conflict of interest disclosure - aspmn conference documents/handouts/fri… · why all the pulse...
Post on 20-Mar-2018
216 Views
Preview:
TRANSCRIPT
1
1
Thoracic Epidurals (TEA) in Adult Surgical Patients: An Overview, Clinical Pearls & Lessons Learned 1 Year After Introducing Opioid Free TEA
Board Certified-Pain ManagementNurse Practitioner, Acute Pain ServiceSunnybrook Health Sciences CentreAdjunct Lecturer, Lawrence S. Bloomberg Faculty of Nursing, University of Toronto.
Jason Sawyer, RN (EC), MN, BC
Conflict of Interest Disclosure
Authors Conflicts of Interest;
– Jason Sawyer. Has received financial compensation from Purdue
Pharma for preparing & providing pain management lectures. Last
lecture: Winter 2013
•1212 beds - 677 acute care•16 000 operative procedures/year•1.2 million patient visits/year•10 000 + employees•5th largest cancer centre in North America
2
4
Acute Pain Service
• 2 Nurse Practitioners Monday-Friday
• Staff or Fellow Anesthesiologist 7 days – Tues-Tues
• 3300-3500 patients/year
• 400-500 surgical epidurals
5
Agenda• Losing the battle with postoperative pain management?
• Overview of the advantages of TEA
• Overview of thoracic epidural analgesia (TEA)
– Anatomy of the epidural space
– Review of commonly used local anesthetics and opioids
• ASPMN Listserve Survey results (2014)
• Describe common TEA related side effects and their treatment
– Hypotension, pruritus, nausea, vomiting, urinary retention
• Describe our experience with epinephrine as a substitution for opioid in thoracic epidurals
6 6
What Do We Know……• Pain is still poorly managed postoperatively ( Sawyer et al. 2008, 2010)
• Higher in-hospital pain scores correlate with higher post-discharge pain scores (Vandenkerkhof, 2006)
• Pain, depression and fatigue account for 1/3 of variation in older adultsfunctional status 1 month after major abdominal surgery (Zalon, 2004)
• Post-discharge health care utilization is greater in those with higher pain scores in-hospital and post-discharge (Vandenkerkhof, 2006)
3
7 7
What Do We Know……
• Pain severity adversely effects quality of life in the immediate postop period (Wu, 2003)
• Post-op pain contributes to decreased HRQL 1 month post-discharge, & interfered with ADL’s and sleep (Strassels, 2004)
• Patients that experienced severe pain and utilized the most analgesics the first 7 days postop have ↑ risk of developing chronic post surgical pain (CPSP) (Visser 2006)
8
9
4
10
11
If you were given a strong pain killer like morphine after surgery, how worried would you be about becoming addicted?
1. Not worried at all
2. A little bit worried
3. More than a little bit worried
4. Very worried
12
Would you try to limit how much strong pain killers like morphine you use because you worried about becoming addicted?
1. Yes
2. No
5
13
14
“Oh, Just Give Them PCA”…..
• Opioids are not benign
• Opioid Induced Hyperalgesia (OIH)
• Significant increase in addiction to legal opioid prescriptions
• 5 –fold increase in prescription opioid related deaths in the US(CDC 2013)
14
15
Brief Summary
• Effective postoperative pain management remains an elusive goal
• Severe pain in the postoperative period is a key factor in developing CPSP
– But not everyone with severe acute pain develops chronic pain
• Patients and families have strong beliefs regarding opioids
• What to do…..what to do….
