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Regional Anesthesia and Pain Management

The Effects of Thoracic Epidural Anesthesia on Intraoperative Visceral Perfusion and Metabolism

Kapral, Stephan MD; Gollmann, Gabriele MD; Bachmann, Dietmar MD; Prohaska, Barbara MD; Likar, Rudolf MD; Jandrasits, Oliver MD; Weinstabl, Christian MD; Lehofer, Franz MD

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doi: 10.1213/00000539-199902000-00034
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Abstract

The endocrine, metabolic, and inflammatory responses to injury and infection consist of a variety of physiological changes, collectively called the surgical stress response. This process is considered to be detrimental to restoring homeostasis, wound healing, and returning the organism to a normal state of health and activity. Although the endocrine and metabolic changes have been extensively studied [1,2], little attention has been paid to the pathophysiology of intestinal changes, such as gastrointestinal ischemia during surgery, which may result in a decrease of bowel function [3] and a breakdown of the intestinal barrier in the normal gut [4]. Global indices of adequacy of tissue perfusion, such as blood pressure, heart rate, cardiac output, urine flow, and arterial pH, may not reflect regional perfusion [5,6]. In experimental models, the intramucosal pH (pHi) of the gut is a reliable index of local tissue perfusion [7]. The gastric pHi can be measured easily and reproducibly using a silicone balloon tonometer placed in the lumen of the stomach [6] by using the Henderson-Hasselbalch equation [8]. pHi can be calculated from the corrected intramucosal CO2 (PiCO2) and arterial bicarbonate concentration.

The stress response to major abdominal surgery [9] may be inhibited by epidural anesthesia. Furthermore, thoracic epidural anesthesia (TEA) has a beneficial effect on bowel function [10,11]. Postoperative epidural pain management results in reduced postoperative morbidity [12] and shorter hospital stay [13]. Therefore, we hypothesized that using TEA perioperatively may result in the maintenance of normal visceral perfusion and intraabdominal metabolism.

The aim of this intraoperative study was to evaluate the impact of TEA on pHi in patients undergoing major abdominal surgery.

Methods

After institutional approval and informed consent, 30 patients (ASA physical status II or III) scheduled for major abdominal surgery were included in the study. Patients with congestive heart failure, coronary artery disease, coagulopathies, perforated viscus, esophageal or gastric pathology, and esophageal or gastric surgery were excluded, as were pregnant patients. All patients were premedicated with oral triazolam (0.25 mg). On arrival at the operating room, an infusion of 500 mL of lactated Ringer's solution was started. A radial artery catheter was inserted for blood pressure monitoring and blood sampling. Additionally, a gastric tonometer tube (TRIP[trade mark sign] NGS Catheter; Instrumentarium Corp., Helsinki, Finland) was placed into the stomach via the nasogastric route. An epidural catheter was inserted into the epidural space through an 18-gauge Tuohy needle using the paramedian approach. Catheters were inserted at the T5-6 to T9-10 interspace. Using a placebo-controlled design, patients were randomly allocated into two groups. In the TEA group (n = 15), 8 mL of bupivacaine 0.5% was administered, and in the control group (n = 15), 8 mL of isotonic sodium chloride solution was injected into the epidural space. The level of epidural anesthesia was evaluated by the detection of cold 30 min after the local anesthetic injection. General anesthesia was induced with 3 mg/kg propofol, 50 [micro sign]g/kg alfentanil, and 0.15 mg/kg alcuronium and was maintained with a propofol drip (3-7 mg [center dot] kg-1 [center dot] h-1) and 25 [micro sign]g/kg alfentanil according to patient requirements.

Before the administration of the local anesthetic or placebo and anesthesia induction, the following baseline measurements were performed: systolic, mean arterial blood pressure, diastolic arterial blood pressure, heart rate (HR), oxygen saturation (SaO2), central body temperature (urine catheter probe), and arterial and gastric secretion samples. Arterial blood gas analysis and measurement of intramucosal CO (2) (PiCO2) were performed using a standard blood gas analyzer (BG Electrolyts[trade mark sign]; Instrumentation Laboratory, Lexington, MA).

