Comparison between epidural and intravenous analgesia effects on disease-free survival after colorectal cancer surgery: a randomised multicentre controlled trial.

BACKGROUND: Thoracic epidural analgesia (TEA) has been suggested to improve survival after curative surgery for colorectal cancer compared with systemic opioid analgesia. The evidence, exclusively based on retrospective studies, is contradictory. METHODS: In this prospective, multicentre study, patients scheduled for elective colorectal cancer surgery between June 2011 and May 2017 were randomised to TEA or patient-controlled i.v. analgesia (PCA) with morphine. The primary endpoint was disease-free survival at 5 yr after surgery. Secondary outcomes were postoperative pain, complications, length of stay (LOS) at the hospital, and first return to intended oncologic therapy (RIOT). RESULTS: We enrolled 221 (110 TEA and 111 PCA) patients in the study, and 180 (89 TEA and 91 PCA) were included in the primary outcome. Disease-free survival at 5 yr was 76% in the TEA group and 69% in the PCA group; unadjusted hazard ratio (HR): 1.31 (95% confidence interval [CI]: 0.74-2.32), P=0.35; adjusted HR: 1.19 (95% CI: 0.61-2.31), P=0.61. Patients in the TEA group had significantly better pain relief during the first 24 h, but not thereafter, in open and minimally invasive procedures. There were no differences in postoperative complications, LOS, or RIOT between the groups. CONCLUSIONS: There was no significant difference between the TEA and PCA groups in disease-free survival at 5 yr in patients undergoing surgery for colorectal cancer. Other than a reduction in postoperative pain during the first 24 h after surgery, no other differences were found between TEA compared with i.v. PCA with morphine.

The Effect of the No Pain Labor & Delivery-Global Health Initiative on Cesarean Delivery and Neonatal Outcomes in China: An Interrupted Time-Series Analysis.

BACKGROUND: The proportion of live births by cesarean delivery (CD) in China is significant, with some, particularly rural, provinces reporting up to 62.5%. The No Pain Labor & Delivery-Global Health Initiative (NPLD-GHI) was established to improve obstetric and neonatal outcomes in China, including through a reduction of CD through educational efforts. The purpose of this study was to determine whether a reduction in CD at a rural Chinese hospital occurred after NPLD-GHI. We hypothesized that a reduction in CD trend would be observed. METHODS: The NPLD-GHI program visited the Weixian Renmin Hospital, Hebei Province, China, from June 15 to 21, 2014. The educational intervention included problem-based learning, bedside teaching, simulation drill training, and multidisciplinary debriefings. An interrupted time-series analysis using segmented logistic regression models was performed on data collected between June 1, 2013 and May 31, 2015 to assess whether the level and/or trend over time in the proportion of CD births would decline after the program intervention. The primary outcome was monthly proportion of CD births. Secondary outcomes included neonatal intensive care unit (NICU) admissions and extended NICU length of stay, neonatal antibiotic and intubation use, and labor epidural analgesia use. RESULTS: Following NPLD-GHI, there was a level decrease in CD with an estimated odds ratio (95% confidence interval [CI]) of 0.87 (0.78-0.98), P = .017, with odds (95% CI) of monthly CD reduction an estimated 3% (1-5; P < .001), more in the post- versus preintervention periods. For labor epidural analgesia, there was a level increase (estimated odds ratio [95% CI] of 1.76 [1.48-2.09]; P < .001) and a slope decrease (estimated odds ratio [95% CI] of 0.94 [0.92-0.97]; P < .001). NICU admissions did not have a level change (estimated odds ratio [95% CI] of 0.99 [0.87-1.12]; P = .835), but the odds (95% CI) of monthly reduction in NICU admission was estimated 9% (7-11; P < .001), greater in post- versus preintervention. Neonatal intubation level and slope changes were not statistically significant. For neonatal antibiotic administration, while the level change was not statistically significant, there was a decrease in the slope with an odds (95% CI) of monthly reduction estimated 6% (3-9; P < .001), greater post- versus preintervention. CONCLUSIONS: In a large, rural Chinese hospital, live births by CD were lower following NPLD-GHI and associated with increased use of labor epidural analgesia. We also found decreasing NICU admissions. International-based educational programs can significantly alter practices associated with maternal and neonatal outcomes.

