Indian Journal of Critical Care Medicine

Register      Login

SEARCH WITHIN CONTENT

FIND ARTICLE

Volume / Issue

Online First

Archive
Related articles

VOLUME 23 , ISSUE 2 ( February, 2019 ) > List of Articles

ORIGINAL ARTICLE

Effect of Segmental Thoracic Epidural Block on Pancreatitis Induced Organ Dysfunction: A Preliminary Study

Yash Raj Gupta, Gargi Rai, Arun Gupta

Keywords : Pancreatitis, Procalcitonin, Sepsis, Thoracic epidural block

Citation Information : Gupta YR, Rai G, Gupta A. Effect of Segmental Thoracic Epidural Block on Pancreatitis Induced Organ Dysfunction: A Preliminary Study. Indian J Crit Care Med 2019; 23 (2):89-94.

DOI: 10.5005/jp-journals-10071-23123

License: CC BY-NC 4.0

Published Online: 01-02-2019

Copyright Statement:  Copyright © 2019; Jaypee Brothers Medical Publishers (P) Ltd.


Abstract

Background: This preliminary randomized controlled study evaluated effect of thoracic epidural block (TEB) on progression of acute pancreatitis induced organ dysfunction/failure. Materials and Methods: Patients with predicted severe acute pancreatitis, without contraindication to TEB were randomized to receive (group TE) or not receive a TEB (group NTE) (n = 16 each). For group TE, TEB was performed at T8-9 or T9-10 vertebral level, with infusion of ropivacaine (0.2%) along with fentanyl 2 μg/mL; in group NTE, intravenous morphine was used instead, both interventions titrated to NRS of <4. SOFA score was assessed daily till discharge from ICU, and aggregate SOFA calculated by summing worst scores for each of organ system during ICU stay as primary outcome measure. Other surrogate measures of patient outcome were recorded as secondary objectives. Results: Aggregate SOFA score was statistically similar between both groups (group NTE: 3 [2 - 4]; group TE: 5 [2 - 6]) (P = 0.379); but there was trend of improvement in SOFA score in group TE versus a worsening in group NTE. Duration of hospital stay, and number of patients requiring mechanical ventilation were statistically similar; mortality was insignificantly lesser for group TE (12.5% versus 6.6%; p = 1.000). Fall in serum procalcitonin was significantly greater for group TE. Conclusion: Thoracic epidural was associated with insignificant clinical trend towards better organ functions and lesser mortality; along with significantly greater fall in serum procalcitonin. These are encouraging results that could guide future use of thoracic epidural in acute pancreatitis for its non-analgesic benefits.


