Characterization of Epidural Analgesia Interruption and Associated Outcomes After Esophagectomy.

Byrd CT, Kim RK, Manapat P, He H, Tsui BCH, Shrager JB, Berry MF, Backhus LM, Lui NS, Liou DZ. Characterization of Epidural Analgesia Interruption and Associated Outcomes After Esophagectomy. The Journal of surgical research. 2023 Oct 1; 290:92-100.

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Abstract:

INTRODUCTION: Interruption of thoracic epidural analgesia may impact the postoperative course following esophagectomy. This study investigates the incidence and causes of epidural interruption in esophagectomy patients along with associated postoperative outcomes. METHODS: This single-institution retrospective analysis examined patients undergoing esophagectomy who received a thoracic epidural catheter from 2016 to 2020. Patients were stratified according to whether epidural catheter infusion was interrupted or not postoperatively. Outcomes were compared between the two groups, and predictors of epidural interruption and postoperative complications were estimated using multivariable logistic regression. RESULTS: Of the 168 patients who received a thoracic epidural before esophagectomy, 60 (35.7%) required epidural interruption and 108 (64.3%) did not. Interruption commonly occurred on postoperative day 1 and was due to hypotension 80% of the time. Heart failure (10.0% versus 0.9%, P  =  0.009), atrial fibrillation (20.0% versus 3.7%, P  =  0.002), preoperative opioid use (30.0% versus 16.7%, P  =  0.043), and higher American Society of Anesthesiology classification (88.4% versus 70.4%, P  =  0.008) were more prevalent in the epidural interruption cohort. The female gender was associated with epidural interruption on multivariable logistic regression (adjusted odds ratio [AOR] 2.45, P  =  0.039). Patients in the epidural interruption cohort had a higher incidence of delirium (30.5% versus 13.9%, P  =  0.010), sepsis (13.6% versus 3.7%, P  =  0.028), and severe anastomotic leak (18.3% versus 7.4%, P  =  0.032). On adjusted analysis, heart disease (AOR 4.26, P  =  0.027), BMI < 18.5 (AOR 9.83, P  =  0.031), and epidural interruption due to hypotension (AOR 3.51, P  =  0.037) were associated with severe anastomotic leak. CONCLUSIONS: Early epidural interruption secondary to hypotension in esophagectomy patients may be a harbinger of postoperative complications such as sepsis and severe anastomotic leak. Patients requiring epidural interruption due to hypotension should have a low threshold for additional workup and early intervention.