Evolving pediatric epidural practice: An institution's clinical experience over 20 years-A retrospective observational cohort study.

BACKGROUND AND OBJECTIVES: Epidural analgesia is an effective, established perioperative intervention in all age-groups. In children, however, epidural-related data are limited compared to the adult population. The aim of this study was to examine the use of pediatric epidural analgesia in our institution and, thereby, add to the existing data pool. METHODOLOGY: Patients who received epidural analgesia as part of their perioperative management between 1996 and 2016 at Great Ormond Street Hospital, London, UK, were studied to determine how epidural practice has changed over time, associated incidence of serious adverse events, complications, and patient/parent satisfaction. Epidural use and monitoring were in accordance with standard hospital protocols. Data were prospectively collected and entered into a secure database by trained personnel. These data were subsequently extracted for retrospective analysis. RESULTS: A total of 3876 patients were included. The median age was 4.4 years (range 1 day to 20 years), and the median weight was 20.3 kg. Across all age-groups, the lumbar region was the most common site of epidural insertion while urology (42.2%) and general surgery (37.3%) were the specialities for which it was most utilized. Over the study period, the number of epidurals performed declined while the number of surgical procedures performed simultaneously increased. The infusate most commonly used was local anesthetic with preservative-free morphine (71.9%). In 923 (23.2%) patients, systemic opioids were additionally used for analgesic management by means of patient-controlled analgesia or nurse-controlled analgesia. There was one serious adverse event in the form of permanent nerve injury, giving an overall incidence of approximately 1:3800. Other complications included postoperative nausea and vomiting (35.9%), urinary retention (4.4%), and pruritus (31%). Overall global satisfaction with the service was generally high, with 95% providing a rating of "very good" or "good." CONCLUSION: This study evaluated two decades of epidural practice in our institution. Epidural analgesia remains a safe, effective option for postoperative analgesia, but its use has declined over time, and this trend is likely to continue. Rates of serious adverse events and complications were low and comparable to those published in other similar studies. Global satisfaction among patients/parents remains high.

Labour analgesia: update and literature review.

Pain relief is an important component of modern obstetric care and can be produced by neuraxial, systemic, or inhalational analgesia or various physical techniques. We review the most recent evidence on the efficacy and safety of these techniques. Over the past decade, the availability of safer local anaesthetics, ultra-short acting opioids, combined spinal-epidural needles, patient-controlled analgesic devices, and ultrasound have revolutionised obstetric regional analgesia. Recent meta-analyses have supported epidural analgesia as the most efficacious technique, as it leads to higher maternal satisfaction and good maternal and fetal safety profiles. We examine the controversies and myths concerning the initiation, maintenance, and discontinuation of epidural analgesia. Recent evidence will also be reviewed to address concerns about the effects of epidural analgesia on the rates of instrumental and operative delivery, lower back pain, and breastfeeding. New developments in labour analgesia are also discussed.

The Effect of Labor Epidural Analgesia on Breastfeeding Outcomes: A Prospective Observational Cohort Study in a Mixed-Parity Cohort.

