The Impact of Epidural Analgesia on the Rate of Thromboembolism without Chemical Thromboprophylaxis in Major Oncologic Surgery.

Patients with abdominopelvic cancers are at increased risk of venous thromboembolism (VTE) due to their malignancy. We evaluated outcomes and the rate of VTE in patients undergoing abdominopelvic surgery for malignancy with preoperative epidural analgesia without postoperative chemical VTE prophylaxis. A retrospective review between 2009 and 2015 identified 285 patients with malignancy who underwent abdominopelvic surgery by a single surgeon (AWS). Lower extremity venous duplex scans (VDS) were performed preoperatively and before discharge. Demographics, procedures, and VTE outcomes were reviewed. The median age was 66 years. The average operative time was 315 minutes. All patients ambulated on postoperative day (POD) one or two. Epidural catheters (ECs) were removed on postoperative day four or five. No patient received VTE prophylaxis while an epidural catheter was in place. Preoperative lower extremity VDS revealed above-knee deep vein thrombosis (DVT) in seven patients (2.5%). Postoperative lower extremity VDS revealed acute DVT in 24 patients (8.4%): nine (3.2%) above-knee and 15 (5.2%) below-knee. The nine patients with above-knee DVT were anticoagulated after epidural removal. No patient developed a pulmonary embolism. Our data suggest that patients undergoing major open operations with epidural analgesia have low rates of DVT and may obviate the need for chemical prophylaxis. However, larger studies are required to determine the overall effects of epidural analgesia on the development of DVTs postoperatively.

Propofol versus midazolam for premedication: a placebo­controlled, randomized double­blinded study.

BACKGROUND: It has been previously reported that subhypnotic doses of propofol could offer an advantage over midazolam for premedication. This study was designed to test the hypothesis that a 20 mg IV dose of propofol would be more effective than a standard 2 mg IV dose of midazolam for reducing acute anxiety prior to induction of anesthesia. METHODS: One hundred twenty outpatients scheduled to undergo orthopedic surgery were randomly assigned to one of three study groups: control (saline); propofol (20 mg); or midazolam (2 mg). Immediately before administering the study medication, each patient evaluated their level of acute anxiety and sedation on 11­point verbal rating scales (VRSs) 0=none- 10=highest, and they were also shown a picture. Upon arrival in the OR ~5 min after administering the study medication, anxiety and sedation levels were reassessed and a second picture was shown. At discharge from the recovery area, anxiety and sedation levels and their ability to recall the two pictures were reassessed. RESULTS: Compared to the saline group, both propofol and midazolam produced significant increases in the patient's level of sedation upon entering the OR (+2.5±2.4 vs. +4.6±2.5 and +5.2±2.3, respectively [p<0.001]). Propofol was effective as midazolam compared to saline in reducing the patient's level of preinduction anxiety (from 3.2±2.2 to1.8±1.8 vs. 3.1±2.2 to 2.3±2.1 and 2.7±1.8 to 2.8±2.1, respectively). Propofol produced more pain on injection and midazolam significantly reduced recall of the second picture. CONCLUSIONS: When administered ~5 min prior to entering the OR, propofol, 20mg IV, was as effective as midazolam 2mg IV in reducing anxiety.

Thromboprophylaxis and major oncologic surgery performed with epidural analgesia.

OBJECTIVE: To evaluate clinical outcomes in patients with cancer undergoing major abdominal surgery who received preoperative indwelling epidural catheters (ECs) and no postoperative thromboprophylaxis. DESIGN: Retrospective analysis of a prospective database. SETTING: Tertiary referral medical center. PATIENTS Between January 1, 2009, and July 31, 2011, 119 patients, with a mean age of 64.5 years (range, 34-95 years), underwent major abdominal oncologic surgery with an indwelling EC. MAIN OUTCOME MEASURES: Records of all patients were reviewed for age, duration of surgery, hospital length of stay, and clinical outcomes. All patients underwent lower extremity venous duplex ultrasonography prior to hospital discharge. RESULTS: The average operative time was 338 minutes. Mean (SD) intensive care unit stay was 2.8 (1.4) days (range, 1-7 days). Patients ambulated by postoperative day 1 or 2. Most ECs were removed on postoperative day 4. There were no major complications from the EC. Fifty-two patients (44%) were treated with deep venous thrombosis prophylaxis on postoperative day 4 after removal of the EC. Lower extremity duplex studies showed 8 patients (6.7%) had an acute thrombus. One patient (0.8%) developed an asymptomatic proximal deep venous thrombosis and 7 patients (5.9%) developed distal superficial thrombi. No patient developed a pulmonary embolus. CONCLUSIONS Thromboembolic complications following major abdominal surgery for cancer may be reduced with the use of ECs. Epidural catheters may directly prevent deep venous thrombosis through sympathetic blockade, resulting in increased blood flow to the lower extremities. This effect may also be attributable to earlier ambulation. These results suggest that patients who have an EC and do not receive concurrent postoperative thromboprophylaxis do not have an increased risk for thromboembolic events.