PDF Share
  1. Banks PA, Bollen TL et al. Acute Pancreatitis Classification Working Group. Classification of acute pancreatitis--2012: revision of the Atlanta classification and definitions by international consensus. Gut 2013;62:102-111.
  2. Working Group IAP/APA Acute Pancreatitis Guidelines. IAP/APA evidence-based guidelines for the management of acute pancreatitis. Pancreatology 2013;13:1-15.
  3. Cuthbertson CM, Christophi C. Disturbances of the microcirculation in acute pancreatitis. Br J Surg 2006;93:518-530.
  4. Freise H, Lauer S, Anthonsen S, et al. Thoracic epidural analgesia augments ileal mucosal capillary perfusion and improves survival in severe acute pancreatitis in rats. Anesthesiology 2006;105:354-359.
  5. Demirag A, Pastor CM, Morel P, et al. Epidural anaesthesia restores pancreatic microcirculation and decreases the severity of acute pancreatitis. World J Gastroenterol 2006;12:915-920.
  6. Freise H, Lauer S, Konietzny E, Hinkelmann J, Minin E, Van Aken HK, et al. Hepatic effects of thoracic epidural analgesia in experimental severe acute pancreatitis. Anesthesiology 2009;111:1249-1256.
  7. Bachmann KA, Trepte CJ, Tomkötter L, Hinsch A, Stork J, Bergmann W, et al. Effects of thoracic epidural anesthesia on survival and microcirculation in severe acute pancreatitis: a randomized experimental trial. Crit Care 2013;17:R281.
  8. Sadowski SM, Andres A, Morel P, Schiffer E, Frossard JL, Platon A, et al. Epidural anesthesia improves pancreatic perfusion and decreases the severity of acute pancreatitis. World J Gastroenterol 2015;21:12448-56.
  9. Harper D, McNaught CE. The role of thoracic epidural anesthesia in severe acute pancreatitis. Crit Care 2014;18:106-107.
  10. Johnson CD, Abu-Hilal M. Persistent organ failure during the first week as a marker of fatal outcome in acute pancreatitis. Gut 2004;53:1340e4.
  11. Working Party of the British Society of Gastroenterology; Association of Surgeons of Great Britain and Ireland; Pancreatic Society of Great Britain and Ireland; Association of Upper GI Surgeons of Great Britain and Ireland. UK guidelines for the management of acute pancreatitis. Gut 2005;54:1-9.
  12. Vincent JL, Moreno R, Takala J, Willatts S, De Mendonça A, Bruining H, et al. The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure. On behalf of the Working Group on Sepsis-Related Problems of the European Society of Intensive Care Medicine. Intensive Care Med 1996;22:707-710.
  13. De Campos T, Cerqueira C, Kuryura L, Parreira JG, Soldá S, Perlingeiro JA, et al. Morbimortality indicators in severe acute pancreatitis. JOP 2008;9:690-697.
  14. Singh RK, Poddar B, Baronia AK, Azim A, Gurjar M, Singhal S, et al. Audit of patients with severe acute pancreatitis admitted to an intensive care unit. Indian J Gastroenterol 2012;31:243-252.
  15. Ceriani R, Mazzoni M, Bortone F, Gandini S, Solinas C, Susini G, et al. Application of the sequential organ failure assessment score to cardiac surgical patients. Chest 2003;123:1229-1239.
  16. Lee EC, Whitehead AL, Jacques RM, Julious SA. The statistical interpretation of pilot trials: should significance thresholds be reconsidered? BMC Med Res Methodol 2014;14:41.
  17. Huang HL, Nie X, Cai B, Tang JT, He Y, Miao Q, et al. Procalcitonin levels predict acute kidney injury and prognosis in acute pancreatitis: a prospective study. PLoS One 2013;8:e82250.
  18. Spackman DR, McLeod AD, Prineas SN, Leach RM, Reynolds F. Effect of epidural blockade on indicators of splanchnic perfusion and gut function in critically ill patients with peritonitis: a randomised comparison of epidural bupivacaine with systemic morphine. Intensive Care Med 2000;26:1638-1645.
  19. Jabaudon M, Belhadj-Tahar N, Rimmelé T, Joannes-Boyau O, Bulyez S, Lefrant JY, et al; Azurea Network. Thoracic Epidural Analgesia and Mortality in Acute Pancreatitis: A Multicenter Propensity Analysis. Crit Care Med 2018;46:e198-e205.
  20. Fleszler F, Friedenberg F, Krevsky B, Friedel D, Braitman LE. Abdominal computed tomography prolongs length of stay and is frequently unnecessary in the evaluation of acute pancreatitis. Am J Med Sci 2003;325:251-255.
  21. Spanier BW, Nio Y, van der Hulst RW, Tuynman HA, Dijkgraaf MG, Bruno MJ. Practice and yield of early CT scan in acute pancreatitis: a Dutch Observational Multicenter Study. Pancreatology 2010;10: 222-228.
  22. Jabaudon M, Chabanne R, Sossou A, Bertrand PM, Kauffmann S, Chartier C, et al. Epidural analgesia in the intensive care unit: An observational series of 121 patients. Anaesth Crit Care Pain Med 2015;34:217-223.
  23. Bernhardt A, Kortgen A, Niesel HC, Goertz A. Using epidural anesthesia in patients with acute pancreatitis--prospective study of 121 patients. Anaesthesiol Reanim 2002;27:16-22.
  24. Browne RA, Ashworth EJ. The use of epidural block in acute pancreatitis: a report of eight cases. Can Anaesth Soc J 1969;16:416-424.
PDF Share
PDF Share

© Jaypee Brothers Medical Publishers (P) LTD.