BACKGROUND: The effect of labor epidural analgesia (LEA) on successful breastfeeding has been evaluated in several studies with divergent results. We hypothesized that LEA would not influence breastfeeding status 6 weeks postpartum in women who intended to breastfeed in an environment that encourages breastfeeding. METHODS: In this prospective observational cohort study, a total of 1204 women intending to breastfeed, delivering vaginally with or without LEA, were included; breastfeeding was recorded at 3 days and 6 weeks postpartum. Primary outcome was breastfeeding at 6 weeks, and the χ test was used for comparisons between women delivering with and without LEA, according to parity status and previous breastfeeding experience. Total epidural fentanyl dose and oxytocin use (yes/no) were recorded. A multivariable logistic regression was performed to assess factors affecting breastfeeding at 6 weeks. RESULTS: The overall breastfeeding rate at 6 weeks was 76.9%; it was significantly lower among women delivering with LEA (74.0%) compared with women delivering without LEA (83.4%; P < .001). Among 398 nulliparous women, 84.9% delivered with LEA, compared with 61.8% of multiparous women (P < .001). Multiparous women (N = 806) were more likely to breastfeed at 6 weeks (80.0% vs 70.6% nullipara; P < .001). Using multivariable logistic regression that accounted for 14 covariates including parity, and an interaction term between parity and LEA use, LEA was significantly associated with reduced breastfeeding at 6 weeks (odds ratio, 0.60; 95% confidence interval, 0.40-0.90; P = .015). In a modified multivariable logistic regression where parity was replaced with previous breastfeeding experience, both as a covariate and in the interaction term, only previous breastfeeding experience was associated with increased breastfeeding at 6 weeks (odds ratio, 3.17; 95% confidence interval, 1.72-5.80; P < .001). CONCLUSIONS: In our mixed-parity cohort, delivering with LEA was associated with reduced likelihood of breastfeeding at 6 weeks. However, integrating women's previous breastfeeding experience, the breastfeeding rate was not different between women delivering with and without LEA among the subset of multiparous women with previous breastfeeding experience. Therefore, our findings suggest that offering lactation support to the subset of women with no previous breastfeeding experience may be a simple approach to improve breastfeeding success. This concept subscribes to the notion that women at risk for an undesired outcome be offered tailored interventions with a personalized approach.

Effect of Epidural Infusion Bolus Delivery Rate on the Duration of Labor Analgesia: A Randomized Clinical Trial.

BACKGROUND: Programmed intermittent boluses of local anesthetic have been shown to be superior to continuous infusions for maintenance of labor analgesia. High-rate epidural boluses increase delivery pressure at the catheter orifice and may improve drug distribution in the epidural space. We hypothesized that high-rate drug delivery would improve labor analgesia and reduce the requirement for provider-administered supplemental boluses for breakthrough pain. METHODS: Nulliparous women with a singleton pregnancy at a cervical dilation of less than or equal to 5 cm at request for neuraxial analgesia were eligible for this superiority-design, double-blind, randomized controlled trial. Neuraxial analgesia was initiated with intrathecal fentanyl 25 µg. The maintenance epidural solution was bupivacaine 0.625 mg/ml with fentanyl 1.95 µg/ml. Programmed (every 60 min) intermittent boluses (10 ml) and patient controlled bolus (5 ml bolus, lockout interval: 10 min) were administered at a rate of 100 ml/h (low-rate) or 300 ml/h (high-rate). The primary outcome was percentage of patients requiring provider-administered supplemental bolus analgesia. RESULTS: One hundred eight women were randomized to the low- and 102 to the high-rate group. Provider-administered supplemental bolus doses were requested by 44 of 108 (40.7%) in the low- and 37 of 102 (36.3%) in the high-rate group (difference -4.4%; 95% CI of the difference, -18.5 to 9.1%; P = 0.67). Patient requested/delivered epidural bolus ratio and the hourly bupivacaine consumption were not different between groups. No subject had an adverse event. CONCLUSIONS: Labor analgesia quality, assessed by need for provider- and patient-administered supplemental analgesia and hourly bupivacaine consumption was not improved by high-rate epidural bolus administration.

Labor Analgesia as a Predictor for Reduced Postpartum Depression Scores: A Retrospective Observational Study.

