Evidencia en Analgesia Epidural en Cirugía Abdominal A bierta

Evidencia en Analgesia Epidural en Cirugía Abdominal Abierta

Carlos G. Patiño Hidalgo (Residente)David Rincón (Tutor)

Junio 2012

Prejuicios

VentajasAnalgesia

Complicaciones pulmonares

Eventos coronarios

Función intestinal POP

Recidiva tumoral

< Estancia hospitalaria

< Mortalidad

Desventajas

Hipotensión

Uso de LEV y vasopresor

Anastomosis intestinal

> Estancia hospitalaria

> Mortalidad

Analgesia

Meta-análisis

• De 1966 a 2002 – 100 estudios– Total pacientes 7077

• Grupos– Epidural– Opioide sistémico

Block BM, Liu SS, Rowlingson AJ, Cowan AR, Cowan JA, Wu CL. Efficacy of Postoperative Epidural Analgesia. JAMA: 2003;290(18):2455–63.

• Analgesia• Sitio quirúrgico y lugar del c

atéter torácico o lumbar

• Efectos secundarios

Analgesia

Block BM, Liu SS, Rowlingson AJ, Cowan AR, Cowan JA, Wu CL. Efficacy of Postoperative Epidural Analgesia. JAMA: 2003;290(18):2455–63.

Analgesia

Block BM, Liu SS, Rowlingson AJ, Cowan AR, Cowan JA, Wu CL. Efficacy of Postoperative Epidural Analgesia. JAMA: 2003;290(18):2455–63.

Analgesia

Block BM, Liu SS, Rowlingson AJ, Cowan AR, Cowan JA, Wu CL. Efficacy of Postoperative Epidural Analgesia. JAMA: 2003;290(18):2455–63.

Analgesia

Meta-análisis• De 1996 a 2004

– 48 estudios– 1625 pacientes epidural – 1583 pacientes PCA

• Grupos– PCA, – CEA y PCEA

Wu CL, Cohen SR, Richman JM, Rowlingson AJ, Courpas GE, Cheung K, et al. Efficacy of postoperative patient-controlled and continuous infusion epidural analgesia versus intravenous patient-controlled analgesia with opioids: a meta-analysis. Anesthesiology 2005 Nov;103(5):1079–88. PMID: 16249683

– Analgesia– Efectos Adversos

Analgesia

Wu CL, Cohen SR, Richman JM, Rowlingson AJ, Courpas GE, Cheung K, et al. Efficacy of postoperative patient-controlled and continuous infusion epidural analgesia versus intravenous patient-controlled analgesia with opioids: a meta-analysis. Anesthesiology 2005 Nov;103(5):1079–88;. PMID: 16249683

Efectos secundarios

Wu CL, Cohen SR, Richman JM, Rowlingson AJ, Courpas GE, Cheung K, et al. Efficacy of postoperative patient-controlled and continuous infusion epidural analgesia versus intravenous patient-controlled analgesia with opioids: a meta-analysis. Anesthesiology 2005 Nov;103(5):1079–88;. PMID: 16249683

Analgesia, hipotensión, estancia

Meta-análisis

• De 1987 y 2005 – 16 artículos

• Grupos– Opioide sistémico

n=400 – AE AL y AL+OP n=406

(AE 24 horas a 6 días)

Marret E, Remy C, Bonnet F. Meta-analysis of epidural analgesia versus parenteral opioid analgesia after colorectal surgery. The British journal of surgery. 2007;94(6):665–73. PMID: 17514701

• Analgesia• Hipotensión • Estancia

Analgesia, hipotensión.

Marret E, Remy C, Bonnet F. Meta-analysis of epidural analgesia versus parenteral opioid analgesia after colorectal surgery. The British journal of surgery. 2007;94(6):665–73. PMID: 17514701

Estancia

Marret E, Remy C, Bonnet F. Meta-analysis of epidural analgesia versus parenteral opioid analgesia after colorectal surgery. The British journal of surgery. 2007;94(6):665–73. PMID: 17514701

Vasopresor y anastomosis

Cohorte Histórica

• De 2000 y 2004 – 223 paciente con 259

anastomosis por cualquier causa (cáncer 61%)

• Grupos– Vasopresor 113 (50%)– No vasopresor

Zakrison T. Perioperative vasopressors are associated with an increased risk of gastrointestinal anastomotic leakage. world journal of surgery. 2007;31:1627–34. PMID: 17551781

• Exposición a Vasopresor• Uso de Líquidos

Endovenosos• Mortalidad

Vasopresor y anastomosis

Zakrison T. Perioperative vasopressors are associated with an increased risk of gastrointestinal anastomotic leakage. world journal of surgery. 2007;31:1627–34. PMID: 17551781

Vasopresor y anastomosis

Experimental animal

• 42 conejos de Nueva Zelanda

• Grupos (6)1. Control2. Dopamina 5,10,15,20,25

mcg /kg/min

Adanir T, Nazli O, Kara C, Aksun M, Sozutek A, Sencan A, et al. The relationship between vasopressor dose and anastomotic leak in colon surgery: an experimental trial. International journal of surgery. 2010; 8(3):221–4. PMID: 20096810

