overinflated benefits and de-emphasized risks

1
belief excluding these patients a priori from the beneficial effects of epidural anesthesia would be unjustified. Tatiana Sidiropoulou, M.D. Mario Dauri, M.D. Department of Anesthesiology University of Rome “Tor Vergata” Rome, Italy References 1. Sidiropoulou T, Pompeo E, Bozzao A, Lunardi P, Dauri M. Epidural hematoma after thoracic epidural catheter re- moval in the absence of risk factors. Reg Anesth Pain Med 2003;28:531-534. 2. Kvolik S, Glavas-Obrovac L, Sakic K, Margaretic D, Karner K. Anaesthetic implications of anticancer chemotherapy. Eur J Anaesthesiol 2003;20:859-871. 3. Smorenburg S, Hutten B, Prins M. Should patients with ve- nous thromboembolism and cancer be treated differently? Haemostasis 1999;29(Suppl 1):91-97. 4. Mannaerts G, Van Zundert A, Meeusen V. Anaesthesia for advanced rectal cancer patients treated with combined major resections and intraoperative radiotherapy. Eur J Anaesthesiol 2002;19:742-748. 5. Slinger PD. Pro: Every post-thoracotomy patient deserves thoracic epidural analgesia. J Cardiothorac Vasc Anesth 1999;13:350-354. Accepted for publication March 18, 2004. doi:10.1016/j.rapm.2004.03.005 Overinflated Benefits and De-emphasized Risks To the Editor: In Denise Wedel’s Editorial “He Said, She Said, NSAIDs,” 1 she states that Kehlet’s multimodal therapy for the management of perioperative pain “. . . has become standard practice in acute and chronic pain manage- ment.” She then states that, “Proposed and documented benefits include improved pain relief, reduction of peri- operative stress response, shorter hospital stay, lowered hospital costs, and reduced morbidity and mortality,” quoting Kehlet’s review, “Multimodal Strategies to Im- prove Surgical Outcome.” 2 It is encouraging that she uses the word proposed, be- cause as yet the literature is very soft on any of the benefits of multimodal therapy for perioperative pain management. Certainly with respect to outcome, Kehlet himself writes, “. . . the overall effect of pain relieving techniques on postoperative morbidity has so far been rather small or non-demonstrable by statistical analysis.” 3 As leaders in regional anesthesia and pain medicine, we need to be particularly cautious in ascribing benefit to what has become “standard practice” without convincing evidence. This is extremely important when one consid- ers the devastating complication of permanent neurologic deficit inherent in neuraxial manipulation and continu- ous epidural analgesia. Until now, the risk of neuraxial hematoma in patients receiving perioperative low molec- ular weight heparin or intraoperative and postoperative anticoagulation, or in patients who develop postoperative coagulopathy for a multitude of reasons, has probably not generated the concern it deserves. Hopefully the disturbing data emerging on the inci- dence of neuraxial and spinal infection associated with epidural catheterization in postoperative pain manage- ment 4 will convince those who continue to inflate the benefits and belittle the risks, to pause and reevaluate their practice. Gordon O. Launcelott, M.D., F.R.C.P.C. Associate Professor, Anaesthesia Dalhousie University Director, Acute Pain Service QE II Health Sciences Centre Halifax, Nova Scotia Canada References 1. Wedel DJ, Berry D. He said, she said, NSAIDs. Reg Anesth Pain Med 2003;28:372-375. 2. Kehlet H, Wilmore DW. Multimodal strategies to improve surgical outcome. Am J Surg 2002;183:630-641. 3. Kehlet H, Holte K. Effect of postoperative analgesia on surgi- cal outcome. Br J Anaesth 2001;87:62-72. 4. Wang LP, Hauerberg J, Schmidt JF. Incidence of spinal epi- dural abscess after epidural analgesia: A national 1-year survey. Anesthesiology 1999;91:1928-1936. Accepted for publication March 2, 2004. doi:10.1016/j.rapm.2004.03.002 Adding Methylprednisolone to Local Anesthetic Increases the Duration of Axillary Block To the Editor: Prolonging the duration of local anesthetic action is often desirable, because it increases block duration, leading to longer surgical anesthesia and analgesia. Epinephrine, clonidine, 1 microspheres saturated with local anesthetic, 2,3 and liposome-encapsulated local anesthetics 4 have all been used to extend the effect of local anesthetics. Thirteen years ago, while treating some of our reflex sympathetic dystrophy patients with axillary block to en- hance aggressive physical therapy, we discovered seren- dipitously that brachial plexus blockade is prolonged if methylprednisolone (Depomedrol; Pharmacia Corpora- tion, New York, NY) is added to the administered solu- tion. We herein share our findings from a pilot study. The study was approved by the Crystal Clinic Surgery Center Research Committee, and informed consent was obtained from 100 surgical patients (between January and April 1997) who required long-acting axillary block- ade for upper extremity procedures. Patients were di- vided evenly into 2 groups. All solutions contained 20 mL 2% mepivacaine, 20 mL 0.75% bupivacaine, and 0.2 mg epinephrine. Every other solution contained methylpred- nisolone 40 mg. The patients and surgeons were unaware of what solution they received. An additional 5 to 10 mL of a solution containing equal amounts of 1% mepiva- 380 Regional Anesthesia and Pain Medicine Vol. 29 No. 4 July–August 2004

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Page 1: Overinflated benefits and de-emphasized risks

belief excluding these patients a priori from the beneficialeffects of epidural anesthesia would be unjustified.

