You are on page 1of 10

Alexandria Journal of Anaesthesia and Intensive Care

Combined Epidural-General Anesthesia (CEGA)


In Patients Undergoing Pancreatic Surgery:
Comparison Between Bupivacaine 0.125% And 0.25%
Essam A. Eid. MD*, Samarkandi A.H. FFASC, KSFS**, Faisal AlSaif. FRCS, AB***

*Assist Prof., Anesthesia Department, Liver Institute, Mounofia University


Associat.Prof.,Anaesthesia, King Khaled University Hospital (KKUH), Riyadh
** Prof. Anesthesia, Head of department of Anesth&ICU (KKUH), King Saud University
***Assist. Prof., Head of Hepatobiliary Unit, KKUH, Riyadh, KSA
Background: Major abdominal surgery results in homodynamic instability mainly due to
endogenous prostacyclin release, bleeding, major intercompartemental fluid shift and the hormonal
surgical response. This study compared the effects of low thoracic epidural anesthesia with
0.125% and 0.25% bupivacaine on haemodynamic variables, sevoflurane requirements, and
stress hormone responses during pancreatic surgery under combined epidural-general
anaesthesia (CEGA).
Materials and Methods: Forty patients undergoing different pancreatic surgery were randomly
allocated into two equal groups to receive 10 ml of either isobaric bupivacaine 0.125% (group I) or
0.25% (group II) by low thoracic epidural with sevoflurane general anaesthesia. Sevoflurane was
adjusted to achieve a target bispectral index (BIS) of 4060. Measurements included the inspired
(FISEVO) and the end-tidal sevoflurane concentrations (E'SEVO), blood pressure (BP) and heart rate
(HR) before surgery and every 5 min during surgery for 2 h, and stress hormones. Plasma samples
for stress response evaluation were taken before and 1 and 2 h after the start of surgery for
measurements of epinephrine, and cortisol.
Results: During surgery, both groups were similar for HR, BP and BIS, but FISEVO and E'SEVO were
significantly higher and more fluctuated with bupivacaine 0.125% than with 0.25%. Moreover, the
total amount of propofol used for induction of general anesthesia and the total fentanyl used during
anesthesia were significantly low in 0.25% bupivacaine group. Intraoperative requirements of
ephedrine were higher in 0.25% bupivacaine group. Intraoperative blood loss and fluid
requirements were significantly increase in 0.125% group. Plasma concentrations of epinephrine
and cortisol were found to be higher with bupivacaine 0.125% as compared with 0.25%.
Conclusion: Combined thoracic epidural-general anesthesia (CEGA) for pancreatic surgery, with
0.25% bupivacaine significantly reduces sevoflurane requirements, blood loss and fluid
requirements. In addition, bupivacaine 0.25% suppressed the stress hormone responses better
than 0.125% did. However this was on the expenses of more ephedrine requirements.

tumor of the head of the


pancreas will often compress
the
common
bile
duct
embedded in its posterior surface. This is
revealed by painless obstructive jaundice
and a distended gall bladder, which may be
palpable below the right costal margin.
Tumors of the body and tail of the pancreas
are in some ways more insidious than those
of the head because they do not compress
the common bile duct and can escape
detection
until
they
have
either
metastasized or involved major arteries
related to the pancreas(1). Surgical removal
of tumors of the pancreas is the only way to
cure patients with pancreatic cancer(2).
Major upper abdominal surgeries,
including pancreatic, are associated with
exaggerated hormonal and inflammatory

responses during surgery that continued in


the postoperative period(3). Previous studies
in surgical populations have demonstrated
that neuraxial blockade of the sympathetic
nervous system results in a decrease of
postoperative morbidity(4,5). There may be
advantages to anesthetic strategies that
attenuate the adrenergic response to
surgical
stress
without
jeopardizing
homodynamic stability. In this context,
thoracic epidural anesthesia gain popularity
as a fixed component of anesthetic protocol
for pancreatic surgery. However, still there
is controversy about site, dose and
concentration of the local anesthetic used in
thoracic epidural anesthesia(5). The foregut
(including
pancreas)
receives
its
sympathetic innervations from T5-T9. Low
thoracic epidural anesthesia (TEA) i.e. T10-