Presión de EstallidoNiveles de Hidroxiprolina y Colágeno

Anastomosis

Adanir T, Nazli O, Kara C, Aksun M, Sozutek A, Sencan A, et al. The relationship between vasopressor dose and anastomotic leak in colon surgery: an experimental trial. International journal of surgery. 2010; 8(3):221–4. PMID: 20096810

Dehiscencia Anastomosis intestinal

Experimental animal

• 40 conejos de Nueva Zelanda• Grupos

– Infusión Epidural NaCl 0.9% (bolo 0.4ml/Kg, infusión 0.2ml/kg/h)

– Infusión Epidural Lidocaina 1% (bolo 0.4ml/Kg, infusión 0.2ml/kg/h)

Adanir T, Aksun M, Karaoren GY, Karabuga T, Nazli O, Sencan A, et al. Effect of epidural anesthesia on anastomotic leakage in colonic surgery: experimental study. Turkish Journal of Trauma and Emergency Surgery . 2012;18 (1) 5-10. PMID: 22290043

Anastomosis y epidural

Adanir T, Aksun M, Karaoren GY, Karabuga T, Nazli O, Sencan A, et al. Effect of epidural anesthesia on anastomotic leakage in colonic surgery: experimental study. Turkish Journal of Trauma and Emergency Surgery . 2012;18 (1) 5-10. PMID: 22290043

Función intestinal

Ensayo Clínico Controlado

• 42 pacientes para cirugía colon y recta electiva

• Grupos– AE bupivacaina y fentanil– PCA morfina

Carli F, Phil M, Tmdel JL, Sc M, Belliveau P, D M. The Effect of Intraoperative Thoracic Epidural Anesthesia and Postoperative Analgesia on Bowel Function After Colorectal Surgery. Dis Colon Rectum. 2001;44:1083–9. PMID: 11535845

• Función Intestinal

Función Intestinal

Carli F, Phil M, Tmdel JL, Sc M, Belliveau P, D M. The Effect of Intraoperative Thoracic Epidural Anesthesia and Postoperative Analgesia on Bowel Function After Colorectal Surgery. Dis Colon Rectum. 2001;44:1083–9. PMID: 11535845

Complicaciones pulmonares

Meta-Análisis

• Búsqueda de 1966 a 2006– 58 estudios– 5904 pacientes

• Grupos– Epidural– Opioide sistémico

Pöpping DM, Elia N, Marret E, Remy C, Tramèr MR. Protective effects of epidural analgesia on pulmonary complications after abdominal and thoracic surgery: a meta-analysis. Archives of surgery. 2008 Oct;143(10):990–9. PMID: 18936379

• Neumonía

• Hipotensión

• Mortalidad

Complicaciones pulmonares

Otras complicaciones

Evento coronario

Meta-Análisis

• De 1966 a 1998– 17 Estudios– 11 Ensayos Clínicos Controlados– 1173 pacientes

• Grupos– Epidural por más de 24

horas– Opioide sistémico

Beattie WS, Badner NH, Choi P. Epidural analgesia reduces postoperative myocardial infarction: a meta-analysis. Anesthesia and analgesia. 2001 Oct;93(4):853–8. PMID: 11574345

Infarto Agudo PostoperatorioMortalidad intra Hospitalización

Análisis de subgrupos

Infarto postoperatorio

Beattie WS, Badner NH, Choi P. Epidural analgesia reduces postoperative myocardial infarction: a meta-analysis. Anesthesia and analgesia. 2001 Oct;93(4):853–8. PMID: 11574345

Muerte intrahospitalaria

Beattie WS, Badner NH, Choi P. Epidural analgesia reduces postoperative myocardial infarction: a meta-analysis. Anesthesia and analgesia. 2001 Oct;93(4):853–8. PMID: 11574345

Recidiva tumoral

Dos series Histórica• De 1994 a 1997

• Grupos– Epidural + General n=

103– AINE + General n= 158

Wuethrich PY, Hsu Schmitz S-F, Kessler TM, Thalmann GN, Studer UE, Stueber F, et al. Potential influence of the anesthetic technique used during open radical prostatectomy on prostate cancer-related outcome: a retrospective study. Anesthesiology. 2010 Sep;113(3):570–6. PMID: 20683253

– Sobrevida libre de progresión

Recidiva tumoral

Wuethrich PY, Hsu Schmitz S-F, Kessler TM, Thalmann GN, Studer UE, Stueber F, et al. Potential influence of the anesthetic technique used during open radical prostatectomy on prostate cancer-related outcome: a retrospective study. Anesthesiology. 2010 Sep;113(3):570–6. PMID: 20683253

OTRAS ALTERNATIVAS

Infusión de Tramadol

Ensayo Clínico Controlado– 69 pacientes

• Grupos con PCA morfina 1mg/ml

– Tramal Qx:1mg/Kg; Inf 0.2 mg/Kg/h

– Control SSN• Metodo

– ECC doble ciego

Webb AR, Bs MB, Leong S, Bs MB, Myles PS, Bs MB, et al. The Addition of a Tramadol Infusion to Morphine Patient-Controlled Analgesia After Abdominal Surgery: A Double-Blinded, Placebo-Controlled Randomized Trial. Anesthesia & Analgesia. 2002;95:1713–8.