BACKGROUND: Using labor, epidural analgesia has been linked to a reduced risk of postpartum depression, but the role of labor pain relief in this association remains unclear. The goal of this study was to test the hypothesis that effective epidural analgesia during labor is associated with reduced postpartum depression symptomatology. METHODS: A single, institutional, retrospective, observational cohort design was chosen. The primary outcome was Edinburgh postnatal depression scale (EPDS) score, measured at the 6-week postpartum visit. Subjects included in the final analysis had (1) received labor epidural analgesia; (2) pain assessed during labor both before and during initiation of labor epidural analgesia by 0-10 numeric rating scores; and (3) depression risk assessed by the EPDS and documented at their 6-week postpartum visit. Simple and multiple linear regression was used to identify the best model for assessing the association between pain improvement, defined as percent improvement in pain (PIP), and depression, after adjusting for a history of anxiety or depression, other psychiatric history, abuse, trauma, mode of delivery, and other maternal or fetal comorbid diseases. RESULTS: Two hundred one patients were included in the final analysis. Women with higher improvements in pain were associated with lower EPDS scores (r = 0.025; P = .002). Variables known to be associated with depression (body mass index, anxiety and/or depression, third- and fourth-degree perineal lacerations, and anemia) were significantly correlated with EPDS score and included in the final model. After we adjusted for these covariates, PIP remained a significant predictor of EPDS score (r = 0.49; P = .008), accounting for 6.6% of the variability in postpartum depression scores. The full model including pain, body mass index, anxiety and/or depression, perineal lacerations, and anemia explained 24% of the variability in postpartum depression scores. CONCLUSIONS: Although the extent of labor pain relief by epidural analgesia predicts lower postpartum depression scores, the relative contribution of PIP to risk for postpartum depression symptoms may be less than other established risk factors for depression. These data support that the clinical significance of labor analgesia in the development of postpartum depression needs to be more clearly defined.

Epidural Space Identification With Loss of Resistance Technique for Epidural Analgesia During Labor: A Randomized Controlled Study Using Air or Saline-New Arguments for an Old Controversy.

BACKGROUND: The best technique to identify the epidural space for labor analgesia is still unclear despite the publication of various randomized controlled studies and meta-analyses. Our aim was to assess the superiority of the saline loss of resistance (SLOR) technique over the air loss of resistance (ALOR) technique with respect to the quality of the block. METHODS: Consenting parturients admitted to our obstetric suite for spontaneous or induced labor were randomized to receive epidural analgesia using either the ALOR or SLOR technique. Our primary outcome was to compare the impact of the SLOR and ALOR technique on pain score improvement measured 30 minutes after administration of epidural block. Our secondary outcomes included the density of motor blockade and analgesic efficacy measured at 30 minutes. Primary and secondary outcomes were compared using the Student t test and Mann-Whitney U test. Statistical significance was set at P < .017 for primary and secondary outcomes, considering Bonferroni correction for multiple comparisons. Other comparisons were considered exploratory. RESULTS: Four hundred parturients were included; 24 were excluded from the final analysis. After 30 minutes, pain score reduction (ALOR, 4.7 ± 2.9/10; SLOR, 4.9 ± 3.0/10; P = .49), motor block (ALOR, 1.4 ± 0.8; SLOR, 1.3 ± 0.8; P = .27), and efficacy of the block (ALOR, 1.0 ± 0.7; SLOR, 1.0 ± 0.6; P = .87) did not differ significantly between groups. CONCLUSIONS: Pain score reduction after 30 minutes and onset of the block were not affected by the technique used to locate the epidural space.

Trends in practice and safety measures of epidural analgesia: Report of a national survey.