6
16
17
18
7
19
• Postop matched pair cohorts epidural and PCA (88 188 patients) across surgical populations
• Epidural associated with small reduction in 30 day mortality (1.7 vs2.0 RR 0.89 CI 0.81-0.98 p= 0.02 NNT=477)
• Epidural patients generally had a higher co-morbidity burden
• “Furthermore, the increased burden of co-morbid illness in patients who received epidural anaesthesia would suggest that our study, if anything, is biased against epidural anaesthesia” pg 567
20
21
8
22
Year : 2009 | Volume : 12 | Issue : 2 | Page : 166-167
High thoracic epidural analgesia for cardiac surgery: Time to move from morbidity to quality of recovery indicators
Colin F RoyseAnaesthesia and Pain Management Unit, Department of Pharmacology, University of Melbourne; and Cardiothoracic Anaesthetist, The Royal Melbourne Hospital, Australia
23
• The analgesic benefits of TEA are well described in the literature across many surgical populations
• Efforts to find reductions in morbidity and mortality are difficult because incidence rates of serious outcomes are very low
– Despite epidurals are often placed in less well patients
• More evidence required regarding TEA (and ultimately quality pain management)
– Quality of recovery
– Quality of life
– Chronic post surgical pain
24
Thoracic Epidurals- Some Lingo
• Cephalad/Rostral towards the head (up)
• Caudal towards the tail (down)
• Attenuate dampen
• Lipophillic fat friendly
• Hydrophillic water friendly
9
25
Where It All Started
August Bier 1861-1949
surgeon
James Leonard Corning 1855-1923
neurologist
1885 Spinal cocaine1898 Spinal AnestheticAssisted by August
Hildebrandt
26
27
Epidural Anatomy
• Epidural space is a potential space, containing crevices around the epidural contents (fat, veins, lymphatics, nerve roots, dural sac)
• These layers and textures affect the flow of analgesics through the space
• Epidural venous flow is predominantly located anteriorly
• Veins lack valves
McLeod, 2004, Richardson, 2005, Bauer, 2012
10
28
Epidural Anatomy
• Ligamentum flavum is non continuous and not pain sensitive
• Proximity to CSF/Spinal Cord is crucial
• Sympathetic fibres T1-L2
29
Some Effect
• Age– 40% less dose for (60-79) vs (20-
39)
– Diminished fatty tissue
– Decrease in myelinated nerves
– Increased epidural space compliance
• 4-6 cm threaded into epidural space
Minimal/No Effect
• Height, weight BMI
• positioning
• Gravity
• Needle direction
30
Some Effect• Site of insertion determines
distribution
• Total mass of LA more important than concentration or volume
Minimal/No Effect
• Fractional vs single bolus injection
• Epidural pressures
• Pressure in adjacent body cavities
11
31
32
What Analgesics?
• Local Anesthetics
• Opioids
• Epinephrine
33
Epidural Local Anesthetics
• Primary route of action is spinal nerve roots
– Weak effect on spinal cord and paravertebral nerves
• Majority absorbed systemically via venous system (peak 10-30 mins)
– Epidural fat
– Diffusion across dura
• Lipid soluable
• Ester local anesthetics metabolized by plasmapseudocholinesterase (rarely used for epidural analgesia)
• Amide local anesthetics metabolized in the liver– Most commonly used are bupivacaine and ropivacaine
12
34
• Smaller nerves more susceptible to effects of LA– Pain, temperature, touch, motor proprioception -
• Myelinated fibres are more susceptible to effects of LA– Myelination speeds conduction in Nodes of Ranvier which contain high
concentrations of Na+ channels
• Positive temperature or pin prick (qualitative) assessments do notnecessarily equal analgesia- only let you know where the LA is spreading
35
Epidural Opioid Site of ActionSubstantia Gelatinosa of Spinal Cord
Primarily Spinal Effect Hydrophilic Lipophilic Primarily
Supraspinal
Morphine Hydromorphone (Dilaudid)
Fentanyl
36 36
Why THORACIC Epidural?
• Virtually no Motor Block– Vs Lumbar Epidural
• Incision Congruent Placement
• Minimizes the surgical stress response
• Earlier return of bowel function– Sympathetic blockade– Increases GI blood flow & splanchnic perfusion aiding in return
of motility
Kozian et al 2005
13
37 37
– Earlier return of bowel function (Taqi 2007, ; Carli 2001)
• Inhibition of splanchnic reflexes (Kehlet, 2001)
• Inhibition of nociceptive afferents
• Inhibition of sympathetic efferents
– Compensatory activation of non anesthetized sympatheticsegments (Waurick 2005)
• Vasodilation of veins and arteries in blocked area
• Blockade of spinal reflex arcs– (Wetterslev 2001)
38
39 39
Questions Without An Answer
– Ideal mixture of solution (LA and/or opioid) still unknown
• LA only - no opioid side effects but possibly more hypotension• Opioid only no better than systemic opioids and ↑ side effects• LA + opioid best ?• Other adjuncts?
• (Wetterslev 2001, Brown 2004)
14
40
Side Effects, Big & Small
41
42
15
43
Presented as Mean %
PruritusN=21 461
NauseaN= 20 606
VomitingN=11 423
Urinary RetentionN=12 513
Mild SedationN= 9451
All 14.7 25.2 20.2 23 23.9
IM 3.4 17 21.9 15.2 53.7
IV-PCA 13.8 32 20.7 13.4 56.5
Epidural 16.1 18.8 16.2 29.1 14.3
Presented as Mean %
Respiratory depression naloxone
useN= 55 404
Hemodynamic depression (all
definitions)N= 24 955
Respiratory depression by decreased ventilatory frequency
N= 29 607
Respiratory depression by decreased O2 sats N= 1516
Respiratory depression by
elevated PaCO2 N= 3170
All 0.3 4.7 1.1 17 3.3
IM 1.4 3.6 0.8 37 1.3
IV-PCA 1.9 0.7 1.2 11.5 1.3
Epidural 0.1 5.5 1.1 15 6
44
Do you routinely use etCO2 or continuous pulse oximetry for your patients with thoracic epidurals that contain opioids? N= 73
Yes No
45
• Mechanism of Opioid Induced Pruritus (OIP)is poorly understood
• Mu opioid receptors seem to play a key role
– Spinal cord not brain or periphery
• Histamine release has very little role
– So antihistamines will most likely not help!
