Strandby Rune B, Ambrus Rikard, Achiam Michael P, Goetze Jens P, Secher Niels H, Svendsen Lars B
Department of Surgical Gastroenterology, Rigshospitalet, Copenhagen, Denmark
Department of Surgical Gastroenterology, Rigshospitalet, Copenhagen, Denmark.
Reg Anesth Pain Med. 2019 May 24. doi: 10.1136/rapm-2019-100508.
A side effect to thoracic epidural anesthesia (TEA) is hypotension induced by central hypovolemia. This study addressed whether early activation (EA) versus late activation (LA) of TEA affects plasma pro-atrial natriuretic peptide (proANP) reflecting deviations in the central blood volume (CBV). We hypothesized that EA TEA would reduce plasma proANP, thus reflecting a decrease in CBV.
A randomized, controlled, single-blinded trial was conducted. Patients undergoing open esophagectomy were randomized to EA (n=25, after induction of general anesthesia) or LA TEA (n=25, after re-established gastric continuity) with the epidural catheter placed at the interspaces Th7-8 or Th8-9. Plasma proANP was determined repetitively along with hemodynamic variables and administration of fluid/vasopressors as postoperative complications were noted.
With EA TEA, plasma proANP decreased following induction of anesthesia to the end of surgery (13%; 113±68 to 99±49 pmol/L; p=0.026), but that was not the case in the LA group (3%; 97±44 to 94±49 pmol/L; p=0.565) despite equal fluid balance (+1584±582 vs +1560±563 mL; p=0.888). Accordingly, the EA group required excessive treatment with vasopressors to maintain MAP >60 mm Hg during surgery (2.7±2 vs 1.6±1.4 ephedrine boluses; p=0.033 and infusion of phenylephrine for 216±86 vs 58±91 min; p<0.001). Plasma proANP and fluid balance were correlated only for EA patients (r=0.44; 95% CI 0.04 to 0.91; p=0.033).
EA TEA reduces plasma proANP indicating that CBV becomes affected. Based on a correlation between plasma proANP and fluid balance, a 2000 mL volume surplus of lactated Ringer's solution is required to maintain plasma proANP stable during open esophagectomy.
2014-002036-14 (https://www.clinicaltrialsregister.eu/ctr-search/search?query=2014-002036-14).
胸段硬膜外麻醉（TEA）的一个副作用是中枢性血容量不足引起的低血压。本研究探讨了TEA的早期激活（EA）与晚期激活（LA）是否会影响反映中枢血容量（CBV）偏差的血浆前心房利钠肽（proANP）。我们假设EA TEA会降低血浆proANP，从而反映CBV的减少。
进行了一项随机、对照、单盲试验。接受开放性食管切除术的患者被随机分为EA组（n = 25，在全身麻醉诱导后）或LA TEA组（n = 25，在重建胃连续性后），硬膜外导管置于胸7 - 8或胸8 - 9间隙。随着术后并发症的出现，重复测定血浆proANP以及血流动力学变量和液体/血管升压药的使用情况。
EA TEA组中，从麻醉诱导到手术结束，血浆proANP降低（13%；从113±68 pmol/L降至99±49 pmol/L；p = 0.026），但LA组并非如此（3%；从97±44 pmol/L降至94±49 pmol/L；p = 0.565），尽管液体平衡相同（+1584±582 vs +1560±563 mL；p = 0.888）。因此，EA组在手术期间需要额外使用血管升压药来维持平均动脉压（MAP）>60 mmHg（麻黄碱推注量为2.7±2 vs 1.6±1.4；p = 0.033，去氧肾上腺素输注时间为216±86 vs 58±91分钟；p<0.001）。仅在EA组患者中，血浆proANP与液体平衡相关（r = 0.44；95%可信区间0.04至0.91；p = 0.033）。
EA TEA降低血浆proANP，表明CBV受到影响。基于血浆proANP与液体平衡之间的相关性，在开放性食管切除术中需要2000 mL乳酸林格氏液的容量过剩来维持血浆proANP稳定。
2014 - 002036 - 14（https://www.clinicaltrialsregister.eu/ctr-search/search?query=2014-002036-14）
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