The Efficacy of Thoracic Epidural Neostigmine Infusion After Thoracotomy

Abstract

Few anesthesia studies have explored perioperative continuous epidural infusion of neostigmine. We examined such a regimen in thoracotomy patients. Ninety patients were randomized to one of three groups in this double-blind trial. Before anesthesia induction, an epidural catheter was inserted in all patients at T5-8 levels under local anesthesia. Pre-neo patients received bolus 500-microg epidural neostigmine before anesthesia induction followed by infusion of 125 microg/h until the end of surgery. Post-neo patients received epidural saline during the same time periods plus bolus 500-microg epidural neostigmine at end of surgery. Patients in the control group received saline placebo during all three periods. Patients in the neostigmine groups postoperatively received patient-controlled epidural analgesia with morphine 0.02 mg/mL, bupivacaine 0.08 mg/mL, and neostigmine 7 microg/mL. Control patient-controlled epidural analgesia excluded neostigmine. Data were recorded for 6 postoperative days. Daily patient-controlled epidural analgesia consumption (mL) for Pre-neo patients was significantly less than that of post-neo and control group patients for postoperative days 1-6 (at least 10% and 16% less, respectively; P < 0.05). There was a modest decrease in pain intensity on postoperative days 3-6 for pre-neo patients versus other groups (P < 0.05). These results suggest that continuous thoracic epidural neostigmine started before anesthesia provided preemptive, preventive analgesia and an analgesic-sparing effect that improved postoperative analgesia for these patients without increasing the incidence of adverse effects.

Postoperative analgesic effects of epidural administration of neostigmine alone or in combination with morphine in dogs undergoing orthopedic surgery of the pelvic limbs

“…8,9,16,17,21 According to these previous studies, 8,9,16,17,21 no apparent dose-effect relation existed between the dose of neostigmine for epidural administration and the incidence of these adverse effects. In addition, the incidence of nausea and vomiting was not significantly higher in patients given neostigmine epidurally, compared with the incidence in those that did not receive the anticholinesterase agent.…”

“…5 This drug was found to be devoid of neurotoxic effects when injected intrathecally in dogs, rats, and sheep. 6,7 Clinical studies 8,9 in humans who underwent surgeries expected to result in severe postoperative pain demonstrated that the combination of morphine with neostigmine improved postoperative analgesia, compared with the analgesic outcome for each drug alone, without increasing adverse effects.…”

A Prospective Randomized Double-Blind Study to Determine the Effect of Thoracic Epidural Neostigmine on Postoperative Ileus After Abdominal Aortic Surgery

“…Neostigmine is an acetylcholinesterase inhibitor used as a neuroaxial adjuvant drug to enhance the analgesic effect of local anesthetics. 18,19 Although neostigmine accomplishes analgesia by inhibiting endogen neurotransmitter acetylcholine degradation, increased acetylcholine in the medulla spinalis stimulates all muscarinic and nicotinic receptors. Therefore, increased acetylcholine together with analgesia leads to many adverse effects, such as motor weakness, hypertension, tachycardia, vaginal contraction, ejaculation, urinary retention, and bowel incontinence.…”

New Drugs for Epidural Analgesia

“…However, the authors assumed the lack of adverse effects nausea, vomiting, sedation, tachycardia, hypertension to the small simple size studied [112].…”