BACKGROUND: The clinical use of epidural analgesia has changed over past decades. Minimally invasive surgery and emergence of alternative analgesic techniques have led to an overall decline in its use. In addition, there is increasing awareness of the patient-specific risks for complications such as spinal haematoma and abscess. Local guidelines for management of severe neurological complications during or after epidural analgesia, ie, "epidural alert systems", have been introduced in hospitals to coordinate and potentially streamline early diagnosis and treatment. How widely such protocols have been implemented in daily practice is unknown. METHODS: We conducted a survey to analyse trends in practice, key indications, safety measures, safety reporting, and management of complications of epidural analgesia in the Netherlands. Data were gathered using a web-based questionnaire and analysed using descriptive statistics. RESULTS: Questionnaires from 85 of all 94 Dutch hospitals performing epidural analgesia were collected and analysed, a 90% response rate. Fifty-five percent reported a trend towards decreased use of perioperative epidural analgesia, while 68% reported increasing use of epidural analgesia for labour. Reported key indications for epidural analgesia were thoracotomy, upper abdominal laparotomy, and abdominal cancer debulking. An epidural alert system for neurological complications of epidural analgesia was available in 45% of hospitals. CONCLUSIONS: This national audit concerning use and safety of epidural analgesia demonstrates that a minority of Dutch hospitals have procedures to manage suspected neurological complications of epidural analgesia, whereas in the remaining hospitals responsibilities and timelines for management of epidural emergencies are determined on an ad hoc basis.

Obstetric interventions, trends, and drivers of change: A 20-year population-based study from Iceland.

BACKGROUND: Population data on obstetric interventions is often limited to cesarean delivery. We aimed to provide a more comprehensive overview of trends in use of several common obstetric interventions over the past 2 decades. METHODS: The study was based on nationwide data from the Icelandic Medical Birth Register. Incidence of labor induction, epidural analgesia, cesarean, and instrumental delivery was calculated for all births in 1995-2014. Change over time was expressed as relative risk (RR), using Poisson regression with 95% confidence intervals (CI) adjusted for several maternal and pregnancy-related characteristics. Analyses were stratified by women's parity and diagnosis of diabetes or hypertensive disorder. RESULTS: During the study period, there were 81 389 intended vaginal births and 5544 elective cesarean deliveries. Among both primiparous and multiparous women, we observed a marked increase across time for labor induction (RR 1.78 [CI 1.67-1.91] and RR 1.83 [CI 1.73-1.93], respectively) and epidural analgesia (RR 1.40 [CI 1.36-1.45] and RR 1.74 [CI 1.66-1.83], respectively). A similar trend of smaller magnitude was observed among women with hypertensive disorders but no time trend was observed among women with diabetes. Incidence of cesarean and instrumental delivery remained stable across time. DISCUSSION: The use of labor induction and epidural analgesia increased considerably over time, while the cesarean delivery rate remained low and stable. Increases in labor induction and epidural analgesia were most pronounced for women without a diagnosis of diabetes or hypertensive disorder and were not explained by maternal characteristics such as advanced age.

Survey of Postoperative Regional Analgesia for Thoracoscopic Surgeries in Canada.

OBJECTIVES: To determine the preferences and perceptions regarding analgesic options for video-assisted thoracic surgery (VATS) among thoracic anesthesiologists in Canada. DESIGN: A cross-sectional survey of thoracic anesthesiologists with 30 multiple choice questions was e-mailed through an online survey tool called FluidSurveys was performed to members of the Canadian Anesthesiologists' Society. SETTING: A nationwide survey. PARTICIPANTS: Members of Canadian Anesthesiologists' Society who provide thoracic anesthesia INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Participant characteristics and outcomes are described using counts and percentages. The frequency of use of each technique for each surgical category is described in percentages and 95% confidence intervals. Based on the responses obtained from individual centers, approximately 469 anesthesiologists provided thoracic care in Canada at the time of the survey. The response rate to the survey was 19% (n = 89). Epidural analgesia was preferred by 93.42% (95% CI 85-98) for open surgeries compared with 41% (30-52) for VATS lobectomies. The difference was statistically significant-52% (37-67). Patient-controlled analgesia was preferred by 27% (19-39) for VATS lobectomies and 46% (35-57) for VATS minor resections. Only 14% preferred paravertebral block for any VATS surgeries. CONCLUSIONS: The use of analgesic techniques for VATS surgeries is variable and largely dictated by provider preferences. The majority still prefer epidural analgesia compared with paravertebral catheter (placed either by the anesthesiologist or surgeon). A broadly acceptable choice that is effective, safe, and technically less demanding requires comparative effectiveness studies and more uniform training for physicians.