The pHi was calculated after an equilibration period of 45 min by inserting the values of PiCO2 and the arterial bicarbonate into a modified Henderson-Hasselbalch equation. A pHi of 7.32 was taken as the lower limit of normal [4,15,18]. Measurements were obtained before and 60, 120, 180, and 240 min after local anesthetic injection. Surgery began immediately after anesthesia induction; therefore, measurements from 60 to 240 min were taken intraoperatively. After the study, the epidural catheter was used for pain management in all patients for 5-7 days using a patient-controlled motor pump (CADD-PCA[trade mark sign]; Pharmacia Deltec Inc., St. Paul, MN).

The size of the groups was estimated with reference to our pilot study [14] and previous studies [4,15]. Data are expressed in mean values +/- SD and were compared by using unpaired Student's t-tests and chi squared test using Yates rectification. A P value <0.05 was considered significant.

Results

The maximal pHi decrease during the observation period was larger (P < 0.001) in the control group (0.16 +/- 0.04) than in the TEA group (0.07 +/- 0.05). There were 10 patients in the control group and 2 patients in the TEA group who had evidence of gastric mucosal ischemia (pHi <7.32) at the end of surgery, which is statistically significant (P < 0.01). The pHi changes are shown in Figure 1, and PiCO2 data are plotted in Figure 2. After 180 and 240 min, both pHi and PiCO (2) reached statistically significant differences between groups.

F1-34
Figure 1:
Time course of the changes in intramucosal pH (pHi) during anesthesia induction and maintenance in major abdominal surgery patients. Thoracic epidural anesthesia (TEA; [black diamond]) group: pHi values remained unchanged throughout the study period. Control group ([black square]): a significant decrease (*P < 0.05) in pHi was recorded after 180 min and 240 min.
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Figure 2:
Mean +/- SD of intramucosal CO2 (PiCO2) measurements. Thoracic epidural anesthesia (TEA; [black diamond]) group: PiCO2 had an unchanged course during the study. Control group ([black square]): a significant increase (*P < 0.05) in PiCO2 was noted at 180 min and 240 min of the study, resulting in a dependent intramucosal pH decrease.

No surgical or anesthetic complications were seen in either group. No surgical gastrointestinal complications were recorded postoperatively. The block in the TEA group was established from T1 to T12 (median 10 segments, range 8-12 segments) using 8 mL of bupivacaine 0.5%. There were no significant differences between the TEA and control groups in gender (male to female 7:8 in both groups), age (59 +/- 16 vs 63 +/- 12 yr), weight (76 +/- 10 vs 71 +/- 14 kg), or height (170 +/- 9 vs 168 +/- 7 cm). Surgical procedures are summarized in Table 1. The duration of surgery was similar in both groups (229 +/- 51 vs 219 +/- 47 min). Mean arterial pressure was unchanged without intergroup differences during the study. A slight increase in HR was observed in the TEA group, reaching a level of significance after 120 min (Figure 3). There was no significant difference in SaO2 and decrease of central body temperature between the TEA and control groups (1.2 +/- 0.6 vs 1.5 +/- 0.9[degree sign]C). Blood gases were not different between groups (Table 2). A significant increase of PaO2 in both groups was caused by a fraction of inspired oxygen of 0.4-0.5 during mechanical ventilation.

