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use of epidurals for colorectal surgery
- julian m brown (21 June 2005)
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Re: use of epidurals for colorectal surgery
- John A W Wildsmith (23 June 2005)
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Variations in Perioperative Surgical Care: Defining 'Best-Practice' Remains Controversial
- Catherine J Walter, John R. T. Monson (29 June 2005)
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Fluid restriction is controversial at best
- Edward Burdett, Michael G Mythen (14 July 2005)
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Starved, stressed ...and drowned? Perioperative practice and a choice of perspective.
- Kristoffer Lassen, Olle Ljungqvist, Cornelis HC Dejong, Jonatan Hausel, Ken Fearon and Arthur Revhaug (9 September 2005)
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julian m brown, consultant anaesthetist department of anaesthesia, frenchay hospital, frenchay park road, bristol bs16 1le
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Editor- Lassen et al1 have published an interesting survey of perioperative practice in colorectal surgery. The authors consider epidural analgesia to be optimal and failure to use it outside a high dependency unit to be conservative. They also advocate the use of a fluid restricted strategy. The use of epidural analgesia leads to vasodilatation which in the ward setting is likely to be managed with increased intravenous fluids. It seems likely that the units in their survey which routinely use epidurals on wards are simply unable to use the fluid restricted strategy which the authors favour. Two large randomised controlled trials have failed to demonstrate any mortality or morbidity benefit from the use of epidural analgesia in major intra-abdominal surgery2,3. The use of epidurals outside a high dependency setting cannot be considered superior care and may contribute to post operative fluid problems. 1. Lassen K, et al on behalf of the Enhanced Recovery After Surgery (ERAS) Group Patterns in current perioperative practice: survey of colorectal surgeons in five northern European countries BMJ 2005:1420- 1421 2. Rigg JRA, Jamrozik K, Myles PS, et al and the MASTER Anaesthesia Trial Study Group. Epidural anaesthesia and analgesia and outcome of major surgery: a randomised trial. Lancet 2002; 359: 1276-1282 3. Park WY, Thompson J, Lee KK. Effect of epidural anesthesia and analgesia on perioperative outcome. A randomised controlled Veterans' Administration study. Ann Surg 2001; 234: 560-571 Competing interests: None declared |
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John A W Wildsmith, Professor of Anaesthesia Dundee DD5 2LQ
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Dr Brown's views will be supported by many who read this paper which might have been less contentious in some of its statements if an anaesthetist had been amongst the authors. If groups are going to make comments about the use (or lack of use) of a particular technique then they should include a relevant expert among them to provide the necessary input. Having relieved myself of that whinge, I think that there are other issues which need further comment. The name of the area (general ward or high dependency area) in which patients are managed after major surgery (with or without an epidural) matters naught: what matters is the quality/quantity of medical and nursing care available. However, the staff involved must also have expertise and experience in the supervision of patients receiving epidural analgesia if it is to be used safely and effectively. In many hospitals that level of care can only be guaranteed in the defined high dependency unit, although if the level of care available in a general ward is not appropriate to epidural supervision I am not sure I would want major surgery there anyway, no matter what type of analgesia was used! As to the debate about the influence of epidural analgesia on surgical outcome, Dr Brown refers correctly to two important studies, but ignores the many questions which surround these papers and the subject as a whole. Space precludes full consideration of these questions here, but one key point is that no one has ever disputed that the quality of pain relief is vastly superior. In a perfect world that should be evidence enough, but the other questions do need to be addressd[1]. I believe that properly conducted and managed (easy to state, harder to achieve) epidural analgesia can provide marked benefits: we simply have not proved it yet in the wider setting. 1. Wildsmith JAW. No sceptic me, but the long day’s task is not yet done: The 2002 Gaston Labat Lecture. Regional Anesthesia & Pain Management 2002; 27: 503-8. Competing interests: I have acted as a consultant to, and received research funding from, AstraZeneca |
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Catherine J Walter, Clinical research fellow Academic Surgical Unit, Castle Hill Hospital, Cottingham, Hull HU16 5JQ, John R. T. Monson