Gastrointestinal motility following thoracic surgery: the effect of thoracic epidural analgesia. A randomised controlled trial.

BACKGROUNDS: Impairment of gastrointestinal (GI) motility is an undesirable but inevitable consequence of surgery. This prospective randomised controlled study tested the hypothesis that postoperative thoracic epidural analgesia (TEA) with ropivacaine or a combination of ropivacaine and morphine accelerates postoperative GI function and shortens the duration of postoperative ileus following major thoracic surgery compared to intravenous (IV) morphine. METHODS: Thirty patients scheduled for major thoracic surgery were randomised to three groups. All patients had bowel motility assessments 1 week preoperatively. All patients received general anaesthesia. Group Ep-R received TEA with ropivacaine; group Ep-RM received TEA with ropivacaine and morphine and group IV-M received IV morphine via patient controlled analgesia pump (PCA). Bowel motility was assessed by clinical examination in addition to oro-ceacal transit time (OCTT) on the first and third postoperative days and colonic transit time (CTT). RESULTS: Overall the OCTT demonstrated a 2.5-fold decrease in bowel motility on the first postoperative day. The OCTT test revealed statistically significant differences between all groups (Ep-R vs Ep-RM, p = 0.43/Ep-R vs IV-M, p = 0.039 / Ep-RM vs IV-M, p < 0.001). Also, very significant differences were found in the OCCT test between days (Ep-R vs Ep-RM, p < 0.001/Ep-R vs IV-M, p < 0.001 / Ep-RM vs IV-M, p = 0.014). There were no significant differences in the CTT test or the clinical signs between groups. However, 70% of the patients in the Ep-R group and 80% in the Ep-RM group defecated by the third day compared to only 10% in the IV-M group, (p = 0.004). CONCLUSIONS: Objective tests demonstrated the delayed motility of the whole GI system postoperatively following thoracic surgery. They also demonstrated that continuous epidural analgesia with or without morphine improved GI motility in comparison to intravenous morphine. These differences were more pronounced on the third postoperative day. TRIAL REGISTRATION: ISRCTN number: 11953159 , retrospectively registered on 20/03/2017.

Epidural Hematoma and Abscess Related to Thoracic Epidural Analgesia: A Single-Center Study of 2,907 Patients Who Underwent Lung Surgery.

OBJECTIVE: To report the major complications (epidural hematoma and abscess) of postoperative thoracic epidural analgesia in patients who underwent lung surgery. DESIGN: Prospective, monocentric study. SETTING: A university hospital. PARTICIPANTS: All lung surgical patients who received postoperative thoracic epidural analgesia between November 2007 and November 2015. INTERVENTIONS: Thoracic epidural analgesia for patients who underwent lung surgery. MEASUREMENTS AND MAIN RESULTS: During the study period, data for 2,907 patients were recorded. The following 3 major complications were encountered: 1 case of epidural hematoma (0.34 case/1,000; 95% confidence interval 0.061-1.946), for which surgery was performed, and 2 cases of epidural abscesses (0.68 case/1,000; 95% confidence interval 0.189-2.505), which were treated medically. CONCLUSIONS: The risk range of serious complications was moderate; only the patient who experienced an epidural hematoma also experienced permanent sequelae.

Obstetric analgesia - update 2016.

Neuraxial labor analgesia can be initiated via combined spinal-epidural (CSE) or stand-alone epidural. Pros and cons of these techniques are outlined in this review. In recent years computer-integrated patient-controlled epidural analgesia (CI-PCEA) and programed intermittent epidural boluses (PIEB) have been developed, adding to continuous infusion and PCEA for the maintenance of neuraxial analgesia. Postdural puncture headache (PDPH) and fever can occur secondary to labor epidural that both have clinical relevance for the care givers. Insights into the mechanism of epidural fever and treatment strategies for PDPH are outlined. Due to the increase in obesity the specific considerations for this patient group are discussed. New data have been presented for remifentanil, an ultra-shortly acting opioid, that is used in obstetric analgesia. Without breaking new data, the use of nitrous oxide especially by midwives has a kind of renaissance, and this will be discussed, too.

