Comparison Features of Methods of Epidural Analgesia as a Part of Combined Anesthesia in Laparoscopic Surgery

The objective: choosing the optimal method of epidural analgesia combined with general anesthesia for typical laparoscopic colorectal surgeries by comparing three different options for its implementation.

Subjects and Methods. 90 patients aged 60 to 85 years were examined, they all underwent planned laparoscopic interventions for colorectal cancer under combined anesthesia (general + epidural anesthesia). Depending on the method of administration of ropivacaine to achieve an epidural block, they were randomized into three groups. In Group 1, it was administered at a concentration of 0.25% in the form of a continuous infusion at a rate of 8 ml/h during the first hour, then 6 ml/ h until the end of the operation. In Group 2, its concentration was increased to 0.375%, the rate of continuous infusion was 8 ml/ h in the first hour, then 6 ml/h. Patients of Group 3 first received ropivacaine as a bolus before the induction of general anesthesia (0.375% – 8 ml over 5 min), then continued administration continuously but at a concentration of 0.25% at a rate of 6 ml/h. Endpoints for hemodynamic assessment: upon admission to the operating room, after induction of anesthesia, after application of carboxyperitoneum, after 1 hour of laparoscopic stage, after elimination of carboxyperitoneum, after extubation, and 1 hour after transfer to the ICU. The total dose of fentanyl was recorded. The assessment of the sensory block was performed using a cold test, the severity of the pain syndrome ‒ on a visual-analog scale (10 points), the density of the block ‒ on an ordinal scale, its upper and lower levels were noted. The motor block was evaluated using a modified Bromage scale.

Results. The doses of fentanyl, rocuronium and the consumption of desflurane during general anesthesia, the values of the BIS index and the time of awakening of patients in all groups did not differ. The average doses of ropivacaine in the groups were different. The total volume of ropivacaine solution was the largest in Group 3, there were no significant differences in the volume of the injected local anesthetic between Group 1 and Group 2. The number of patients who needed vasopressor support with norepinephrine during anesthesia in Group 1 was less versus Groups 2 and 3. The maximum intraoperative dose of norepinephrine and duration of its use were also lower in Group 1. When applying carboxyperitoneum, the most pronounced decrease in hemodynamic parameters was revealed in patients of Group 3. At the 4th stage of the study, after 1 hour of the laparoscopic stage, hemodynamic parameters were higher in patients of Group 1. There were no significant differences in pain intensity between the groups after surgery.

At the same time, the level of motor block was significantly higher in patients of Group 2, while in Groups 1 and 3, motor block did not develop in most of the patients.

Conclusion: The optimal method of epidural analgesia in typical laparoscopic colorectal operations is the use of 0.25% ropivacaine concentration as a continuous infusion only due to ensuring an acceptable level of analgesia, adequate distribution of the sensory block, the minimum degree of motor block, as well as the least negative effect on hemodynamic parameters which reduces the volume of infusion therapy and doses of vasopressors.

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