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Table 2 Human studies focusing on the role of thoracic epidural analgesia in acute pancreatitis

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
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
  1. TEA thoracic epidural analgesia, AP acute pancreatitis