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Lassen and colleagues highlight the important issue of variation in surgical practice which currently exists across Europe.1 Clearly this study may under estimate the true variation in practice seen throughout the whole of Northern Europe by only sampling countries containing ERAS- group (Enhanced Recovery After Surgery) consultants. After all, the ERAS Group has an expressed interest in enhancing recovery after surgery by optimising perioperative care through modulating the areas of patient management examined within the survey.2 None-the-less such variation will either be due to an absence of evidence guiding management of patients or, alternatively, insufficient implementation of effective treatments derived from rigorous evidence. The authors assume it is the latter problem. Rather than implicitly blaming some surgeons and surgical centres for not implementing ‘best practice’ it might be that these surgeons and anaesthetists do not accept current evidence for such practice as being sufficiently robust in order to change their practice. Take Brandstrup et al’s paper on fluid restriction for example, would the authors not agree that we are right to be cautious of a trial that reports methods of allocation concealment which allows for potential subversion of randomisation, and has a post-randomisation exclusion rate of 18%?3,4 In effect what Lassen et al’s study actually represents are the perceptions that lead ERAS surgeons and their national colleagues hold, or feel they should hold, about their current perioperative management. In order to promote uniformity in perioperative practice surely the first step is to reach a consensus about what represents current and robust best -evidence by using sound and systematic evaluations of the available literature. 1 Lassen K, Revhaug A, Meyenfelt M, Dejong C, Hannemann P, Ljungqvist O, Nygren J, Hausel J, Fearon K, Andersen J. Patterns in current perioperative practice: survey of colorectal surgeons in five northern European countries. BMJ 2005;1420 2 The National Research Register http://www.nrr.nhs.uk/ViewDocument.asp?ID=N0217110493 [19.06.05] 3 Brandstrup B, Tonnesen H, Beier-Holgersen R, Hjortso E, Ording H, Lindorff-Larsen K, et al. Effects of intravenous fluid restriction on postoperative complications: comparison of two perioperative fluid regimems: a randomised assessor-blinded multicenter trial. Ann Surg 2003; 238: 641 4 Schultz K. Subverting Randomization in Controlled Trials. JAMA 1995; 274: 1456 Competing interests: None declared |
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Edward Burdett, Research Fellow UCL Centre for Anaesthesia, Middlesex Hospital, Mortimer Street, London W1T 3AA, Michael G Mythen
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Editor – Lassen et al1 has pointed out that surgical practice differs between Northern European centres but uses misleading evidence to compare them to the gold standard. In judging those centres that fluid restrict as following best evidence, Lassen ignores the point: there is an important difference between encouraging fluid restriction and avoiding fluid overload. The study he quotes to support his hypothesis2, which was published several months after he began his own, suggests that an excess of normal saline is associated with an increase in morbidity post-operatively. There is no doubt that large amounts of normal saline causes metabolic acidosis3l, and that an excess of crystalloid impairs tissue perfusion. But we know also that goal-directed therapy produces superior outcome to a traditional ‘one-size-fits-all’ approach4. It is with relief, therefore that we find that few centres dogmatically restrict fluid therapy after laparotomy, but with concern that Lassen believes they should. Reference List (1) Lassen K, Hannemann P, Ljungqvist O, Fearon K, Dejong CH, von Meyenfeldt MF et al. Patterns in current perioperative practice: survey of colorectal surgeons in five northern European countries. BMJ 2005; 330(7505):1420-1421. (2) Brandstrup B, Tonnesen H, Beier-Holgersen R, Hjortso E, Ording H, Lindorff-Larsen K et al. Effects of intravenous fluid restriction on postoperative complications: comparison of two perioperative fluid regimens: a randomized assessor-blinded multicenter trial. Ann Surg 2003; 238(5):641-648. (3) Scheingraber S, Rehm M, Sehmisch C, Finsterer U. Rapid saline infusion produces hyperchloremic acidosis in patients undergoing gynecologic surgery. Anesthesiology 1999; 90(5):1265-1270. (4) Gan TJ, Soppitt A, Maroof M, El-Moalem H, Robertson KM, Moretti E et al. Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery. Anesthesiology 2002; 97(4):820-826. Competing interests: None declared |
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Kristoffer Lassen, Consultant surgeon University Hospital Northern Norway, Olle Ljungqvist, Cornelis HC Dejong, Jonatan Hausel, Ken Fearon and Arthur Revhaug