Neuraxial analgesia effects on labour progression: facts, fallacies, uncertainties and the future.

Approximately 60% of women who labour in the USA receive some form of neuraxial analgesia, but concerns have been raised regarding whether it negatively impacts the labour and delivery process. In this review, we attempt to clarify what has been established as truths, falsities and uncertainties regarding the effects of this form of pain relief on labour progression, negative and/or positive. Additionally, although the term 'epidural' has become synonymous with neuraxial analgesia, we discuss two other techniques, combined spinal-epidural and continuous spinal analgesia, that are gaining popularity, as well as their effects on labour progression.

Anesthesia for cesarean delivery in the Czech Republic: a 2011 national survey.

BACKGROUND: The purpose of this national survey was to determine current anesthesia practices for cesarean delivery in the Czech Republic. METHODS: In November 2011, we invited all departments of obstetric anesthesia in the Czech Republic to participate in a prospective study to monitor consecutive peripartum obstetric anesthesia procedures. Data were recorded online in the TrialDB database (Yale University, New Haven, CT). RESULTS: The response rate was 51% (49 of 97 departments); participating centers represented 60% of all births in the country during the study period. There were 1943 cases of peripartum anesthesia care, of which 1166 cases (60%) were anesthesia for cesarean delivery. Estimates were weighted based on population distribution of cesarean delivery among types of participating centers. Neuraxial anesthesia was used in 55.6% (95% confidence interval [CI], 52.8%-58.5%); the distribution of anesthesia techniques differed among type of participating center. The rate of neuraxial anesthesia in university hospitals was 55.6% (95% CI, 51.5%-59.6%), 32.4% (95% CI, 26.4%-39.0%) in regional hospitals, and 60.7% (95% CI, 55.2%-66.0%) in local hospitals. The reasons for cesarean delivery under general anesthesia were emergency procedure (67%), refusal of neuraxial blockade by parturient (30%), failure of neuraxial anesthesia (6%), and preoperative administration of low-molecular-weight heparin (3%). Postcesarean analgesia was primarily provided by systemic opioid (66%) and nonopioid analgesics (61%), solely or in combination. Epidural postoperative analgesia was used in 14% of cases. Compared with national neuraxial anesthesia rate data published in the 1990s (6.7% in 1993), there has been an upward trend in the use of neuraxial anesthesia for cesarean delivery during the 21st century (40.5% in 2000) in the Czech Republic. CONCLUSIONS: The rate of neuraxial anesthesia use for cesarean delivery has increased in the Czech Republic in the last 2 decades. However, the current rate of general anesthesia is high compared with other Western countries.

The efficacy and safety of epidural-based analgesia in a case series of patients undergoing lung transplantation.

OBJECTIVE: Successful pain management after lung transplantation is critical to ensure adequate respiratory effort and graft expansion. The authors investigated whether thoracic epidural analgesia (TEA) provided adequate pain control after lung transplantation without added morbidity. DESIGN: Retrospective review. SETTING: University teaching hospital. PARTICIPANTS: One hundred twenty-three patients who presented to this institution for lung transplantation from January 2008 to June 2013. INTERVENTIONS: Patient demographics, postoperative pain scores, and epidural-related complications were abstracted from the institutional electronic database. The authors used the previously validated Quality of Recovery (QoR) score and Visual Analog Scale (VAS) as measures of recovery. MEASUREMENTS AND MAIN RESULTS: Of the 123 patients who underwent lung transplantation in this time frame, 119 patients had thoracic epidurals placed for postoperative analgesia. The mean age was 49.4 years (range, 18-73), and 60 (50.4%) were male. The most common indications for transplant were pulmonary fibrosis (33.6%), cystic fibrosis (26.1%), and chronic obstructive pulmonary disease (20.2%). The median length of stay in the intensive care unit and duration of mechanical ventilation were 21 and 1.2 days, respectively. Eight (6.7%) patients experienced postoperative pulmonary compromise (eg, pneumonia, prolonged intubation). No serious complications were associated with TEA placement. On days 1, 3, and 7 after TEA placement, the mean QoR was 7.6, 9.4, and 9.7, and the mean VAS was 2.5, 2.1, and 2.0, respectively. CONCLUSIONS: In this case series, the authors observed excellent analgesia and no serious complications associated with TEA. Therefore, an epidural-centric approach to pain control after lung transplantation should be considered in appropriate patients.