• Dolor• Signos vitales

Tramadol

Webb AR, Bs MB, Leong S, Bs MB, Myles PS, Bs MB, et al. The Addition of a Tramadol Infusion to Morphine Patient-Controlled Analgesia After Abdominal Surgery: A Double-Blinded, Placebo-Controlled Randomized Trial. Anesthesia & Analgesia. 2002;95:1713–8.

Tramadol

Webb AR, Bs MB, Leong S, Bs MB, Myles PS, Bs MB, et al. The Addition of a Tramadol Infusion to Morphine Patient-Controlled Analgesia After Abdominal Surgery: A Double-Blinded, Placebo-Controlled Randomized Trial. Anesthesia & Analgesia. 2002;95:1713–8.

Cx Tórax

RevisiónDe 1950 a 2009 - 7 articulos

• Dolor• Retención urinaria• Nausea• Prurito• Hipotensión• VEF1

• Oximetría• PAO2/FIO2

• Cortisol plasma• Estancia

Scarci M, Joshi A, Attia R. In patients undergoing thoracic surgery is paravertebral block as effective as epidural analgesia for pain management? Interactive cardiovascular and thoracic surgery . 2010; 10(1):92–6. PIMD: 19854794

Cx Laparoscópica

Ensayo Clínico Controlado

• N=91 pacientes Qx colon laparoscópica• Grupos

– Epidural– Espinal– PCA

Levy BF, Scott MJ, Fawcett W, Fry C, Rockall T. Randomized clinical trial of epidural, spinal or patient-controlled analgesia for patients undergoing laparoscopic colorectal surgery. The British journal of surgery. 2011 Aug;98(8):1068–78. PMID: 21590762

– Estancia– Calidad de vida– Dolor– L.E.V adicionales en POP– Función intestinal

Estancia

Levy BF, Scott MJ, Fawcett W, Fry C, Rockall T. Randomized clinical trial of epidural, spinal or patient-controlled analgesia for patients undergoing laparoscopic colorectal surgery. The British journal of surgery. 2011 Aug;98(8):1068–78. PMID: 21590762

Dolor

Levy BF, Scott MJ, Fawcett W, Fry C, Rockall T. Randomized clinical trial of epidural, spinal or patient-controlled analgesia for patients undergoing laparoscopic colorectal surgery. The British journal of surgery. 2011 Aug;98(8):1068–78. PMID: 21590762

Función intestinal

Levy BF, Scott MJ, Fawcett W, Fry C, Rockall T. Randomized clinical trial of epidural, spinal or patient-controlled analgesia for patients undergoing laparoscopic colorectal surgery. The British journal of surgery. 2011 Aug;98(8):1068–78. PMID: 21590762

Cx Laparoscópica

Revisión sistemática

• De 1966 a 2005– 8 Ensayos Clínicos

Controlados• Grupos

– Epidural– PCA– Ketocorolaco– Lidocaina– Espinal

Levy B, Tilney H, Dowson H and Rockall T. A systematic review of postoperative analgesia following laparoscopic colorectal surgery. Colorectal Disease. 2010;12:5–15.

• Estancia 3rtc =, 1 Ch mejor AE

• Nausea y vómito• Retención urinaria• Re admisión

Nausea y vómito

Levy B, Tilney H, Dowson H and Rockall T. A systematic review of postoperative analgesia following laparoscopic colorectal surgery. Colorectal Disease. 2010;12:5–15.

Retención urinaria y Re Admisión

Levy B, Tilney H, Dowson H and Rockall T. A systematic review of postoperative analgesia following laparoscopic colorectal surgery. Colorectal Disease. 2010;12:5–15.

ConclusionesEl uso de analgesia epidural en Cx abdominal mayor abierta (comparada con la analgesia IV)

Mejora la analgesiaAumenta el riesgo de hipotensiónAumenta el uso de vasopresores y LEVNo prolonga la estancia hospitalaria ni aumenta la mortalidadNo aumenta el riesgo de dehiscencia de la anastomosisMejora la función intestinal postoperatoriaDisminuye el riesgo de complicaciones pulmonares (neumonía)Disminuye el riesgo de eventos coronarios agudos (epidural torácica)Podría disminuir el riesgo de recidiva tumoral

Conclusiones

Existen otras alternativas….El efecto clínico del uso de tramadol en infusión NO parece ser diferente al uso de opioides IVEl bloqueo para-vertebral puede ser una alternativa a la analgesia epidural en Cx de tóraxEl uso de anestesia/analgesia espinal podría ser una alternativa en Cx laparoscopica

Junio 2012

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