Abstract ID: A18

Abstract Title: The effects of epidural catheter location on outcomes in women undergoing gynecologic surgery with an abdominal incision: A randomized clinical trial

Authors: Richman J1, Ahmad H2, Rowlingson A3, Wu C4
         Johns Hopkins University Baltimore MD USA1, Johns Hopkins University 2, Johns Hopkins University 3, Johns Hopkins University 4
Poster Type: Discussion


ABSTRACT BODY

Introduction: The optimal insertion site (if any) for epidural catheter placement after abdominal gynecologic surgery is not known and has not been investigated. The surgical incision for most gynecologic surgeries corresponds to the L1-T8 dermatomes, which implies that a low thoracic epidural may be ideal.
Methods: Adult women undergoing elective total abdominal hysterectomy (TAH), myomectomy or exploratory laparotomy for gynecologic surgery were randomized in a double blind study to either lumbar epidural analgesia (LEA) or thoracic epidural analgesia (TEA). Catheters were dosed intraoperatively and patients were placed on patient controlled epidural analgesia (PCEA) (bupivacaine 0.125% with 5mcg/cc fentanyl at 4cc continuous, 2 cc demand and 10 minute lockout). Preoperative tests of motor function using Bromage scores and electronic dynamometry along with sensory and proprioceptive testing were performed prior to epidural placement and repeated the morning after surgery. Visual Analog Scale (VAS) pain was recorded in the postoperative period along with several outcome measures and a one week follow up phone call was made.
Results: A total of 103 patients enrolled with 88 patients completing the study. There were no significant differences in patient demographic data (Table 1). Motor blockade was increased with the use of LEA compared to TEA but was statistically significant only for right leg knee extension and straight leg raise (dynamometry) and knee extension and flexion (Bromage) (Table 2). TEA compared with LEA resulted in significantly fewer sensory deficits to prinprick in the left leg only, with no statistical difference for the right leg or response to cold testing. No difference in VAS pain scores were noted during the hospital stay; however, pain scores reported by the patients 7 days after surgery were higher at both rest (TEA 3.5 ± 2.3, LEA 2.4 ± 2.0 p<0.05) and maximal (TEA 6.6 ± 2.9, LEA 4.9 ± 2.4 p<0.05) for TEA (Table 3). There was a statistically significant decrease in pruritus with LEA compared with TEA and no difference in nausea/vomiting or Quality of Recovery 9 questionnaire scores. No statistically significant differences between lumbar and thoracic epidural patients were detected when subjects were asked to rate how fatigue interfered with the following activities on a scale of 0 (not at all) to 10 (completely interfered): general activity, mood, walking ability, normal work, relations with other people and enjoyment of life.
Discussion: In our study we randomized patients receiving gynecologic surgery to either TEA or LEA to evaluate patient oriented outcomes. It was hypothesized by the authors that TEA (T9-11) would produce less motor block and potentially decreased pain due to catheter-incision congruent placement. Although a decrease in motor block was seen with TEA, this was statistically significant for only limited measures and no difference in VAS postoperative day one was observed. Surprisingly, higher VAS scores were reported 7 days after surgery with TEA. A small decrease in motor blockade may still be clinically significant but other side effects associated with TEA in this study do not support that it is clearly superior to LEA for gynecologic surgery.

ATTACHED FILES

A18_Table 1.doc

A18_Table 2.doc

A18_Table 3.doc

Reg Anesth Pain Med 2005; 30(3):A18