Effects of epidural-and-general anesthesia combined versus general anesthesia alone on the venous hemodynamics of the lower limb

Summary

Our hypothesis was that, due to its sympatholytic action, epidural anesthesia (EA) administered as part of anesthesia in abdominal surgery would generate a marked venous leg flow enhancement, thus aiding in the prevention of peroperative venous stasis. We studied, and comprehensively quantified the venous haemodynamic changes in the lower limb during and immediately after abdominal surgery performed under EA and general (GA) anesthesia combined, in comparison to GA alone. This is a prospective, randomized, controlled study, stratified for hypertension and smoking, comprising ASA 1-2 patients undergoing elective total abdominal hysterectomy. Those with peripheral vascular or chronic venous disease, prior DVT or BMI>35 were excluded. Eligible recruits received either GA (Group GA) (n = 10; age 36-65, median 50) alone or epidural anesthesia (EA) and GA combined (Group EA/GA) (n = 9; age 32-58, median 46). EA (L_1-2) was administered using lignocaine 2%. Both groups had GA induced with fentanyl and propofol, maintained with N₂O and isoflurane; larygoscopy was facilitated with vecuronium; analgesia was provided either with morphine (Group GA) or epidurally with 2% lignocaine boli (Group EA/GA). Hemodynamics were determined at the popliteal vein in the horizontal supine position at baseline (resting prior to anesthesia), post epidural (20 min after delivery of EA), post induction (15 min after laryngeal intubation), surgery (upon uterus removal) and recovery (30 min after extubation). There was no difference in the mean velocity[V_mean] between the 2 groups at baseline (p = 0.35_{[Mann-Whitney]}), and post induction (p = 0.5_{[Mann-Whitney]}). However V_mean was significantly higher in Group EA/GA than Group GA, both at surgery (point estimate[PE]: 1.8 cm/s; 95% CI: 0.01, 6.3 cm/s; p <0.05_{[Mann-Whitney]}) and recovery (PE: 2.6 cm/s; 95% CI: 0.4, 5.1 cm/s; p = 0.02_{[Mann-Whitney]}). Volume flow[V_Q] was similar in the 2 groups at baseline and post induction (both, p >0.1_{[Mann-Whitney]}), but was significantly higher in Group EA/GA at surgery (PE: 54 ml/min; 95% CI: 18, 159 ml/min; p = 0.045_{[Mann-Whitney]}) and recovery (PE: 49 ml/min; 95% CI: 16, 129 ml/min; p=0.0037_{[Mann-Whitney]}). Peak velocity, V_mean and V_Q increased significantly post epidural in Group EA/GA. Contrary to the venous leg flow attenuation in elective abdominal surgery under GA and upon its recovery, EA administered as part of GA is associated with a significant enhancement of both V_mean and V_Q. This beneficial hemodynamic effect of EA at the vulnerable stage of recovery may be critically essential in light of enhanced blood viscosity, fibrinolytic shutdown, endothelial/platelet activation and immobility, acting in synergy with putative cardiorespiratory protection. The results of this study lend support to the preferential selection of combined EA/GA in subjects at high risk for venous thromboembolism, particularly when optimal DVT prophylaxis is practically unattainable due to limitations pertaining to the nature of surgery.