Early removal of urinary catheter after surgery requiring thoracic epidural: a prospective trial.

OBJECTIVES: To prevent urinary retention, urinary catheters commonly are removed only after thoracic epidural discontinuation after thoracotomy. However, prolonged catheterization increases the risk of infection. The purpose of this study was to determine the rates of urinary retention and catheter-associated infection after early catheter removal. DESIGN: This study described a prospective trial instituting an early urinary catheter removal protocol compared with a historic control group of patients. SETTING: The protocol was instituted at a single, academic thoracic surgery unit. PARTICIPANTS: The study group was comprised of patients undergoing surgery requiring thoracotomy who received an intraoperative epidural for postoperative pain control. INTERVENTIONS: An early urinary catheter removal protocol was instituted prospectively, with all catheters removed on or before postoperative day 2. Urinary retention was determined by bladder ultrasound and treated with recatheterization. MEASUREMENTS AND MAIN RESULTS: The primary outcomes were urinary retention rate, defined as bladder volume>400 mL, and urinary tract infection rate. Results were compared with a retrospective cohort of 210 consecutive patients who underwent surgery before protocol initiation. Among the 101 prospectively enrolled patients, urinary retention rate was higher (26.7% v 12.4%, p = 0.003), while urinary tract infection rate improved moderately (1% v 3.8%, p = 0.280). CONCLUSIONS: Early removal of urinary catheters with thoracic epidurals in place is associated with a high incidence of urinary retention. However, an early catheter removal protocol may play a role in a multifaceted approach to reducing the incidence of catheter-associated urinary tract infections.

Seven years of patient-controlled epidural analgesia in a Swedish hospital: a prospective survey.

BACKGROUND: Epidural analgesia for postoperative pain relief needs to be monitored regularly in order to evaluate benefits and avoid potential hazards. OBJECTIVES: To evaluate efficacy and safety profile of a ward-based regimen for postoperative epidural analgesia combining patient-controlled epidural analgesia (PCEA) and continuous epidural infusion (CEI). DESIGN: We conducted a prospective survey in all patients who received postoperative epidural analgesia between March 2004 and February 2011. PATIENTS: We analysed 4663 patients undergoing elective and acute surgery. SETTING: University hospital in Sweden. RESULTS: The median level of catheter insertion ranged from T8 in high abdominal surgery to T11 in gynaecological surgery. Mean infusion rate was 5.4 ±â€Š1.6 ml h and was adjusted for age. Mean duration was 3.3 ±â€Š2.1 days. Eighty-seven percent of the patients rated satisfaction 8 to 10 out of 10 on a post-treatment scale. Reasons for termination were elective in 77.1%, due to inadequate pain relief in 11.4%, due to suspected infection in 0.7% and due to other causes in 10.9%. Of the latter, dislodgement of the catheter (4.0%) and leakage from the puncture site (1.4%) dominated. Catheter reinsertion was performed in 5.3% of the patients, and in 5.0%, the treatment was converted into an intravenous (i.v.) morphine patient-controlled analgesia regimen. The incidence of motor blockade was 1.7%, sedation 2.1%, nausea 12.8% and pruritus 18.8%. Bolus doses accounted for 16% of the total infusion volume. No epidural haematoma was seen. One epidural abscess requiring antibiotic treatment occurred. CONCLUSION: Our prospective survey indicates that PCEA in combination with CEI is effective and relatively well tolerated. The incidence of side effects is generally low and severe adverse events very rare.