• The more invasive the opioid administration, the higher the incidence of OIP
45
16
46
Very few trials
Propofol (IV) 10-20 mg
Nalbuphine (IV) 4mg
Naltrexone (PO) 6 mg
Naloxone infusions (2mcg/kg/hr)
Ondansetron (IV) 8mg
Antihistamines –sedating effect may break the itch/scratch cycle
47
What intervention do you use FIRST for pruritus you suspect is from opioid in the thoracic epidural?
Administer Diphenhydramine
Administer Nalbuphine
Administer Naloxone
Administer Naloxone infusion
Administer Ondansetron
Reduce/change the opioid in theepiduralRemove the opioid from the epidural
48
PONV 101 (Watcha & White 2002)
12/27/201248
17
4949
50
51
Urinary Retention
18
52
Side Effects With TEA
• Incidence of nausea, vomiting and naloxone use lower in epidural groups vs IV-PCA
• No single agent will be universally effective for PONV- evidence that algorithms are beneficial in appropriately screened patients (Krancke2007)
• Most side effects are related to the opioids
53
Side Effects With TEA
• Incidence of pruritus much higher, but is not histamine mediated. Limited evidence for Ondansetron (Zofran) and opioid reversal agents
• Incidence of urinary retention with TEA is approximately 10% and early removal demonstrates a decrease in UTI
• With the incidence of respiratory depression approximately 0.1%......Why all the Pulse Oximetry/EtCO2 monitoring, and taking up ICU beds for epidural patients?
54
Historical TEA delivery at Sunnybrook
• Choice of a single ropivacaine (Naropin) concentration (0.2%) withoptions for hydromorphone (Dilaudid) 5 or 10 mcg/ml
• No PCEA component
• Trouble shooting involved large doses of lidocaine (Xylocaine)
• High infusion rates not uncommon (15-20ml/hr)
19
55
• Perceived excessive failure rate
• Not uncommon to add IV-PCA opioid to epidural
• Suboptimal outcomes for chronic pain/chronic opioid users that receive epidurals
• Despite safely aggressive multimodal analgesia withNSAIDS/Gabapentinoids/Acetaminophen
56
Lessons Learned Adding Epinephrine
• Quickly
– Adding epinephrine (Adrenaline) to Ropivacaine (Naropin) /HYDROmorphone (Dilaudid) combination frequently caused pruritus when none existed before (particularly with 10 mcg/ml HYDROmorphone) in the same patient
– Ropivacaine (Naropin) 0.2% with Epinephrine (Adrenaline) 5mcg/ml did not seem to work consistently as well as we would have liked
57
PharmacologicaloptimizationDose Volume Concentration Choice of
medications
Technical Aspects – Catheter & LineHigher success rate with placement
>5cm into epidural space
tunneling Test dose Line patency
Technical Aspects- PlacementParavertebral, pleural
cavity and intravascular placement
Secondary migration after
insertion
Imprecise catheter
placement
Method of epidural space identification
20
58
History of Epinephrine Use
• Used as an adjunct for saddle block anesthesia in 1950 (Priddle & Andros)
• “ The intrathecal use of vasoconstrictors in conjunction with the various local anesthetic agents as a means of increasing the effectiveness of spinal anesthesia dates back some 45 years” (Priddle &Andros 1950 pp 156)
• Small study (3 groups 6 patients total) obstetrical patients• 3rd group
– 1mg of epinephrine (1cc of 1:1000 epinephrine with 1cc of 5% dextrose into CSF
– “complete relief of pain of uterine contraction”– No systemic effects noted
59
How Neuraxial Epinephrine Works
• α2-adreno receptor agonist
• Independently causes segmental hypoalgesia when given epidurally to pinprick (100 mcg) (Curatolo et al 1997) & pinprick/ice (50mcg)(Bromage et al 1983)
• Direct spinal application of epinephrine elevated the nociceptivethreshold in an animal model (Reddy et al 1980)
• Absorbed into the CSF and binds to α2 adrenoreceptors in substantia gelatinosa of the dorsal horn (Curatolo et al 1997)
60
• Epidural Epinephrine (100mcg) reduced peak plasma concentrations of 20ml of 0.5% bupivacaine or 2% lidocaine by 25%in 40 patients undergoing minor general/ortho procedures (Burm et al 1986)
• No delayed peak onset time when added to lidocaine and bupivacaine
• Longer duration of block
21
61
• Epidural Epinephrine (100 mcg) decreased peak plasma morphine levels (10mg epidural) by 60% in a study of 3 healthy volunteers (Bromage et al 1983)
• Profound exacerbation of side effects including resp. depression 6-16 hours post morphine
• Rostral spread significantly greater at 2-6 hours