Keywords

Epidural anesthesia - venous hemodynamics - stasis

• References

• 1 Rodgers A, Walker N, Schug S. et al. Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials. Br Med J 2000; 321: 1493.
• 2 Park WY, Thompson JS, Lee KK. Effect of epidural anesthesia and analgesia on perioperative outcome: a randomized, controlled Veterans Affairs cooperative study. Ann Surg 2001; 234: 560-9.
• 3 Jorgensen LN, Rasmussen LS, Nielsen PT. et al. Antithrombotic efficacy of continuous extradural analgesia after knee replacement. Br J Anaesth 1991; 66: 8-12.
• 4 Sharrock NE, Haas SB, Hargett MJ. et al. Effects of epidural anesthesia on the incidence of deep-vein thrombosis after total knee arthroplasty. J Bone Joint Surg Am 1991; 73 (04) 502-6. Erratum in: J Bone Joint Surg Am 1991; 73: 952.
• 5 Modig J, Hjelmstedt A, Sahlstedt B. et al. Comparative influences of epidural and general anaesthesia on deep venous thrombosis and pulmonary embolism after total hip replacement. Acta Chir Scand 1981; 147: 125-30.
• 6 Modig J. The role of lumbar epidural anaesthesia as antithrombotic prophylaxis in total hip replacement. Acta Chir Scand 1985; 151: 589-94.
• 7 Rosenfeld BA, Beattie C, Christopherson R. et al. The effects of different anesthetic regimens on fibrinolysis and the development of postoperative arterial thrombosis. Perioperative Ischemia Randomized Anesthesia Trial Study Group. Anesthesiology 1993; 79: 435-43.
• 8 Henny CP, Odoom JA, ten Cate H. et al. Effects of extradural bupivacaine on the haemostatic system. Br J Anaesth 1986; 58: 301-5.
• 9 Tuman KJ, McCarthy RJ, March RJ. et al. Effects of epidural anesthesia and analgesia on coagulation and outcome after major vascular surgery. Anesth Analg 199; 73: 696-704.
• 10 Modig J. Influence of regional anesthesia, local anesthetics, and sympathicomimetics on the pathophysiology of deep vein thrombosis. Acta Chir Scand Suppl 1989; 550: 119-24 discussion 124-7. Review.
• 11 Rordam P, Olesen HL, Sindrup J. et al. Effect of epidural anaesthesia on dorsal pedis arterial diameter and blood flow. Clin Physiol 1995; 15: 143-9.
• 12 Modig J, Malmberg P, Karlstrom G. Effect of epidural versus general anaesthesia on calf blood flow. Acta Anaesthesiol Scand 1980; 24: 305-9.
• 13 Perhoniemi V, Linko K. Effect of spinal versus epidural anaesthesia with 0.5% bupivacaine on lower limb blood flow. Acta Anaesthesiol Scand 1987; 31: 117-21.
• 14 Hosoda R, Hattori M, Shimada Y. Favorable effects of epidural analgesia on hemodynamics, oxygenation and metabolic variables in the immediate post-anesthetic period. Acta Anaesthesiol Scand 1993; 37: 469-74.
• 15 Hickey NC, Wilkes MP, Howes D. et al. The effect of epidural anaesthesia on peripheral resistance and graft flow following femorodistal reconstruction. Eur J Vasc Endovasc Surg 1995; 09: 93-6.
• 16 Lee A. Local techniques. In Aikenhead AR, Rowbotham DJ, Smith G. Textbook of Anaesthesia. Churchill Livingstone; London: 2001: 555-75.
• 17 Poikolainen E, Hendolin H. Effects of lumbar epidural analgesia and general anaesthesia on flow velocity in the femoral vein and postoperative deep vein thrombosis. Acta Chir Scand 1983; 149: 361-4.
• 18 Porter JM, Moneta GL. Reporting standards in venous disease: an update. International Consensus Committee on Chronic Venous Disease. J Vasc Surg 1995; 21: 635-45.
• 19 van Bemmelen PS, Bedford G, Beach K. et al. Quantitative segmental evaluation of venous valvular reflux with duplex ultrasound scanning. J Vasc Surg 1989; 10: 425-31.