AJAICAJAIC-Vol. (10
(10)
2007
10) No. 1 Marsh 2007

Alexandria Journal of Anaesthesia and Intensive Care


12, produces segmental block to the
sympathetic supply of the upper abdominal
dermatomes
without
affecting
lower
abdomen or lower limbs sympathetic
supply(6).
Combined Epidural-General Anesthesia
(CEGA) technique has widely been used in
major abdominal surgery for decades(4).
Clinical experience has shown that there
are less general anesthetic requirements
when the two techniques are provided
simultaneously. Epidural anaesthesia blocks
the nociceptive input originating from the
surgical site to some degree. Postoperative
pain state results from afferent C-fiber input
generated by the tissue injury, and the
central facilitation from the continuing
stimulus(6). Neuraxial anesthesia can alter
both processes by reducing the preterminal
release
of
neurotransmitters
and
hyperpolarizing the postterminal secondorder neurons(7). In addition, neuraxial
anesthesia has a supraspinal general
anesthesia effect that suppresses the level
of consciousness(8). It is possible to perform
upper abdominal procedures under thoracic
epidural anesthesia alone, but the height of
block required, with the position of the
surgical retractors and manipulation near
the diaphragm, make it difficult to avoid
significant patient discomfort and risk(6).
Epidural anesthesia should be combined
with general anesthesia for intrathoracic
surgery and upper abdominal procedures
near the diaphragm (7). Inhalational agents
provide amnesia and allow endotracheal
intubation in patients undergoing the
combined anesthetic technique. Minimal
expired concentrations of the volatile
anesthetics (0.25-0.5 % isoflurane) are
required(8). Epidural analgesia allows earlier
mobilization, reduces the risk of deep
venous thrombosis, and allows better
cooperation with chest physiotherapy,
preventing chest infections and reduces
over-all postoperative morbidity(9).
The ratio of the two techniques
(epidural/general anesthesia) has been
arbitrarily determined: varying concentrations
of local anesthetic are used, and general
anesthesia is administered empirically or
based on cardiovascular responses during
surgery without knowing the depth of
anesthesia and the impact of epidural. The
bispectral index score (BIS) was introduced as

an estimation of anesthetic effect and could


indicate adequate depth of anesthesia during
surgery(10). The purpose of this study was to
compare the effects of low thoracic epidural
anesthesia (T10-12) with either bupivacaine
0.125% or 0.25% on hemodynamic variables,
sevoflurane requirements, and stress hormone
responses (epinephrine, cortisol) during
pancreatic surgery under combined epiduralgeneral anesthesia (CEGA). Sevoflurane
anesthesia was monitored with bispectral
index score (BIS) to keep the score between
40-60.
MATERIALS AND METHODS
Forty patients of both sexes scheduled
for pancreatic surgery were included after
the study protocol was approved by the
local Ethical Review Board committee. All
patients gave written informed consent.
Patients were selected to justify ASA
physical status I, II, or III. Patients who had
a history of major back problems,
coagulation
abnormality,
neurological
disease and advanced cardiopulmonary
disabilities were excluded. Patients were
assigned to one of the two treatment groups
by using a table of random numbers.
Premedication consisted of 2.0 mg
lorazepam orally in the evening before
surgery and 2 h before the induction of
anesthesia. Upon arrival to the holding
area, standard monitors were connected to
the patients (ECG, NIBP, SO2), and a 16gauge IV cannula was placed and the left
radial artery were catheterized with a 20gauge catheter under local anesthesia.
Patients were placed in the sitting position,
and an epidural catheter was inserted in the
T10-11 or T11-12 interspace using the loss
of resistance technique. Instead of the
conventional method of a test dose with
lidocaine and adrenaline to confirm the
catheter placement, we used a catheter
advancement technique (CAT)(11). With this
technique, after eliciting lack of resistance,
the ability to advance 20 cm of a soft
epidural catheter without a stylet and with
minimal resistance was taken as a
successful indicator for catheter placement.
The catheter was then withdrawn to the 15cm mark, and gravity drainage of
cerebrospinal fluid or blood was tested.