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Table 1:
Diagnosis and Surgical Procedures of Both Study Groups
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Figure 3:
A slight increase of heart rate (HR) was observed in the thoracic epidural anesthesia (TEA; [black diamond]) group, reaching a level of significance after 120 min (*P < 0.05). [black square] = control group.
T2-34
Table 2:
Arterial Blood Samples

Discussion

The major findings of the present study, which focused on the intraoperative period, was that the control group showed a significant decrease in pHi as an effect of increased PiCO2. However, none of our study patients showed clinical signs of postoperative organ dysfunction. A potential influence of these findings by changes in hemodynamics, oxygenation, and central body temperature can be excluded, as there were no differences in these variables between the two groups. Only a small but significant increase in HR was recorded in the TEA group. This increased HR may result in an increased cardiac output and increased visceral perfusion. It is possible that cardiorespiratory variables greater than normal levels are necessary for perfusion of gastric mucosa during surgery [4]. Previous studies aiming to reduce the incidence of postoperative complications have relied on supernormal cardiac output [16]. The assumption is that an increased total oxygen consumption is synonymous with increased oxygen demand. We do not have data for total body oxygen transport or consumption, but adequacy of the global circulation does not guarantee adequacy of perfusion in vulnerable tissues, as various studies have shown [6,7]. Gastric pHi indirectly reflects the adequacy of oxygen delivery to the splanchnic bed. This area is particularly vulnerable to insufficient cardiac output [4]. Doubts regarding the calculation of pHi have been raised when normocapnia is not maintained or when bicarbonate is administered [17]. However, in this study, arterial pH and HCO3 showed no significant changes and no intergroup differences, whereas pHi and PiCO2 displayed an unstable course in the control group and stable conditions in the TEA group. Additionally, 10 of the 15 patients in the control group had evidence of gastric ischemia (pHi <7.32), whereas only 2 patients in the TEA group had a pHi <7.32. These findings lead to the conclusion that the pHi changes recorded in this study may have been influenced by the administration of bupivacaine into the epidural space.

Our results are in accordance with previous studies. Sutcliffe et al. [18] demonstrated that the injection of epidural bupivacaine 0.125% supplemented with diamorphine 0.2 mg/mL, followed by a bypass, resulted in a decreased incidence of low pHi postoperatively, compared with a group in which diamorphine 0.2 mg/mL alone was administered epidurally in the same way. Johansson et al. [15] demonstrated that the epidural administration of bupivacaine resulted in an immediate increase of signal level using a laser Doppler flowmeter as a measure of increased arterial perfusion of the intestinal wall. Additionally, an obvious visible increase in small bowel motility was observed in 10 of 15 patients. Similar results have been reported by Aitkenhead et al. [19], who observed a 22% increase in blood flow in the canine colon after subarachnoidal spinal nerve block.

However, previous studies have not discussed the question of whether epidural anesthesia blocks the reduction of visceral blood flow and small bowel motility caused by surgical manipulation. This effect on intestinal blood flow may be due to decreased mesenteric vascular resistance secondary to sympathetic block, resulting in an adequacy of intramucosal oxygenation, as the data from our study, which were collected during surgery, show.

Postoperative epidural bupivacaine application prevents short intestinal paralysis, as reported by Ahn et al. [20]. Their deduction was that general sympatholysis is of major importance for this effect. Thorn et al. [21], who studied the effects of epidural morphine and bupivacaine in healthy volunteers, concluded that local anesthetic blockade of sympathetic efferents may increase gastrointestinal motility. In the present study, bowel motility was not recorded. However, our data suggest that the maintenance of pHi as a measure of unchanged intestinal metabolism may result in stable bowel function during surgery. Additionally, evidence of gastric mucosal ischemia is associated with increased postoperative complications and costs [4]. Regardless of the initial stimulus (surgery, anesthesia, bacterial infection), the integrity of gut mucosa is compromised by ischemia. This leads to translocation of bacteria and endotoxin from the gut lumen [22]. The subsequent stimulation of inflammatory pathways can eventually lead to the characteristic tissue destruction seen in multiorgan failure. Postoperative organ dysfunction involves the whole organism, with tissue destruction distant from the site of surgery secondary to uncontrolled activation of inflammatory pathway. Therefore, attention must be focused on prevention [4].

In conclusion, the major finding of our study is that TEA prevented the decrease of pHi during major abdominal surgery as an effect of stable visceral perfusion. TEA may be a helpful method for intra- and postoperative treatment of surgical stress.

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© 1999 International Anesthesia Research Society