• Similar attenuation of cold pressor test ONLY until 16-22 hrs
62
• Niemi et al 2001/2002/2003
• All 3 randomized double blind crossover studies
– Effect of fentanyl added to bupivacaine/adrenaline
– Effect of adrenaline added to ropivacaine/fentanyl
– 3 concentrations of adrenaline added to fentanyl and bupivacaine
• 2mcg/ml more effective than 1 or 1.5mcg/ml (Niemi & Brevik 2003)
63
Adding Fentanyl (20 pts) 2001
• Bupiv 0.1% fent & epi 2mcg/ml
• Without fentanyl pain with coughing significantly worse after 3 hours
• Pain decreased within 15 mins and no difference within 1 hr of reintroducing fentanyl
• No change in sensory blockade during non fentanyl times
• No difference in any side effects with or without fentanyl
• No difference in time out of bed
Adding Epinephrine 12 pts 2002
• Ropiv 0.1%/& fent/epi 2mcg/ml
• Without Epi pain with coughing significantly worse within 2 hrs
• Pain decreased within 15 mins and no difference within 1 hr of reintroducing epi
• Significant regression of sensory blockade with removal of epinephrine
• Nausea increases significantly when epinephrine removed
• Significantly more mobilization with epinephrine
22
64
What Does This Mean Clinically?
• Epinephrine given epidurally:
– Has its own antinociceptive properties
– Likely increases the amount of opioid and LA reaching the spinal cord & nerve roots
– More intense and prolonged analgesic effect
– Wider sensory coverage
– Reduced concentrations of each class of analgesia are required– (Niemi et al 2002)
– Reduces systemic absorption of opioids and LA by 25-60%
65
ASPMN Listserve Survey Results
• Local anesthetics
– 2/3 bupivacaine (most common 0.1%)
– 1/3 ropivacaine (most common 0.1-0.2%)
• Epinephrine (2) Clonidine (1)
• Opioids– 55% fentanyl (1-5mcg/ml)
– 40% Hydromorphone (4-20mcg/ml)
• Vast majority LA/opioid combination
• Very few had multiple options
66
TEA Management At SunnybrookOctober 2014-Present
• Transition to opioid free epidural analgesia regimen
• Continuous infusion + PCA component
• Epinephrine (Adrenaline) 5mcg/ml and Ropivacaine (Naropin) 0.3% standard solution
• Additional solutions available for individualizing TEA
23
67
68
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
How long, on average, do you keep your thoracic epidurals infusing? N= 74
1 day2 days3 days4 days5 days6 days7 days>7 days
69
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
Anesthesiology preference Acute Pain Service preference Customized based on patientfactors
If you have more than 1 epidural solution to choose from, how do you decide which one to use on your patients? (N=64)
24
71
• Ropivacaine plasma concentrations peak in about 67 hrs (of 120 hrs) (2000,Wiedemann)
• Painful Procedure (this is a single procedure!)
– Small bowel resection, closure of loop ileostomy, abdominal wall hernia repair with components separation, placement of biological mesh (10x25cm), intraperitoneal underlay implant, excision of large skin flaps
72
25
73
# Of Patients Using Each Ropivacaine Concentration
0
50
100
150
200
250
300
350
400
0.125% 0.2% 0.3% 0.4% 0.5%
Pre Opioid FreeEpidurals
Post Opioid FreeEpidurals
74
75
Trouble Shooting (especially at night!)Uncontrolled Pain +/- Sensory Block
• Bolus epidural with morepotent Ropivacaine (Naropin) as opposed to Lidocaine
– 1% Ropivacaine vials
– Cassettes with0.125//0.3//0.5% available on high volume unit
– If satisfactory relief withmore potent bolus- start infusion with same
Appropriate Analgesia & Dense Motor Block
– If shutting off until motor block resolution and restarting at a lower rate does not work
– Lower concentration of Ropivacaine
26
76
77
42.6%
5.6%1.9%
50.0%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0% Bolus the epidural with more of the sameepidural solution infusing through the epiduralpump and increase the rate?
Bolus the epidural catheter with a more potent,different, local anesthetic (e.g. lidocaine), thenresume with the same epidural solution
Bolus the epidural catheter to comfort with amore potent dose of ropivacaine, then resumethe infusion at the more potent dose ofropivacaine.Continue the current epidural solution and addIV-PCA/other route of opioid
What do you do FIRST when a patient has an appropriate bilateral sensory block in the surgical area, but still has moderate/severe pain with coughing?