AJAICAJAIC-Vol. (10
(10)
2007
10) No. 1 Marsh 2007

Alexandria Journal of Anaesthesia and Intensive Care


After the epidural catheter was fixed to the
back, the patients were placed supine and
received 10 ml bupivacaine of either
0.125% (group I) or 0.25% (group II),
combined with fentanyl 2.0 g/ml and 2.0
mg morphine in a double-blinded manner.
The bolus bupivacaine was given in
increments of 3 mls/3 min aiming to block
the somatosensory level T5- T9. A 6.0 ml/hr
infusion of either 0.125% or 0.25%
bupivacaine with fentanyl 2.0 g/ml was
started and continued throughout the
surgical
procedure.
Somatosensory
blockade was evaluated by touching the
skin with ice and performing the pinprick
test. Induction of general anesthesia was
started after 30 min, during this period all
the parameters of epidural anesthesia were
recorded.
Monitoring included invasive arterial blood
pressure (BP), heart rate (HR), pulse oximetry,
bispectral index (BIS), end-expired carbon
dioxide, and inspired (FISEVO) and end-expired
(E'SEVO) sevoflurane concentrations. General
anesthesia was induced with fentanyl (2.0
g/kg) and propofol. Dose of propofol was
titrated according loss of lash reflex and the
amount of propofol and induction time was
observed. Cisatracurium (0.15 mg/kg) was
used to facilitate tracheal intubation. Ventilation
was controlled with a tidal volume of 7.0 ml/kg
(oxygen/air mixture: 50%/50%), obtaining an
end-expiratory pressure (PEEP) of 5.0 cm
H02, and PaCO2 was approximated to 35 mm
Hg by adjusting the respiratory rate and the
minute volume. Anesthesia was maintained by
a continuous infusion of cisatracurium
(0.12/kg/hr) and Sevoflurane adjusted to keep
BIS score between 40-60 throughout the
surgical procedure. A 14.0 F triluminal catheter
was inserted into the right jugular vein for fluid
resuscitation and CVP measurements.
Another 14 G peripheral cannula was secured.
Analgesia was intensified by increments of 1.0
g/kg fentanyl given IV in response to increase
in BIS to a value greater than 60. The total
requirement of intraoperative fentanyl IV was
noted.
Intraoperative fluid administration was
10 ml/kg/hr crystalloids and managed to
keep CVP between 8 to12 mmHg. Blood
loss during surgery has been replaced with
packed RBCs and FFP to keep HB level
around 10 gm/dl.Volume expander ,packed
RBCS and FFP as well as blood loss were

estimated at the end of the procedure. At


the end of surgery, residual neuromuscular
block was reversed with neostigmine 50
g/kg and atropine 20 g/kg, and the
patients were extubated if the procedure
was of less than 6 hr, otherwise patient was
kept ventilated overnight and then
extubated. Upon arrival to the SICU an
epidural infusion of bupivacaine 0.0625% in
a dose of 6.0-8.0 ml/h was immediately
started and titrated according to the Visual
Analog Scale (VAS) measurements.
Patients were told about VAS for pain
assessment during the preoperative visit.
We used a vertical 100-mm VAS with ends
marked as 0 (no pain) and 100 (worst
imaginable pain), and patients were
assessed at 0, 2, 6, 12 and 24 hr after
operation
and
asked
about
their
justifications regarding pain control
Systolic BP (SBP), HR, and BIS were
recorded by an anesthesia registrar who
was blinded to the study group: before
epidural anesthesia, before surgery, every
5 min for the first 2 h during surgery, and
after the completion of surgery until
endotracheal extubation. So were FISEVO
and E'SEVO except for the time point before
induction. Times from start of induction to
loss of eyelash reflex (T1), times from end
of surgery to return of gag reflex (T2) and
respond to verbal command (T3) were also
measured. Plasma samples were taken
immediately before, and 1 and 2 h after the
start of surgery for measurements of
epinephrine and cortisol. Epinephrine was
analyzed by high performance liquid
chromatography assay on an isocratic liquid
chromatograph
interfaced
with
an
electrochemical detector. Cortisol was
determined by radioimmunoassay assay.
Epinephrine and cortisol were not
measured
postoperatively
to
avoid
misinterpretation of their values due to
unpredictable stress factors during the
weaning period.
Patients were followed up at 0, 2, 6, 12,
and 24 h after surgery for pain with VAS
during deep inspiration by the SICU
registrar who was unaware of the drug
given. When VAS on deep inspiration was
more than 4, they received fentanyl 50 g in
10 ml of normal saline through the epidural
catheter. Patients were also questioned
about side effects, such as hallucinations,

AJAICAJAIC-Vol. (10
(10)
2007
10) No. 1 Marsh 2007

Alexandria Journal of Anaesthesia and Intensive Care


pruritus, and nausea and vomiting, in the
first 24 h after surgery. Respiratory rate and
the patients response were used to
diagnose respiratory depression. If the
respiratory rate was <10 breaths/min and
the patient was not verbally responsive,
respiratory depression was diagnosed. If the
patient was not responding and the
respiratory rate was > 10 breaths/min,
excessive
sedation
was
diagnosed.
Complications related to TEA were
recorded like: Failed block and dural
puncture. All patients were asked to answer
a questionnaire about their pain sensation
and general comfort 24 h after surgery.
Statistics: Results are expressed as mean
(SD) unless otherwise stated. SBP, HR,
FISEVO, E'SEVO, and BIS values recorded
every 5 min for the first 2 h during surgery
were averaged to provide overall means as
summary statistics. Changes in SBP, HR,
FISEVO, E'SEVO, and BIS were calculated from
the absolute values of the changes in
corresponding values every 5 min. Patient
characteristics and anesthetic data in both
groups were compared using Students t-

