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
COMENTARIOS …
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