(Epidural solution is Ropivacaine 0.2% + HYDROmorphone 0.010mg/ml; rate 6ml/hr, PCEA 3ml, lockout 15 minutes) incision is midline.Sensory block it T4-
12 bilateral, covering the entire incision. N=57
78
27
79
Bedside Patient Education
• There is not a needle in your back
• Sedation/nausea/vomiting/pruritus NOT from your pain medication
• Leave TEA > 3 days to minimize exposure to opioids
• Outline daily the process of epidural removal.
– What to expect
– How soon to go home
– Considering handing out little “key messages”
80
Clinical Benefits
• No more– Pruritus– Opioid contribution to ileus
• Reduced systemic absorption when using more potent LA concentrations
• No increased motor block observed to date with increased LA concentration
• Reduction in replacement epidurals• Reduction in epidural failure rate• Approximately 15-20% of our major abdominal surgery patients
have no exposure to an opioid during their hospitalization
81
Final Summary
• Epidurals continue to be the main stay for analgesia for many post surgical populations
• It seems they are underutilized in many populations
• We still have not identified the ideal medications/combinations
• Room to improve individuality of epidural analgesia
• Need to dedicate key people to deliver this service and provide continuity of care
• Research should focus on quality of life/recovery, and effect on chronic pain/opioid use
28
82
Thank You
“We cannot do everything at once, but we can do something at once”
(Calvin Coolidge)
“Playing small does not serve the world” (Marianne Williamson)
83
• jason.sawyer@sunnybrook.ca
84
References• 1. Ballantyne JC, McKenna JM, Ryder E: Epidural analgesia-experience of 5628 patients in a large teaching hospital derived through audit. Acute Pain 2003,
4:89-97.
• 2. Basse L, Madsen JL, Kehlet H: Normal gastrointestinal transit after colonic resection using epidural analgesia, enforced oral nutrition and laxative. Br J Surg2001, 88(11):1498-1500.
• 3. Bauer M, George JE, 3rd, Seif J, Farag E: Recent advances in epidural analgesia. Anesthesiol Res Pract 2012, 2012:309219.
• 4. Block BM, Liu SS, Rowlingson AJ, Cowan AR, Cowan JA, Jr., Wu CL: Efficacy of postoperative epidural analgesia: a meta-analysis. Jama 2003, 290(18):2455-2463.
• 5. Breivik H, Niemi G: Does adrenaline improve epidural bupivacaine and fentanyl analgesia after abdominal surgery? Anaesth Intensive Care 2001, 29(4):436-437.
• 6. Brodner G, Van Aken H, Hertle L, Fobker M, Von Eckardstein A, Goeters C, Buerkle H, Harks A, Kehlet H: Multimodal perioperative management--combining thoracic epidural analgesia, forced mobilization, and oral nutrition--reduces hormonal and metabolic stress and improves convalescence after major urologic surgery. Anesth Analg 2001, 92(6):1594-1600.
• 7. Bromage PR, Camporesi EM, Durant PA, Nielsen CH: Influence of epinephrine as an adjuvant to epidural morphine. Anesthesiology 1983, 58(3):257-262.
• 8. Bruce J, Krukowski ZH: Quality of life and chronic pain four years after gastrointestinal surgery. Dis Colon Rectum 2006, 49(9):1362-1370.
• 9. Brull R, McCartney CJ, Chan VW, El-Beheiry H: Neurological complications after regional anesthesia: contemporary estimates of risk. Anesth Analg 2007, 104(4):965-974.
• 10. Burm AG, van Kleef JW, Gladines MP, Olthof G, Spierdijk J: Epidural anesthesia with lidocaine and bupivacaine: effects of epinephrine on the plasma concentration profiles. Anesth Analg 1986, 65(12):1281-1284.
• 11. Camporesi EM, Nielsen CH, Bromage PR, Durant PA: Ventilatory CO2 sensitivity after intravenous and epidural morphine in volunteers. Anesth Analg 1983, 62(7):633-640.
• 12. Carli F, Mayo N, Klubien K, Schricker T, Trudel J, Belliveau P: Epidural analgesia enhances functional exercise capacity and health-related quality of life after colonic surgery: results of a randomized trial. Anesthesiology 2002, 97(3):540-549.
• 13. Carli F, Trudel JL, Belliveau P: The effect of intraoperative thoracic epidural anesthesia and postoperative analgesia on bowel function after colorectal surgery: a prospective, randomized trial. Dis Colon Rectum 2001, 44(8):1083-1089.
• 14. Cashman JN, Dolin SJ: Respiratory and haemodynamic effects of acute postoperative pain management: evidence from published data. Br J Anaesth 2004, 93(2):212-223.