test and 2-test, as appropriate. Mean and


change in SBP, HR, FISEVO, E'SEVO, and BIS
were analyzed using Students t-test, and
the MannWhitney test was used to
determine differences in the maximum level
of sensory blocks between groups. Plasma
concentrations of epinephrine and cortisol
were analyzed using repeated-measures
analysis
of
variance.
P<0.05 was
considered statistically significant.
RESULTS
Patient
characteristics,
surgical
procedures, blood loss and resuscitation
fluid were recorded in the two study groups
(table I). Patients of group I showed
significant increase in blood loss and
requirements for packed RBCs, FFP,
Hydroxyethyl starch and lactated Ringer
solution compared to group II. I.V. fluid and
blood loss represent the values recorded
during the whole surgical procedures. Urine
output was significantly increased in group
II compared to patients of group I.

Table I: Patient characteristics, surgical procedures, blood loss, fluid replacement and
urine output
Group I
(Bupivacaine 0.125%)
(n = 20)
14/6
5411
6913
1689

Sex ratio (m/f)


Age (years)
Body weight (kg)
Height, cm
ASA classification:
ASA I
0
ASA II
17
ASA III
3
Operation time (min)
392125
Anesthesia time (min)
468152
Surgical procedures:
Whippels procedure
15
Pseudo pancreatic cyst
2
Roux en-y
3
Blood loss (ml)
1185589*
Urine output (ml)
984395
Packed RBCs (ml)
1150650*
FFP (ml)
850480*
Hydroxyethyl starch (ml)
1500500*
Lactated Ringer (ml)
5,2531,910*
(number, mean SD)
*P is significant if <0.05. **P is significant if<0.001

AJAICAJAIC-Vol. (10
(10)
2007
10) No. 1 Marsh 2007

Group II
(Bupivacaine 0.25%)
(n =20)
15/5
5316
6811
1707
1
16
3
371114
459167
16
2
2
1030483
1246474*
1000500
640390
1000500
4,5602,660

Alexandria Journal of Anaesthesia and Intensive Care


TEA was performed successfully in all
patients
without
any
observed
complications. The mean upper sensory
blockade level extended to T 4-5 (+/- 1.0
segments), and the lower blockade
extended to T10-11 (+/- 3.5 segments). The
upper levels of sensory block to cold and
pinprick 15 min after the bolus injection
were similar in the two groups, whereas
bupivacaine 0.25% (group II) produced a
significantly higher level of loss of touch
sensation. Base-line SBP, HR, CVP, and
BIS before epidural anesthesia was similar
in both groups and showed insignificant
change (table II).
The timings of special events of
anesthesia
(T1,
T2,
T3)
showed
insignificant decrease in group II compared
to group I. However, the total amount of
propofol used for induction of general
anesthesia and the total fentanyl used
during anesthesia were significantly low in
0.25% bupivacaine group (table III).

During surgery, both groups were


similar for both mean and change per 5 min
in BIS, SBP and HR. The mean and change
per 5 min in FISEVO and E'SEVO were
significantly higher in group I than in group II
(P<0.05). But, ephedrine requirements were
significantly high in group II compared to
group I (P<0.001) (Table IV).
Plasma levels of both epinephrine and
cortisol showed significant increase in postinduction values (after 1 hr and 2hr) in
group I compared to groupII. However,
values of both groups showed significant
increase when compared to base-line
values (Table V, Fig 1)
VAS ((Visual Analogue Scale) showed
insignificant change between the two
groups and the time for the first
postoperative bolus dose and number of
doses were comparable in both groups
(table VI). Side effects were infrequent in
both groups and Patient satisfaction was
almost the same in both groups (table VII).

Table II: Perioperative data


Group I
(bupivacaine 0.125%)
(n= 20)

Group II
(bupivacaine 0.25%)
(n= 20)

Epidural site:
T 10-11
7
6
T 11-12
13
14
Loss of sensation to cold
T 5 (T4-T10)
T4 (T3-T9)
Loss of sensation to pinprick
T5 (T4-T11)
T4 (T4-T10)
Loss of sensation to touch
T 8 (T6-T12)
T 6 (T4-T12)*
Base-line CVP (mmHg)
93
9 4
Base-line HR (beat/min)
7614
7716
Base-line mean BP (mm Hg)
7916
7615
Base-line BIS
96.80.7
97.20.8
Data are presented as mean (SD), absolute number or median (10th, 90th percentiles).
*P<0.05 between two groups
Table III: Anesthetic induction and recovery and total requirements of propofol and
fentanyl.
Group I
Group II
(bupivacaine 0.125%)
(bupivacaine 0.25%)
(n= 20)
(n= 20)
T1: Loss of lash reflex (s)
66 16
6411
T2: Return of gag reflex (s)
498112
501120
T3: Verbal command (s)
528134
534137
Total IV propofol (mg)
14252
11324*
Total IV fentanyl (g)
412310
24640**
Data are presented as mean (SD). *P<0.05 , **P<0.001

