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Effect of Thoracic Epidural Analgesia on Proinflammatory
Cytokines in Patients Subjected
to Protective Lung Ventilation During Ivor Lewis
Esophagectomy

Research Authors
Khaled M. Fares, MD, Sahar A. Mohamed, MD, Hesham M. Hamza, MD, Douaa M. Sayed, MD,
and Diab F. Hetta, Msc
Research Member
Research Year
2014
Research Journal
Pain Physician
Research Vol
Vol 17 NO 4
Research Rank
1
Research_Pages
305-315
Research Abstract

Background: Thoracic epidural analgesia (TEA) has a well-known effect on neurohormonal
response. Attenuation of stress response by post-operative epidural analgesia has shown beneficial
effects such as lower pain scores and less immunological alterations.
Objectives: Investigation of the combined effects of TEA and protective lung ventilation on proinflammatory
cytokines and patients’ outcome after Ivor Lewis esophagectomy.
Study Design: A randomized controlled study.
Setting: Academic medical center.
Methods: Thirty patients of the American Society of Anesthesiologists (ASA) I and II were
randomly allocated into 2 groups: G1 (n = 15) patients received general anesthesia and were
mechanically ventilated with 9 mL/kg during 2 lung ventilations, reduced to 5 mL/kg and 5cm H2O
positive end expiratory pressure (PEEP) during one lung ventilation (OLV) or GII) (n = 15) patients
received TEA and the same general anesthesia and mechanical ventilation used in G1. Assessment
parameters included hemodynamics, pain severity, total analgesic consumption, and measurement
of interleukins (IL) (IL-6 and IL-8) at baseline time after anesthetic induction (TBaseline,); at the end of
the abdominal stage of the operation (TAbdo,); 15 minutes after initiation and at the end of OLV (TOLV
15) and (TOLV End) respectively; one and 20 hours after the end of the surgical procedure (TPostop1 and
TPostop20), respectively, and patient’s outcome also recorded.
Results: There was a significant reduction in mean arterial blood pressure (MAP) and pulse rate
in GII during the intraoperative period, at Tabdo, TOLV15, and TOLV End (P < 0.05). The mean of systolic
blood pressure (SBP) values were significantly lower in GII over all 3 post-operative days (P = 0.001),
and the mean diastolic blood pressure (DBP) showed a significant reduction in GII for 16 hours
post-operatively (P = 0.001). The mean of heart rate values showed a significant reduction in GII
over all 3 post-operative days in comparison to GI (P = 0.001). The mean resting and dynamic VAS
scores were significantly reduced in GII at all time periods studied in comparison to G1 (P = 0.001).
The daily PCA morphine consumption was markedly decreased in GII compared to GI in the first 3
days post-operatively (P = 0.001). There were significant reductions in blood level of IL-6 and IL-8 in
GII compared to G1 over the entire study period (P < 0.05). There were no significant differences in
post-operative adverse effects between the 2 groups (P > 0.05). The duration of stay in PACU was
significantly decreased in GII (10 ± 2 days) compared to GI (15 ± 3 days) (P = 0.001).
Limitations: This study is limited by its sample size.
Conclusion: Our study concluded that TEA reduced the systemic pro-inflammatory response
and provided optimal post-operative pain relief. Although there were no significant differences in
adverse events, there was a trend towards improved outcome. Further clinical studies with larger
numbers of patients are required.