found an increase in liver blood flow measured with PDRICG in patients undergoing major abdominal surgery and treated with thoracic epidural anesthesia in addition to general anesthesia.…”

Anesthetics considerations in peritonitis

“…22,23 Neuraxial block (thoracic epidural) is preferable to other extra-axial blocks such as paravertebral block, tranversus abdominis plane (TAP) block, rectus sheath block and continuous wound infusion, since the first also has a desired positive effect on bowel function and pancreatic microcirculation 24,25 as well as ensuring improved cardiac protection. 26,27 Sepsis is not a contraindication itself, so only serious hemodynamic instability (i.e., septic shock -as is the case for every loco-regional anesthesia maneuver, and most notably neuraxial ones), coagulopathy, and existing anticoagulant therapy should be considered absolute contraindications to this technique. 28 The usual contraindications, such as infection of the entry site of the catheter or patient refusal, should be added to this.…”

The assessment of visceral perfusion using gastric tonometry, for risk of acute gastric ulcer in patients undergoing vascular surgery around the aorta

“…oraz Sala i wsp., obserwując pacjentów podczas zabiegu w obrębie jamy brzusznej, oraz Piper i wsp. podczas zbiegów rekonstrukcji w obrę-bie aorty brzusznej takich korzyści nie wykazali [22][23][24][25]. Nie ma natomiast badań porównujących ukrwienie trzewne podczas znieczulenia zewnątrzoponowego w zależności od poziomu blokady, a obserwowana przez autorów niniejszej pracy grupa chorych jest niewystarczająco liczna, aby można wysunąć wnioski dotyczące jej zastosowania.…”