AJAICAJAIC-Vol. (10
(10)
2007
10) No. 1 Marsh 2007

Alexandria Journal of Anaesthesia and Intensive Care

Table IV: BIS, FISEVO and E'SEVO, SBP, HR and dose of ephedrine during surgery
Group I
(bupivac. 0.125%)
(n= 20)
47.12.3
3.42.4
1.410.36*
0.190.31*
1.220.33*
0.130.07*
98.815.7
7.95.7
70.314.5
5.24.6
8.87.9

Group II
(bupivac, 0.25%)
(n= 20)
44.72.2
3.73.1
1.130.34
0.120.23
0.890.19
0.070.04
95.913.6
6.65.1
68.110.4
6.15.8
21.311.3**

Mean BIS
Change in BIS (/5 min)
Mean FISEVO (%)
Change in FISEVO (% /5 min)
Mean E'SEVO (%)
Change in E'SEVO (% /5 min)
Mean SBP (mm Hg)
Change in SBP (mm Hg /5 min)
Mean HR (beats min1)
Change in HR (beats/5min)
Dose of ephedrine (mg)
Data are presented as mean (SD).
Mean BIS, FISEVO, E'SEVO, SBP, and HR reflect the average of corresponding values recorded
every 5 min for the first 2 h during surgery. Changes in BIS, FISEVO, E'SEVO and SBP were
calculated from the absolute values of the changes in respective values every 5 min.
*P<0.05 between groups, **P<0.001
Table V: Changes in serum epinephrine and Cortisone in both groups
Parameters
Group I
Group II
Serum Epinephrine (pg/ml):
0 hr (baseline value)
20.93.3
20.63.6
After 1 hr
63.59.7*
36.88.9*
After 2 hr
61.99.8*
33.38.3*
Serum Cortisone (g/ml):
0 hr (baseline value)
24.14.2
23.74.1
After 1 hr
75.613.6*
40.89.8*
After 2 hr
84.414.3*
44.99.7*
P is significant in group I compared to group II. * P is significant related to baseline values
in both groups

70
60
50
40

group I

30

group II

20
10
0
0 hr

1 hr

2 hr

90
80
70
60
50
40
30
20
10
0

group I
group II

0 hr

Fig 1: Changes in serum epinephrine (pg/ml),

1 hr

2 hr

and cortisone (
g/ml) in both groups

AJAICAJAIC-Vol. (10
(10)
2007
10) No. 1 Marsh 2007

Alexandria Journal of Anaesthesia and Intensive Care

Table VI: VAS (Visual Analogue Scale) in the two groups after surgery
Group I
(bupivac. 0.125%)
(n= 20)
2.9 1.1
2.9 1.8
3.2 2.1
2.9 1.9
2. 41.1
100%
11.43.7
2.30.6

VAS 0
VAS 2
VAS 6
VAS 12
VAS 24
Patients satisfaction
Time of first bolus [(h)SD]
Total number of bolus doses

Group II
(bupivac. 0.25%)
(n= 20)
2.8 1.0
2.8 1.6
3.3 2.4
2.7 1.8
2.31.2
100%
11.13.4
2.40.4

Table VII: Side effects, time of first bolus dose, number of bolus dose and patient
satisfaction score in the two groups

Nausea/Vomiting [n (%)]
Pruritus [n (%)]
Respiratory depression [n (%)]
Patient satisfaction score (range)

Group I
(bupivac. 0.125%)
(n= 20)
4 (20)
1 (5%)
0 (0)
9.2 (8-10)

DISCUSSION
The
key
pathogenic
factor
in
postoperative morbidity is the surgical
stress response with its potential for
multiorgan damage(12). Thoracic epidural
anesthesia (TEA) significantly dampens the
stress response, and relieves the
postoperative pain. In contrast to lumbar
epidural analgesia, TEA, aimed at placing
the tip of the catheter at the dermatomal
midpoint of the surgical incision, allows the
use of small amounts of opioids and
concentrated local anesthetic. It offers
maximal sympathetic blockade of the heart
and bowel, which promotes coronary
perfusion and gastrointestinal motility, and
provides freedom from lower extremity
motor blockade and opioid-induced side
effects(13). Moreover, in upper-abdominal
surgery, there could be additional routes of
transmission of noxious stimuli to the CNS
through the phrenic nerve and the vagus
nerve(14,15), which almost need very high
doses of opioids in case of giving general
anesthesia without neuraxial block. These
observations were obvious from the results
of 0.25% group II of the present study,
where the total requirements of fentanyl and

