Adverse events of postoperative thoracic epidural analgesia: A retrospective analysis of 7273 cases in a tertiary care teaching hospital.

BACKGROUND: Thoracic epidural analgesia is a well established technique for postoperative pain relief after major abdominal and thoracic surgery. Safety remains a major concern because of serious adverse events including epidural haematoma, abscess and permanent neurological deficit. OBJECTIVE: The aim of this study was to evaluate the incidence and the long-term outcome of serious adverse events associated with thoracic epidural analgesia. DESIGN: Retrospective cohort study. SETTING: The study was conducted at a single institution, a tertiary care teaching hospital. Data were collected over a 10-year period from 2003 until 2012. PATIENTS: Data from 7430 patients were prospectively entered into a standardised acute pain service database. A total of 7273 study participants met the inclusion criteria and were included in the final analyses. The inclusion criteria involved surgical patients receiving a postoperative thoracic epidural analgesia catheter treatment for pain control. Exclusion criteria were defined as obstetric, non-surgical, non-epidural analgesia patients and epidural analgesia catheters that had not been placed by an anaesthesiologist. MAIN OUTCOME MEASURES: The database was queried for serious adverse events which were defined as spinal or epidural haemorrhage; spinal or epidural abscess; permanent neurological deficits; cardiac arrest; death and incomplete removal of the epidural analgesia catheter. Patients' charts were comprehensively reviewed in case of a major adverse event. Patients with an unclear outcome received a mailed questionnaire or were contacted by telephone to determine long-term sequelae. RESULTS: Seven serious adverse events were identified: epidural abscess [n = 1; incidence 1 : 7273 (0.014%, 95% confidence interval, CI, 0 to 0.08%)], persistent neurological damage [n = 1; incidence 1 : 7273 (0.014%, 95% CI, 0 to 0.08%)], cardiac arrest [n = 1; incidence 1 : 7273 (0.014%, 95% CI, 0 to 0.08%)] and catheter breakage leaving a catheter fragment in situ [n = 4; incidence 1 : 1818 (0.055%, 95% CI, 0.01 to 0.14%)]. Apart from the one patient with persistent neurologic deficit, the patients with serious adverse events associated with thoracic epidural analgesia in our cohort suffered no long-term consequences. CONCLUSION: In our single-centre study of thoracic epidural analgesia, serious adverse events occurred in 0.1% cases (1 : 1000), whereas long-term outcome was compromised in 0.014% (1.4 : 10 000) which is similar to the serious adverse event rates and outcomes reported in the current literature.

Symptoms During or Shortly After Isolated Carpal Tunnel Release and Problems Within 24 hours After Surgery.

This study used the National Survey of Ambulatory Surgery (NSAS) database to measure the incidence of and risk factors for symptoms in the ambulatory surgery center and problems within 24 h after isolated carpal tunnel release (CTR). The NSAS contained records on 400,000 adult patients with carpal tunnel syndrome who were treated with CTR in 2006, based on ICD-9 codes. The type of anesthesia used and factors associated with symptoms and problems were sought in bivariate and multivariable statistical analyses. The mean duration of the procedure was 16 ± 8.8 min. Only 5 % were performed under local anesthesia without sedation, 45 % with IV sedation, 28 % regional anesthesia, and 19 % general anesthesia. Symptoms in the ambulatory surgery center or a problem within 24 h after discharge were recorded in 10 % of patients, all of them minor and transient, including difficulties with pain and its treatment. The strongest risk factors were male sex, age of 45 years and older, and participation of an anesthesiologist. Local anesthesia and regional anesthesia were associated with more perioperative symptoms and postoperative problems. Most CTR are performed with some sedation in the United States. CTR is a safe procedure: one in 10 patients will experience a minor issue in the perioperative or immediate postoperative period.

An open-label comparison of local anesthesia with or without sedation for minor hand surgery.

BACKGROUND: The purpose of this study was to assess satisfaction and pain intensity in patients undergoing minor hand surgery under local anesthesia (LA) with or without sedation. METHODS: Seventy-three adult patients presenting to two hand surgeons were enrolled in this prospective observational study in 2012. They completed questionnaires prior to surgery (current pain intensity, Patient Health Questionnaire-2 (PHQ-2) to measure symptoms of depression, Pain Self-Efficacy Questionnaire (PSEQ) to assess the effective coping strategy of pain self-efficacy) and within 48 h after surgery (satisfaction with surgery, satisfaction with anesthesia, pain during the injection, and pain during the procedure). Thirty-seven patients had carpal tunnel release (bilateral in 3), 22 had release of one or more trigger digits, and 12 had excision of a benign tumor, gouty tophus (1 patient), or foreign body (1 patient). Forty-six patients chose LA and 27 chose LA with sedation. RESULTS: There was no difference in satisfaction with surgery or anesthesia by the type of anesthesia. Satisfaction with surgery was associated with older age alone. Satisfaction with anesthesia was associated with no prior surgery for the same condition. Pain during injection and during the procedure were significantly higher without sedation. Pain during injection was associated with younger age and LA. No factors were associated with pain during the procedure. CONCLUSIONS: Patients that had local anesthesia immediately prior to incision with tourniquet use during surgery had more pain during the procedure but were equally satisfied on average with surgery and with anesthesia compared to patients that had sedation.

Combined bendamustine, prednisolone and thalidomide for refractory or relapsed multiple myeloma after autologous stem-cell transplantation or conventional chemotherapy: results of a Phase I clinical trial.

Thalidomide is an effective agent for advanced refractory or relapsed multiple myeloma (MM), although dose-limiting toxicity (DLT) may limit its use. This Phase I study found that a combination of low-dose thalidomide with bendamustine and prednisolone (BPT) maintained or increased efficacy, whilst avoiding DLT in 28 patients with MM that was refractory or that had relapsed after conventional chemotherapy or high-dose therapy with stem-cell support. BPT comprised fixed doses of bendamustine (60 mg/m(2)) and prednisolone (100 mg), and escalating doses of thalidomide (50, 100, 200 mg). Treatment cycles were repeated every 28 d until the occurrence of maximum response, DLT, or disease progression. Twenty-four patients responded after at least two cycles (four complete remission, six very good partial remission, 14 partial remission). Median progression-free and overall survival for all patients was 11 and 19 months respectively. Only mild/moderate non-haematological side effects were observed and no patient developed dose-limiting haematotoxicity. Transient grade 3-4 neutropenia was reported in 12 patients, and grade 3-4 thrombocytopenia occurred in two patients. We conclude that BPT therapy was well tolerated in patients with relapsed or refractory MM, with a response rate higher than 80%. The maximum tolerated dose of thalidomide was not reached in this study.