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Editor! We have with interest read the 4 commentary letters by UK doctors Brown, Wildsmith, Burdett and Walter to our recent paper in this journal.(1) We feel that the presented remarks do not address the central issues of our paper, nor do they affect the main conclusion, which is that in areas where there is no controversy about the evidence, there is still no uniformity in practice. We maintain that by available documentation, an unacceptable proportion of patients are treated sub-optimally, and that many are literally starved, stressed and – if not actually drowned – surely in rough waters. We do not dispute that there are issues that deserve a more detailed discussion. Avoidance of sodium and fluid overload is clearly a better term than fluid/saline restriction, and notably the one we used in three out of four places in our paper. The use of Brandstrups study,(2) as the only reference was due to the space- and reference restrictions imposed by the format our paper was given. While one study alone does not justify a fluid/sodium restricted regimen, literature published prior to our investigation quite clearly warns against sodium/fluid overload.(3,4) As more recent studies have emerged,(5,6) it is easy to agree that the optimal sodium/fluid regimen perioperatively is still unclear. Avoidance of overload remains however, both clinically and semantically, a safe recommendation! Is the use of postoperative epidurals part of optimal evidence-based perioperative care? As commented, the pain-relieving effect of a well placed epidural is very good, and not even questioned by Rigg and co- workers.(7,8) The other important benefit is that it does not preclude immediate mobilisation and oral diet (from the evening of the day of operation). If you do not plan to mobilise your patient immediately after surgery, or if you plan to keep him nil-by-mouth for 48 hours, there is probably no reason to avoid opioids parenterally. Only a multimodal and enhanced regimen will exploit the real benefits of postoperative epidurals.(9,10) In our own centres, the epidurals are handled by ward nurses and hypotension countered mainly by individual dose adjustments. Dr. Wildsmith finds it contentious that surgeons write about peri- operative care without the auspices of an anaesthetist. We can only hope that this remark was made in jest as all the surveyed modalities are the responsibility of the surgeon, and administered or withheld by the surgical ward nurses. Dr. Walter commendably suggests that we "reach a consensus about what represents current and robust best-evidence by using sound and systematic evaluations of the available literature". We completely agree with her view, and base our current work on such a document.(11) On behalf of the authors. Reference List 1. Lassen K, Hannemann P, Ljungqvist O, Fearon K, Dejong CH, Meyenfeldt MF et al. Patterns in current perioperative practice: survey of colorectal surgeons in five northern European countries. BMJ 2005;330:1420 -1. 2. Brandstrup B, Tonnesen H, Beier-Holgersen R, Hjortso E, Ording H, Lindorff-Larsen K et al. Effects of intravenous fluid restriction on postoperative complications: comparison of two perioperative fluid regimens: a randomized assessor-blinded multicenter trial. Ann Surg 2003;238:641-8. 3. Holte K, Sharrock NE, Kehlet H. Pathophysiology and clinical implications of perioperative fluid excess. Br J Anaesth 2002;89:622-32. 4. Lobo DN, Bostock KA, Neal KR, Perkins AC, Rowlands BJ, Allison SP. Effect of salt and water balance on recovery of gastrointestinal function after elective colonic resection: a randomised controlled trial. Lancet 2002;359:1812-8. 5. Holte K, Klarskov B, Christensen DS, Lund C, Nielsen KG, Bie P et al. Liberal versus restrictive fluid administration to improve recovery after laparoscopic cholecystectomy: a randomized, double-blind study. Ann Surg 2004;240:892-9. 6. Nisanevich V, Felsenstein I, Almogy G, Weissman C, Einav S, Matot I. Effect of intraoperative fluid management on outcome after intraabdominal surgery. Anesthesiology 2005;103:25-32. 7. Rigg JR, Jamrozik K, Myles PS, Silbert BS, Peyton PJ, Parsons RW et al. Epidural anaesthesia and analgesia and outcome of major surgery: a randomised trial. Lancet 2002;359:1276-82. 8. Kehlet H, Holte K. Epidural anaesthesia and analgesia in major surgery. The Lancet 2002;360:568-9. 9. Brodner G, Van Aken H, Hertle L, Fobker M, Von Eckardstein A, Goeters C et al. Multimodal perioperative management--combining thoracic epidural analgesia, forced mobilization, and oral nutrition--reduces hormonal and metabolic stress and improves convalescence after major urologic surgery. Anesth Analg 2001;92:1594-600. 10. Kehlet H. Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth 1997;78:606-17. 11. Fearon KC, Ljungqvist O, Von Meyenfeldt M, Revhaug A, Dejong CH, Lassen K et al. Enhanced recovery after surgery: A consensus review of clinical care for patients undergoing colonic resection. Clin Nutr 2005;24:466-77. Competing interests: None declared |
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