Group II
(bupivac. 0.25%)
(n= 20)
3 (15)
0 (0)
0 (0)
9.3 (8-10)

therefore the incidence of opioids side


effects were infrequent.
The
differences
in
sevoflurane
requirements
and
stress
hormone
responses observed between epidural
bupivacaine 0.125% and 0.25% are
probably attributable to the difference in
extent and intensity of the block. Although
the two bupivacaine solutions were similar
for upper level of sensory blocks to cold and
pinprick before the induction of general
anesthesia, the higher concentration of
bupivacaine produced a higher level of loss
of touch sensation. Moreover, neuraxial
anesthesia has a supraspinal effect that
suppresses the level of consciousness as
proved by Hodgson et al(16). In the present
study, the concentration of sevoflurane was
adjusted to obtain a target BIS of 4060
regardless of other variables. Previous
studies(10,16) have demonstrated that the BIS
are a highly predictive monitor for depth of
sedation, and that the probability of
responsiveness becomes small at a BIS
value of 60 or less. Thus, the two groups of
patients in the present study appear to have
been kept constantly in a similarly adequate
depth of anesthesia throughout surgery.

AJAICAJAIC-Vol. (10
(10)
2007
10) No. 1 Marsh 2007

Alexandria Journal of Anaesthesia and Intensive Care


In this study, the inspired anesthetic
concentration was changed only on the
basis of BIS values to keep it between` 4060. Less sevoflurane concentration was
recorded with 0.25% concentration of
bupivacaine (Group II). In clinical practice,
anesthetists do not change the inspired
anesthetic concentration only on the basis
of BIS values(5,17). However, in view to the
changes in SBP and HR during surgery
between the two groups, it is likely that the
depth of general anesthesia is more
variable and fluctuated with the use of lower
concentration of bupivacaine (0.125%).
Zoric et al.(18) used thoracic epiduralgeneral anesthesia for all patients
undergoing major abdominal surgery, since
1997 as a routine. For intraoperative
analgesia
they
used
0.25%
plain
bupivacaine. The most important detail in
their technique is the analgesic solution
(AS) which contains bupivacaine 0.25% (25
mg), fentanyl (50 g) and morphine
hydrochloride (2.0 mg), in total volume of 15
ml.
They
maintained
intraoperative
analgesia with bupivacaine 3 to 5 ml in
intermittent bolus doses. For very light GA
only artificial ventilation with 66% N2O in
O2 and muscle relaxation with pancuronium
is needed. Co analgesia with intravenous
fentanyl was exceptionally seldom needed,
except for induction. Intraoperative drugs
consumption was very small and with
adequate liquid compensation (10 ml/kg/hr),
this technique achieves exceptionally
intraoperative homodynamic stability in
patients, despite long and big operations.
These results are consistent with our results
of the 0.25% bupivacaine group but not
0.125% group. However, we should
mention that our results with 0.25%
bupivacaine (Group II) were on expenses of
significant use of ephedrine to maintain
hemodynamic
According to the verbal Analogue scale
(VAS < 4), 100% patients were satisfied
with this analgesia, which gave possibilities
to mobilization and rehabilitation even in the
first postoperative day. Malenkovic et al.(19)
analyzed the advantages of combined
spinal, epidural and general anesthesia
(CSEGA) versus general anesthesia (GA)
in abdominal surgery. Advantages of
CSEGA versus GA in abdominal surgery
were manifold: better hemodynamic stability

and perfusion of operative region, decrease


of single doses of opioids analgesics, local
and general anesthetics followed by the
decrease of their side effects, better
intensity and longer duration of analgesia
and improved total functional capability of
patients. Final subjective effect of
analgesia, according to verbal descriptive
scale (VDS) of pain was satisfying with 75%
of patients of the CSEGA group (compared
to 15% of patients of the general anesthesia
group) which is very close to our results. In
the present study, 0.25% bupivacaine group
experienced an advantage which is
reported before, where the urine output was
significantly increase compared to the
0.125% group (although UOP in this group
was reasonable), and this observation
might be attributed to the renal vasodilating
effects of thoracic epidural.
Christopher et al.(20) examined the
degree of success at maintaining patients
randomized to epidural or general
anesthesia for peripheral vascular surgery
within predetermined blood pressure (BP)
and heart rate (HR) limits and investigated
the
associations
between
such
hemodynamic control and intraoperative
myocardial ischemia and postoperative
major cardiac morbidity in 100 patients. A
greater percentage of patients randomized
to general anesthesia had intraoperative
BPs more above their limit (95% vs. 72%)
and more rapid changes in HR (75% vs.
48%) or BP(100% vs 73%) than those
randomized to epidural anesthesia. Patients
experiencing
intraoperative
ischemia,
regardless of anesthetic type, more
frequently had BPs greater than 10% above
their upper limit and more rapid HR
changes compared with patients without
ischemia. They concluded that, prevention
of elevated intraoperative BP and rapid
changes in BP or HR may be more
successful with epidural than with general
anesthesia. In the present study, 0.125%
bupivacaine group I, showed better control
of hemodynamic without need for inotropic
support (ephedrine). However, the 0.25%
bupivacaine group II patients showed
significantly less blood loss and accordingly
they need less packed RBCs, FFP,
crystalloids, and colloid solution and
significantly more urine output. These
effects of the 0.25% bupivacaine may be

