Key result
Early activation of thoracic epidural anesthesia decreased plasma proANP by 13% (113 to 99 pmol/L; p=0.026) during esophagectomy, whereas late activation did not (3% decrease; p=0.565).
Why the study?
Thoracic epidural anesthesia can cause hypotension induced by central hypovolemia, but whether early versus late activation affects plasma proANP reflecting central blood volume deviations was unknown.
Does early activation of thoracic epidural anesthesia reduce plasma proANP in patients undergoing open esophagectomy?
RCT (n=50)
single-blinded
randomized
Does early activation of thoracic epidural anesthesia reduce plasma proANP in patients undergoing open esophagectomy?
Early activation of thoracic epidural anesthesia during open esophagectomy reduces plasma proANP, indicating a decrease in central blood volume and necessitating increased vasopressor support.
Answers are grounded in this paper and cite their sources.
May increase vasopressor needs with early thoracic epidural activation; extends evidence on timing effects during esophagectomy.
BACKGROUND AND OBJECTIVES: 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. METHODS: 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. RESULTS: 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). CONCLUSIONS: 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. TRIAL REGISTRATION NUMBER: 2014-002036-14 (https://www.clinicaltrialsregister.eu/ctr-search/search?query=2014-002036-14).
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Strandby et al. (2019) conducted an RCT in open esophagectomy (n=50). Early activation of thoracic epidural anesthesia vs. Late activation of thoracic epidural anesthesia was evaluated on Plasma pro-atrial natriuretic peptide (proANP). Early activation of thoracic epidural anesthesia decreased plasma proANP by 13% (113 to 99 pmol/L; p=0.026) during esophagectomy, whereas late activation did not (3% decrease; p=0.565).
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