• 15. Clarke H, Woodhouse LJ, Kennedy D, Stratford P, Katz J: Strategies Aimed at Preventing Chronic Post-surgical Pain: Comprehensive Perioperative Pain Management after Total Joint Replacement Surgery. Physiother Can 2011, 63(3):289-304.
• 16. Cohen SP, Christo PJ, Moroz L: Pain management in trauma patients. Am J Phys Med Rehabil 2004, 83(2):142-161.
29
85
• 21. Curatolo M, Scaramozzino P, Venuti FS, Orlando A, Zbinden AM: Factors associated with hypotension and bradycardia after epidural blockade. Anesth Analg 1996, 83(5):1033-1040.
• 22. Dolin SJ, Cashman JN, Bland JM: Effectiveness of acute postoperative pain management: I. Evidence from published data. Br J Anaesth 2002, 89(3):409-423.
• 23. Forster JG, Niemi TT, Aromaa U, Neuvonen PJ, Seppala TA, Rosenberg PH: Epinephrine added to a lumbar epidural infusion of a small-dose ropivacaine-fentanyl mixture after arterial bypass surgery of the lower extremities. Acta Anaesthesiol Scand 2003, 47(9):1106-1113.
• 24. Forster JG, Niemi TT, Salmenpera MT, Ikonen S, Rosenberg PH: An evaluation of the epidural catheter position by epidural nerve stimulation in conjunction with continuous epidural analgesia in adult surgical patients. Anesth Analg 2009, 108(1):351-358.
• 25. Freise H, Van Aken HK: Risks and benefits of thoracic epidural anaesthesia. Br J Anaesth 2011, 107(6):859-868.
• 26. Gordon DB, Dahl JL: Quality improvement challenges in pain management. Pain 2004, 107(1-2):1-4.
• 27. Gordon DB, Dahl JL, Miaskowski C, McCarberg B, Todd KH, Paice JA, Lipman AG, Bookbinder M, Sanders SH, Turk DC et al: American pain society recommendations for improving the quality of acute and cancer pain management: American Pain Society Quality of Care Task Force. Arch Intern Med 2005, 165(14):1574-1580.
• 28. Grass JA: The role of epidural anesthesia and analgesia in postoperative outcome. Anesthesiol Clin North America 2000, 18(2):407-428, viii.
• 29. Hernandez JM, Coyle FP, Wright CD, Ballantyne JC: Epidural abscess after epidural anesthesia and continuous epidural analgesia in a patient with gastric lymphoma. J Clin Anesth 2003, 15(1):48-51.
• 30. Holte K, Foss NB, Svensen C, Lund C, Madsen JL, Kehlet H: Epidural anesthesia, hypotension, and changes in intravascular volume. Anesthesiology 2004, 100(2):281-286.
• 31. Holte K, Kehlet H: Epidural analgesia and risk of anastomotic leakage. Reg Anesth Pain Med 2001, 26(2):111-117.
• 32. Horlocker TT, Burton AW, Connis RT, Hughes SC, Nickinovich DG, Palmer CM, Pollock JE, Rathmell JP, Rosenquist RW, Swisher JL et al: Practice guidelines for the prevention, detection, and management of respiratory depression associated with neuraxial opioid administration. Anesthesiology 2009, 110(2):218-230.
• 33. Jorgensen H, Fomsgaard JS, Dirks J, Wetterslev J, Andreasson B, Dahl JB: Effect of epidural bupivacaine vs combined epidural bupivacaine and morphine on gastrointestinal function and pain after major gynaecological surgery. Br J Anaesth 2001, 87(5):727-732.
• 34. Kanai A, Osawa S, Suzuki A, Ozawa A, Okamoto H, Hoka S: Regression of sensory and motor blockade, and analgesia during continuous epidural infusion of ropivacaine and fentanyl in comparison with other local anesthetics. Pain Med 2007, 8(7):546-553.
• 35. Karmakar MK, Ho AM: Acute pain management of patients with multiple fractured ribs. J Trauma 2003, 54(3):615-625.
• 36. Karsh BT, Holden RJ, Alper SJ, Or CK: A human factors engineering paradigm for patient safety: designing to support the performance of the healthcare professional. Qual Saf Health Care 2006, 15 Suppl 1:i59-65.
• 37. Kehlet H, Holte K: Effect of postoperative analgesia on surgical outcome. Br J Anaesth 2001, 87(1):62-72.
86
• 41. Liu SS, Wu CL: Effect of postoperative analgesia on major postoperative complications: a systematic update of the evidence. Anesth Analg 2007, 104(3):689-702.
• 42. Lowery AE, Starr T, Dhingra LK, Rogak L, Hamrick-Price JR, Farberov M, Kirsh KL, Saltz LB, Breitbart WS, Passik SD: Frequency, characteristics, and correlates of pain in a pilot study of colorectal cancer survivors 1-10 years post-treatment. Pain Med 2013, 14(11):1673-1680.