AJAICAJAIC-Vol. (10
(10)
2007
10) No. 1 Marsh 2007

Alexandria Journal of Anaesthesia and Intensive Care


attributed to the extent and depth of the
block and appeared to give these patients
good surgical outcome and maintain body
homeostasis(21). On the other hand, part of
the hemodynamic changes that have been
observed during Whipples operation may
be attributed to the presence of abdominal
mesenteric traction (MT) syndrome that
occur during major abdominal operations
and result in sudden hypotension and
arterial hypoxemia due to a marked release
of
prostacyclin.
This
hemodynamic
response following MT, result in a
deterioration of splanchnic perfusion, can
occasionally is prolonged and severe(22).
Alexander et al(23) observed an MT
response with significant decrease in MAP
in 72% of the patients undergoing pancreas
surgery.
In the present study, the side effects were
rare in both groups which highly support the
optimistic of this technique for upper
abdominal surgery. The work carried by
Siniscalchi et al.(24) support our results. They
compared the intraoperative effects of
combined epidural-general versus general
anesthesia during major liver surgery. Group A
(CEGA)
received
general
anesthesia
(thiopentone,
fentanyl,
vecuronium,
sevoflurane) 15 minutes after placement of an
epidural catheter (T9-T10) and induction of
epidural anesthesia (6 ml 2% naropine).
Continuous epidural infusion was initiated
before surgical incision and continued with
0.2% naropine (7 ml/h) until the end of the
operation. Group B (GA) received general
anesthesia with fentanyl doses according to
hemodynamic parameters and 0.1 mg/kg
morphine 30-40 minutes before cutaneous
suture. A statistically significant difference in
ABP was found between the 2 groups at 15 to
180 min, whereas HR values were
substantially similar. The mean intra-operative
use of vecuronium was significantly higher in
Group B than in Group A, as was that of
fentanyl. Pain intensity on recovery in patients
who received epidural anesthesia was lower
both at rest and on movement. Only the
patients in Group B required additional
analgesics. No motor blockade was observed
in either group. Nausea and vomiting were
more frequent in Group B; hypotension was
more frequent in Group A. The study
confirmed the safety of low thoracic epidural
anesthesia in liver surgery, and recommended

its use as a fixed element of anesthesia for


liver patient without fear of developing epidural
hematoma or the occurrence of sever
hemodynamic changes. Also, epidural
anesthesia significantly decreases the
intraoperative requirements of opioids and
muscle relaxants in patients who are usually
very sick with multiple organ dysfunctions(25).
Conclusion: Our results support the
routine use of low thoracic epidural
analgesia as part of the anesthesia protocol
for patient undergoing pancreatic surgery.
The use of 0.25% bupivacaine with 1.0
g/kg fentanyl plus 2.0 mg morphine gave
excellent anesthetic condition during
surgery and was superior to 0.125%
preparation from all clinical aspect except
the need for more ephedrine which could be
precluded by reducing the bolus dose and
maintenance rate of the 0.25% solution.
REFERENCES

1. Carlos
2.
3.

4.

5.

6.

7.

UC, Kimberly SK. Recent


advances: General surgery. Br Mel J
1997; 315; 586-9.
Bradley E. A clinically based classification
system of acute pancreatitis. Arch Surgery
1993; 128: 586-90
Poon KS, Chang WK, Chen KH, et al.
Evaluation of stress response to surgery
under general anesthesia combined
with spinal analgesia. Acta Anaesthesiol
Scand. 1995; 33(2):85-90.
Davies MJ, Silbert DS.Combined epidural
and general anaesthesia versus general
anesthesia for abdominal aortic surgery: a
prospective randomized trial . Anesth
Intensive Care 1993; 21(6): 790-6
Hodgson PS, Liu SS, Gras TW, et al.
Does epidural anesthesia have general
anesthetic effects? A prospective,
randomized, double-blind, placebocontrolled trial. Anesthesiology 1999;
91: 168792.
Casati L, Fernandez-Galinski S, Barrera
E, et al. Isoflurane requirements during
combined general/epidural anesthesia
for major abdominal surgery. Anesth
Analg 2002; 94: 13317.
Lihara M, Obara T. Recent advances in
minimally invasive pancreatic surgery.
Asian J Surg 2003; 26(2): 86-91.

