From: Thoracic epidural analgesia: a new approach for the treatment of acute pancreatitis?
First author and reference | Year | Number | Type of study | Epidural analgesia | Measures | Findings | Strength of the study |
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Bernhardt [31] | 2002 | 121 | Prospective observational study | Catheters were placed in the thoracolumbar region, varying from T8 to L3, most of them being placed between T10 and L1 70 % were thoracic blocks and 30 % were lumbar blocks Epidural analgesia was managed with boli of 3–5 ml of bupivacaine 0.25 % every 4–6 hours. No continuous administration | Safety of procedure Number of doses given Mortality Pain Number of surgeries needed Days of artificial ventilation Biological parameters | - The median epidural block length was 4.2 days - TEA was well tolerated and considered safe even in severe patients - Catheter-associated hypotension occurred in 12 % of the cases, manageable without complication with fluid replacement and amines - Excellent analgesia was achieved in 72 % of observation days without additional drugs - Normalization of pancreatic enzymes occurred sooner in patients with early placement of catheter -13 % of patients required artificial ventilation (mean 12 days) - 24 % of patients had accidental removal of catheter: 7.4 % had three catheters placed, 3.3 % had four catheters placed, without any infectious complications - Average duration of ICU was 12.4 days | Large sample, representative of general population (mean 53.2 years, extremes 15–87) Precise follow-up of doses needed to reach sufficient analgesia |
Jabaudon [32] | 2015 | 121 | Prospective observational multicenter study | Catheters were placed in the thoracolumbar region: 89 % were thoracic blocks and 11 % were lumbar blocks Each center had its own epidural protocol: 26 % used levobupivacaine and 74 % used ropivacaine Local anesthetics were always combined with sufentanil | Safety of procedure in severe patients Mortality Reason for initiating TEA Sepsis status ICU standard measures | - The mean epidural block length was 11 days - 38 patients (31 %) had acute pancreatitis - 8 % of patients presented catheter-associated hypotension, 2.5 % required punctual administration of vasopressin during the catheter placement - 60 % of patients experienced sepsis, 42 % severe sepsis, 22 % septic shock and showed good tolerance to TEA - 65 % of patients required mechanical ventilation during the ICU stay - 17 % had accidental removal of catheter - one case of epidural abscess | Large sample, but only 38 patients experiencing AP Multicenter study Long epidural duration Good tolerance in severe disease |
Sadowski [33] | 2015 | 35 | Randomized control trial Group 1: AP + TEA [13] Group 2: AP alone [22] | All catheters were placed at the thoracic level between T6 and T9, reaching a T4–T12 sensitive block Epidural analgesia was managed on a patient-controlled protocol, with continuous infusion of bupivacaine 0.1 % + fentanyl 2 μg/ml 6–15 ml/h + boli of 3–5 ml every 30–60 min | Safety of TEA in severe AP patients CT perfusion protocol on admission and 72 h (>20 % difference considered significant) Pain measure, length of hospital stay Use of antibiotics Admission to ICU Patient demographics, comorbidities and etiology of AP | - The median epidural block length was 5.7 days - More patients increased their pancreatic perfusion in the group benefitting from TEA compared with AP (43 % vs 7 % respectively) - TEA helped reduce visual analog pain score compared with AP - No significant differences were noted in ICU admission - Less patients in the TEA group required artificial ventilation compared with AP, without reaching statistical evidence (7.7 % vs 27.3 %, P = 0.22) - No differences were observed in locoregional and systemic complications - No length of stay difference | Randomized control trial Study conducted on patients experiencing severe disease Blinded radiologist |