Tatiana Sidiropoulou, M.D.Mario Dauri, M.D.

Department of AnesthesiologyUniversity of Rome “Tor Vergata”

Rome, Italy

References

1. Sidiropoulou T, Pompeo E, Bozzao A, Lunardi P, Dauri M.Epidural hematoma after thoracic epidural catheter re-moval in the absence of risk factors. Reg Anesth Pain Med2003;28:531-534.

2. Kvolik S, Glavas-Obrovac L, Sakic K, Margaretic D, Karner K.Anaesthetic implications of anticancer chemotherapy. EurJ Anaesthesiol 2003;20:859-871.

3. Smorenburg S, Hutten B, Prins M. Should patients with ve-nous thromboembolism and cancer be treated differently?Haemostasis 1999;29(Suppl 1):91-97.

4. Mannaerts G, Van Zundert A, Meeusen V. Anaesthesia foradvanced rectal cancer patients treated with combinedmajor resections and intraoperative radiotherapy. Eur JAnaesthesiol 2002;19:742-748.

5. Slinger PD. Pro: Every post-thoracotomy patient deservesthoracic epidural analgesia. J Cardiothorac Vasc Anesth1999;13:350-354.

Accepted for publication March 18, 2004.doi:10.1016/j.rapm.2004.03.005

Overinflated Benefits and De-emphasizedRisks

To the Editor:In Denise Wedel’s Editorial “He Said, She Said,

NSAIDs,”1 she states that Kehlet’s multimodal therapy forthe management of perioperative pain “. . . has becomestandard practice in acute and chronic pain manage-ment.” She then states that, “Proposed and documentedbenefits include improved pain relief, reduction of peri-operative stress response, shorter hospital stay, loweredhospital costs, and reduced morbidity and mortality,”quoting Kehlet’s review, “Multimodal Strategies to Im-prove Surgical Outcome.”2

It is encouraging that she uses the word proposed, be-cause as yet the literature is very soft on any of thebenefits of multimodal therapy for perioperative painmanagement. Certainly with respect to outcome, Kehlethimself writes, “. . . the overall effect of pain relievingtechniques on postoperative morbidity has so far beenrather small or non-demonstrable by statistical analysis.”3

As leaders in regional anesthesia and pain medicine,we need to be particularly cautious in ascribing benefit towhat has become “standard practice” without convincingevidence. This is extremely important when one consid-ers the devastating complication of permanent neurologicdeficit inherent in neuraxial manipulation and continu-ous epidural analgesia. Until now, the risk of neuraxialhematoma in patients receiving perioperative low molec-ular weight heparin or intraoperative and postoperativeanticoagulation, or in patients who develop postoperative

coagulopathy for a multitude of reasons, has probably notgenerated the concern it deserves.

Hopefully the disturbing data emerging on the inci-dence of neuraxial and spinal infection associated withepidural catheterization in postoperative pain manage-ment4 will convince those who continue to inflate thebenefits and belittle the risks, to pause and reevaluatetheir practice.

Gordon O. Launcelott, M.D., F.R.C.P.C.Associate Professor, Anaesthesia

Dalhousie UniversityDirector, Acute Pain Service

QE II Health Sciences CentreHalifax, Nova Scotia

Canada

References

1. Wedel DJ, Berry D. He said, she said, NSAIDs. Reg Anesth PainMed 2003;28:372-375.

2. Kehlet H, Wilmore DW. Multimodal strategies to improvesurgical outcome. Am J Surg 2002;183:630-641.

3. Kehlet H, Holte K. Effect of postoperative analgesia on surgi-cal outcome. Br J Anaesth 2001;87:62-72.

4. Wang LP, Hauerberg J, Schmidt JF. Incidence of spinal epi-dural abscess after epidural analgesia: A national 1-yearsurvey. Anesthesiology 1999;91:1928-1936.

Accepted for publication March 2, 2004.doi:10.1016/j.rapm.2004.03.002

Adding Methylprednisolone to LocalAnesthetic Increases the Durationof Axillary Block

To the Editor:Prolonging the duration of local anesthetic action is often

desirable, because it increases block duration, leading tolonger surgical anesthesia and analgesia. Epinephrine,clonidine,1 microspheres saturated with local anesthetic,2,3

and liposome-encapsulated local anesthetics4 have all beenused to extend the effect of local anesthetics.

Thirteen years ago, while treating some of our reflexsympathetic dystrophy patients with axillary block to en-hance aggressive physical therapy, we discovered seren-dipitously that brachial plexus blockade is prolonged ifmethylprednisolone (Depomedrol; Pharmacia Corpora-tion, New York, NY) is added to the administered solu-tion. We herein share our findings from a pilot study.

The study was approved by the Crystal Clinic SurgeryCenter Research Committee, and informed consent wasobtained from 100 surgical patients (between Januaryand April 1997) who required long-acting axillary block-ade for upper extremity procedures. Patients were di-vided evenly into 2 groups. All solutions contained 20 mL2% mepivacaine, 20 mL 0.75% bupivacaine, and 0.2 mgepinephrine. Every other solution contained methylpred-nisolone 40 mg. The patients and surgeons were unawareof what solution they received. An additional 5 to 10 mLof a solution containing equal amounts of 1% mepiva-

380 Regional Anesthesia and Pain Medicine Vol. 29 No. 4 July–August 2004