• 43. Manion SC, Brennan TJ: Thoracic epidural analgesia and acute pain management. Anesthesiology 2011, 115(1):181-188.
• 44. McLeod GA, Cumming C: Thoracic epidural anaesthesia and analgesia. Continuing Education in Anaesthesia, Critical Care & Pain 2004, 4(1):16-21.
• 45. McNicol E, Strassels S, Goudas L, Lau J, Carr D: Nonsteroidal anti-inflammatory drugs, alone or combined with opioids, for cancer pain: a systematic review. J Clin Oncol 2004, 22(10):1975-1992.
• 46. Moiniche S, Hjortso NC, Blemmer T, Dahl JB, Kehlet H: Blood pressure and heart rate during orthostatic stress and walking with continuous postoperative thoracic epidural bupivacaine/morphine. Acta Anaesthesiol Scand 1993, 37(1):65-69.
• 47. Niemi G, Breivik H: Adrenaline markedly improves thoracic epidural analgesia produced by a low-dose infusion of bupivacaine, fentanyl and adrenaline after major surgery. A randomised, double-blind, cross-over study with and without adrenaline. Acta Anaesthesiol Scand 1998, 42(8):897-909.
• 48. Niemi G, Breivik H: Epidural fentanyl markedly improves thoracic epidural analgesia in a low-dose infusion of bupivacaine, adrenaline and fentanyl. A randomized, double-blind crossover study with and without fentanyl. Acta Anaesthesiol Scand 2001, 45(2):221-232.
• 49. Niemi G, Breivik H: Epinephrine markedly improves thoracic epidural analgesia produced by a small-dose infusion of ropivacaine, fentanyl, and epinephrine after major thoracic or abdominal surgery: a randomized, double-blinded crossover study with and without epinephrine. Anesth Analg 2002, 94(6):1598-1605, table of contents.
• 50. Niemi G, Breivik H: The minimally effective concentration of adrenaline in a low-concentration thoracic epidural analgesic infusion of bupivacaine, fentanyl and adrenaline after major surgery. A randomized, double-blind, dose-finding study. Acta Anaesthesiol Scand 2003, 47(4):439-450.
• 51. Niemi TT, Pitkanen M, Syrjala M, Rosenberg PH: Comparison of hypotensive epidural anaesthesia and spinal anaesthesia on blood loss and coagulation during and after total hip arthroplasty. Acta Anaesthesiol Scand 2000, 44(4):457-464.
• 52. Ottesen S: The influence of thoracic epidural analgesia on the circulation at rest and during physical exercise in man. Acta Anaesthesiol Scand 1978, 22(5):537-547.
• 53. Priddle HD, Andros GJ: Primary spinal anesthetic effects of epinephrine. Curr Res Anesth Analg 1950, 29(3):156-162.
• 54. Rao GH, Reddy KR, White JG: The influence of epinephrine on prostacyclin (PGI2) induced dissociation of ADP aggregated plateletes. Prostaglandins Med 1980, 4(6):385-397.
• 55. Rathmell JP, Wu CL, Sinatra RS, Ballantyne JC, Ginsberg B, Gordon DB, Liu SS, Perkins FM, Reuben SS, Rosenquist RW et al: Acute post-surgical pain management: a critical appraisal of current practice, December 2-4, 2005. Reg Anesth Pain Med 2006, 31(4 Suppl 1):1-42.
• 56. Reason J: Understanding adverse events: human factors. Qual Health Care 1995, 4(2):80-89.
87
• 60. Schatz IJ: Orthostatic hypotension. II. Clinical diagnosis, testing, and treatment. Arch Intern Med 1984, 144(5):1037-1041.
• 61. Scott DA, Blake D, Buckland M, Etches R, Halliwell R, Marsland C, Merridew G, Murphy D, Paech M, Schug SA et al: A comparison of epidural ropivacaine infusion alone and in combination with 1, 2, and 4 microg/mL fentanyl for seventy-two hours of postoperative analgesia after major abdominal surgery. Anesth Analg 1999, 88(4):857-864.
• 62. Shipton EA: The transition from acute to chronic post surgical pain. Anaesth Intensive Care 2011, 39(5):824-836.
• 63. Strassels S, McNicol E, Wagner AK, Rogers WB, Gouveia WA, Carr DB: Persistent postoperative pain, health-related quality of life, and functioning 1 month after hospital discharge. Acute Pain 2004, 6:95-104.
• 64. Taqi A, Hong X, Mistraletti G, Stein B, Charlebois P, Carli F: Thoracic epidural analgesia facilitates the restoration of bowel function and dietary intake in patients undergoing laparoscopic colon resection using a traditional, nonaccelerated, perioperative care program. Surg Endosc 2007, 21(2):247-252.