AJAICAJAIC-Vol. (10
(10)
2007
10) No. 1 Marsh 2007

Alexandria Journal of Anaesthesia and Intensive Care


8. Sakura S, Sumi M, Yamada Y, et al.
Quantitative and selective assessment
of sensory block during lumbar epidural
anesthesia with 1% or 2% lidocaine. Br
J Anaesth 1998; 81: 71822.
9. Hans P, Lecoq JP, Brichant JF, et al.
Effect of epidural bupivacaine on the
relationship between the bispectral
index and end-expiratory concentrations
of desflurane. Anaesthesia 1999; 54:
899908.
10. Goertz AW, Hubner C, Seefelder C, et
al. The effect of ephedrine bolus
administration on left ventricular loading
and systolic performance during high
thoracic epidural anesthesia combined
with general anesthesia. Anesth Analg
1994; 78:101-5.
11. Hodgson PS, Liu SS, Gras TW, et al.
Epidural lidocaine decreases sevoflurane
requirement for adequate depth of
anesthesia as measured by the Bispectral
Index monitor. Anesthesiology 2001; 94:
799803.
12. Takeyama K, Yamazaki H, Maeda M, et
al. Straight advancement of epidural
catheter- Comparative assessment by
method and site of epidural needle
puncture and angle of puncture-. Tokai
J Exp Clin Med 2004; 29(2); 27-33
13. Brinkmann A, Seeling W, Wolf CF,
Kneitinger E, Schnberg C.: Vasopressor
hormone response following mesenteric
traction during major abdominal surgery
Acta Anaesthesiol Scand 1998; 42: 948956.
14. Kabon B, Lleischmann E, Treschan T,
et al. Thoracic epidural anesthesia
increases tissue oxygenation during
major abdominal surgery. Anesth Analg.
2003; 97(6):1812-7.
15. Pierre M, Xavier BDJ, Antoine R, et al.
Perioperative risk factors for anastomotic
leakage after esophagectomy-Influence of
thoracic epidural analgesia- Chest 2005;
128: 3461-6
16. Hodgson PS, Liu SS, Gras TW, et al.
Does epidural anesthesia have general
anesthetic
effects?
A
prospective,
randomized,
double-blind,
placebocontrolled trial. Anesthesiology. 1999;
91(6): 1687-92.
17. A. Shono, S. Sakura, Y. Saito, et al.
Comparison of 1% and 2% lidocaine

10

epidural anaesthesia combined with


sevoflurane
general
anaesthesia
utilizing a constant bispectral index. Br J
Anaesth 2003; 91: 8259.
18. Zoric S, Stamenkovic D, Stevanovic S,
et al. Combined spinal epidural and
general anesthesia in abdominal
surgery. Med Arh. 2003; 57(4):21-8
19. Malenkovic V, Zoric S, Randelovic T, et
al. Advantage of combined spinal,
epidural and general anesthesia in
comparison to general anesthesia in
abdominal surgery. Srp Arh Celok Lek.
2003; 131(5): 232-7
20. Christopher R, Glavan NJ, Norris EJ, et
al. Control of blood pressure and heart
rate in patients randomized to epidural
or general anesthesia for lower
extremity vascular surgery. Perioperative
Ischemia
Randomized
Anesthesia Trial (PIRAT) Study Group.
J Clin Anesth. 1996; 8(7): 578-84
21. Seeling W, Bothner U, Eifert B, et al.
Patient controlled analgesia versus
epidural analgesia using bupivacaine or
morphine following major abdominal
surgery. Anaesthesia 1991; 40(11): 61423.
22. Greek CR, Couper NB. Prolonged
hypotension secondary to mesenteric
traction during a transabdominal approach
to a thoracoabdominal aneurysm. J
Cardiothoracic Vasc Anesth 1989; 3; 3413
23. Alexander B, Wolf S, Michael R, et al.
Changes in Gastric Intramucosal pH
following Mesenteric Traction in Patients
Undergoing
Pancreas
Surgery.
Digestive Surgery 1999; 16:117-124.
24. Siniscalchi A, Begliomini B, Matteo G, et
al. Intraoperative effects of combined
versus general anesthesia during major
liver surgery. Minerva Anestesiol. 2003;
69(12): 885-95
25. Balachundhar S, Kathirvel S, Dilip K, et
al. Preoperative epidural ketamine in
combination with morphine does not
have a clinically relevant intra- and
postoperative opioids sparing effect.
Anesth Analg. 2001; 93: 1321-26.

AJAICAJAIC-Vol. (10
(10)
2007
10) No. 1 Marsh 2007