• 20 Nicolaides AN. Cardiovascular Disease Educational and Research Trust. IEuropean Society of Vascular Surgery; The International Angiology Scientific Activity Congress Organization; International Union of Angiology; Union Internationale de Phlebologie at the Abbaye des Vaux de Cernay. Investigation of chronic venous insufficiency: A consensus statement (France, March 5-9, 1997).. Circulation 2000; 102: E126-63.
• 21 Delis KT, Husmann M, Kalodiki E. et al. In situ hemodynamics of perforating veins in chronic venous insufficiency. J Vasc Surg 2001; 33: 773-82.
• 22 Delis KT, Knaggs AL, Sonecha T. et al. Lower limb venous haemodynamic impairment on dependency: Quantification and implications for the “economy class” position. Thromb Haemost 2004; 91: 941-50.
• 23 Hurford WE, Bailin MT, Davison JK. et al. Clinical Anesthesia Procedures of the Massachusetts General Hospital. fifth edition. Lippincott Raven; Philadelphia: 1998
• 24 Altman DG. Practical Statistics for Medical Research. Chapman and Hall/CRC Boca Raton; 1999
• 25 Bowler GM, Lamont MC, Scott DB. Effect of extradural bupivacaine or i.v. diamorphine on calf blood flow in patients after surgery. Br J Anaesth 1987; 59: 1412-9.
• 26 Davis FM, Laurenson VG, Gillespie WJ. et al. Leg blood flow during total hip replacement under spinal or general anaesthesia. Anaesth Intensive Care 1989; 17 (02) 136-43.
• 27 Haljamae H, Frid I, Holm J. et al. Epidural vs general anaesthesia and leg blood flow in patients with occlusive atherosclerotic disease. Eur J Vasc Surg 1988; 02 (06) 395-400.
• 28 Foate JA, Horton H, Davis FM. Lower limb blood flow during transurethral resection of the prostate under spinal or general anaesthesia. Anaesth Intensive Care 1985; 13 (04) 383-6.
• 29 Cousins MJ, Wright CJ. Graft, muscle, skin blood flow after epidural block in vascular surgical procedures. Surg Gynecol Obstet 1971; 133 (01) 59-64.
• 30 Arndt JO, Hock A, Stanton-Hicks M. et al. Peridural anesthesia and the distribution of blood in supine humans. Anesthesiology 1985; 63 (06) 616-23.
• 31 Holm J, Frid J, Akerstrom G. et al. Ankle brachial index (ABI) and leg blood flow following epidural anaesthesia. Int Angiol 1988; 07 (01) 26-31.
• 32 Delis KT, Nicolaides AN, Stansby G. Effect of posture on popliteal artery haemodynamics. Arch Surg 2000; 135: 265-9.
• 33 Breslow MJ, Parker SD, Frank SM. et al. Determinants of catecholamine and cortisol responses to lower extremity revascularization: The PIRAT Study Group. Anesthesiology 1993; 79: 1202-9.
• 34 Drummond GB. The abdominal muscles in anaesthesia and after surgery. Br J Anaesth 2003; 91: 73-80.
• 35 Comerota AJ, Stewart GJ, Alburger PD. et al. Operative venodilation: a previously unsuspected factor in the cause of postoperative deep vein thrombosis. Surgery 1989; 106: 301-8.
• 36 Stewart GJ, Lachman JW, Alburger PD. et al. Intraoperative venous dilatation and subsequent development of deep vein thrombosis in patients undergoing total hip or knee replacement. Ultrasound Med Biol 1990; 16: 133-40.
• 37 Hollmann MW, Wieczorek KS, Smart M. et al. Epidural anesthesia prevents hypercoagulation in patients undergoing major orthopedic surgery. Reg Anesth Pain Med 2001; 26: 215-22.
• 38 Modig J, Borg T, Bagge L. et al. Role of extradural and of general anaesthesia in fibrinolysis and coagulation after total hip replacement. Br J Anaesth 1983; 55: 625-9.
• 39 Mitchell RN. Hemodynamic disorders, thrombosis and shock. In Robbins SL, Cotran RS, Kumar V, Collins T. (editors): Pathologic basis of disease. W.B. Saunders; Philadelphia: 1999: 71-88.
• 40 Meissner MH, Strandness Jr. DE. Pathophysiology and natural history of acute DVT. In Rutherford RB. ed. Vascular Surgery. W.B. Saunders; Philadelphia, Pennsylvania: 2000: 1920-37.