• 65. Tsui SL, Irwin MG, Wong CM, Fung SK, Hui TW, Ng KF, Chan WS, O'Reagan AM: An audit of the safety of an acute pain service. Anaesthesia 1997, 52(11):1042-1047.
• 66. VanDenKerkhof EG, Hopman WM, Reitsma ML, Goldstein DH, Wilson RA, Belliveau P, Gilron I: Chronic pain, healthcare utilization, and quality of life following gastrointestinal surgery. Can J Anaesth 2012, 59(7):670-680.
• 67. VanDenKerkhof EG, Hopman WM, Towheed T, Wilson R, Murdoch J, Rimmer M, Stutzman SS, Tod D, Dagnone V, Goldstein DH: Pain, health-related quality of life and health care utilization after inpatient surgery: a pilot study. Pain Res Manag 2006, 11(1):41-47.
• 68. VIsser EJ: Chronic post-surgical pain: Epidemiology and clinical implications for acute pain management. Acute Pain 2006, 8(2):73-81.
• 69. Visser WA, Lee RA, Gielen MJ: Factors affecting the distribution of neural blockade by local anesthetics in epidural anesthesia and a comparison of lumbar versus thoracic epidural anesthesia. Anesth Analg 2008, 107(2):708-721.
• 70. Visser WA, Liem TH, van Egmond J, Gielen MJ: Extension of sensory blockade after thoracic epidural administration of a test dose of lidocaine at three different levels. Anesth Analg 1998, 86(2):332-335.
• 71. Waurick R, Van Aken H: Update in thoracic epidural anaesthesia. Best Pract Res Clin Anaesthesiol 2005, 19(2):201-213.
• 72. Wu CL, Naqibuddin M, Rowlingson AJ, Lietman SA, Jermyn RM, Fleisher LA: The effect of pain on health-related quality of life in the immediate postoperative period. Anesth Analg 2003, 97(4):1078-1085, table of contents.
• 73. Wu CL, Raja SN: Treatment of acute postoperative pain. Lancet 2011, 377(9784):2215-2225.
• 74. Wu CL, Rowlingson AJ, Partin AW, Kalish MA, Courpas GE, Walsh PC, Fleisher LA: Correlation of postoperative pain to quality of recovery in the immediate postoperative period. Reg Anesth Pain Med 2005, 30(6):516-522.
• 75. Zalon ML: Correlates of recovery among older adults after major abdominal surgery. Nurs Res 2004, 53(2):99-106.
30
88
Photo References
• Slide 13 accessed September 2, 2014 at:– http://www.pinterest.com/greatchoicechir/laughter-is-medicine/
• Slide 27 accessed September 2 2014 at:– https://www.google.ca/search?q=epidural+anatomy+images&newwindow=1&safe=off&tbm=isch&tbo=u&source=univ
&sa=X&ei=0BIGVKOlMpHHgwSqhIKgCQ&ved=0CDYQ7Ak&biw=1280&bih=684#facrc=_&imgdii=5VwGCS8TBELJBM%3A%3B7gSCbhp5TvM54M%3B5VwGCS8TBELJBM%3A&imgrc=5VwGCS8TBELJBM%253A%3BIMLHEmEDJnGhoM%3Bhttp%253A%252F%252Fdroualb.faculty.mjc.edu%252FLecture%252520Notes%252FUnit%2525205%252FFG14_02d.jpg%3Bhttp%253A%252F%252Fdroualb.faculty.mjc.edu%252FLecture%252520Notes%252FUnit%2525205%252Fchapters_14_and_17%252520spinal%252520cord%252520with%252520figures.htm%3B800%3B600
• Slide 27 accessed September 2, 2014 at:– https://www.google.ca/search?newwindow=1&safe=off&hl=en&site=imghp&tbm=isch&source=hp&biw=1280&bih=684&q=epidural
+space+image&oq=epidural+space+&gs_l=img.1.6.0l10.1667.7740.0.10646.21.12.3.6.7.0.188.1032.8j4.12.0....0...1ac.1.52.img..0.21.1069.3abe_IvKSHE#facrc=_&imgdii=_&imgrc=TKnYb0mku79n3M%253A%3B3lLTYnFCpJjZ6M%3Bhttp%253A%252F%252Fwww.castellilaw.com%252Fsites%252Fwww.castellilaw.com%252Ffiles%252F2012%252F11%252Fepidural675325099_1160992062_n3.jpg%3Bhttp%253A%252F%252Fwww.castellilaw.com%252Fblog%252Fcincinnati-injury-attorney-on-the-dangers-of-epidural-steroid-injections.html%3B600%3B3
top related