Urinary retention in thoracic epidural patients

Choi S, Mahon P, Awad IT. Neuraxial anesthesia and bladder dysfunction in the perioperative period: a systematic review. Can J Anaesth. 2012 Jul;59(7):681-703. Erratum in: Can J Anaesth. 2017 Dec 18. Full-text for Emory users.

Principal findings: Our search yielded 94 studies, and in 16 of these studies, the authors reported time to micturition after intrathecal anesthesia of varying local anesthetics and doses. Intrathecal injections were performed in 41 of these studies, epidural anesthesia/analgesia was used in 39 studies, and five studies involved both the intrathecal and epidural routes. Meta-analysis was not possible because of the heterogeneity of interventions and reported outcomes. The duration of detrusor dysfunction after intrathecal anesthesia is correlated with local anesthetic dose and potency. The incidence of urinary retention displays a similar trend and is further increased by the presence of neuraxial opioids, particularly long-acting variants. Urinary tract infection secondary to catheterization occurred rarely.

Conclusions: Neuraxial anesthesia/analgesia results in transient detrusor dysfunction. The duration of dysfunction depends on the potency and dose of medication used; however, it does not appear to result in significant morbidity.

Allen MS, et al. Optimal Timing of Urinary Catheter Removal After Thoracic Operations: A Randomized Controlled Study. Ann Thorac Surg. 2016 Sep;102(3):925-930. Full-text for Emory users.

Results: The study enrolled 374 patients, 217 men (58%) and 157 women (42%). The 247 eligible and evaluated patients, 141 (57.1%) men and 106 (42.9%) women, were a median age of 61.5 years (range, 21 to 87 years). There were no statistically significant differences in any of the preoperative or operative categories between the two groups. Median length of stay was 5 days (range, 2 to 42 days) for all patients, and there was no difference between the two groups. Postoperatively, 19 patients (7.7%) required urinary catheter reinsertion after it was removed. A significantly greater number of patients in the early removal group required reinsertion of the urinary catheter (15 [12.4%] vs 4 [3.2%]); p = 0.0065). Patients whose urinary catheter was removed within 48 hours of the operation had a much higher rate of bladder scans postoperatively (59.5% [n = 72]) and required more in-and-out catheterization than those whose urinary catheter was removed 6 hours after the epidural analgesia was discontinued (31.0% [n = 39]; p < 0.0001). The only documented urinary tract infection in the entire cohort occurred in a patient whose urinary catheter was removed within 48 hours after the operation. No urinary tract infections developed in the 126 patients whose urinary catheter remained in place until the epidural catheter was removed.

Conclusions: In a randomized control trial, patients with an epidural catheter in place after a general thoracic surgical operation have a higher rate of urinary problems when the urinary catheter is removed early, while the epidural catheter is still in place, compared with patients whose urinary catheter is removed after the epidural analgesia is discontinued.

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Management of malignant hyperthermia

Hopkins PM, Girard T, Dalay S, Jenkins B, Thacker A, Patteril M, McGrady E. Malignant hyperthermia 2020: Guideline from the Association of Anaesthetists. Anaesthesia. 2021 May;76(5):655-664. Free full-text.

Kim KSM, Kriss RS, Tautz TJ. Malignant Hyperthermia: A Clinical Review. Adv Anesth. 2019 Dec;37:35-51. Full-text for Emory users.

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Rapid Sequence Intubation

Groth CM, Acquisto NM, Khadem T. Current practices and safety of medication use during rapid sequence intubation. J Crit Care. 2018 Jun;45:65-70.

“A total of 404 patients from 34 geographically diverse institutions were included (mean age 58 ± 22 years, males 59%, pediatric 8%). During RSI, 21%, 87%, and 77% received pre-induction, induction, and paralysis, respectively. Significant differences in medication use by provider type were seen. Etomidate was administered to 58% with sepsis, but was not associated with adrenal insufficiencyKetamine was associated with hypotension post-RSI [RR = 1.78 (1.36–2.35)] and use was low with traumatic brain injury/stroke (1.5%). Succinylcholine was given to 67% of patients with baseline bradycardia and was significantly associated with bradycardia post-RSI [RR = 1.81 (1.11–2.94)]. An additional 13% given succinylcholine had contraindications. Sedation practices post-RSI were not consistent with current practice guidelines and most receiving a non-depolarizing paralytic did not receive adequate sedation post-RSI.”

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Regional anesthesia for arteriovenous fistula surgery

Cole NM, et al. Regional Anesthesia for Arteriovenous Fistula Surgery May Reduce Hospital Length of Stay and Reoperation Rates. Vasc Endovascular Surg. 2018 Aug; 52(6):418-426.

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Results: Patients who received regional anesthesia had the shortest postoperative length of stay (0.67 [standard deviation: 2.0] days) compared to monitored anesthesia care/intravenous (IV) sedation (0.77 [1.8] days) and general anesthesia (1.44 [2.8] days). Administration of regional anesthesia was associated with a shorter length of stay compared to general anesthesia (odds ratio [OR]: 0.55, P = .001). Patients who received monitored anesthesia care/IV sedation had a lower risk of reoperation compared to general anesthesia (OR: 0.65, P = .012) but not compared to regional anesthesia (OR: 0.89, P = .759). Anesthesia type had no significant effects on other measured postoperative complications. Predictors of the type of anesthesia were age and surgical procedure as defined by Current Procedural Terminology code ( P < .001).

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Postoperative negative pressure pulmonary edema

Liu R, Wang J, Zhao G, Su Z. Negative pressure pulmonary edema after general anesthesia: A case report and literature review. Medicine (Baltimore). 2019 Apr;98(17): e15389. doi: 10.1097/MD.0000000000015389.

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It is widely accepted that the central mechanism of postoperative NPPE is related to rapid negative intrapleural pressure increasing due to forceful inspiration against the obstruction, which can be up to 10 times or more that of normal breathing. [7] A typical event leading to acute airway obstruction associated with postoperative NPPE is laryngospasm. Other procedure that increases the risk of NPPE includes oropharyngeal, head, and neck surgery. Five [8–12] of the reported 29 cases involved upper respiratory tract surgery, and 10 [1,3,6,7,13–18] of the cases involved head and neck surgery, which may be related to tissue swelling and the sensitive dilator muscle of the upper airway in head and neck surgeries.

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Article of interest: Retrospective Analysis of the Incidence of Epidural Haematoma in Patients With Epidural Catheters and Abnormal Coagulation Parameters

Gulur P, et al. Retrospective analysis of the incidence of epidural haematoma in patients with epidural catheters and abnormal coagulation parameters. Br J Anaesth. 015;114(5): 808–811.

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“Results: During the study period, 11 600 epidural catheters were placed. In the setting of abnormal coagulation parameters, 278 (2.4%) epidural catheters were placed and 351 (3%) were removed. Two epidural haematomas occurred; both patients had epidural catheters and spinal drains placed for vascular procedures with abnormal coagulation parameters after operatation. The haematomas occurred after removal of the catheters. Based on our study, the incidence of epidural haematoma in patients with abnormal coagulation parameters is 1 in 315 patients, with the lower limit of the 95% confidence interval at 87 and the upper limit at 2597.”

See also: Lee LO, Bateman BT, Kheterpal S, et al. Risk of Epidural Hematoma after Neuraxial Techniques in Thrombocytopenic Parturients: A Report from the Multicenter Perioperative Outcomes Group. Anesthesiology. 2017;126(6):1053–1063.