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Epidural analgesia
- Peter Faber, Andrew Klein (13 March 2007)
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Epidural anaesthesia and stress induced immunosuppression
- Masanori Ogata (13 March 2007)
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Epidural anaesthesia and stress induced immunosuppression
- Shivanand L Chavan (16 February 2007)
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Peter Faber, SpR Anaesthetics Papworth Hospital, Andrew Klein
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Editor – It was with interest we read the paper by Kawasaki and colleagues1. In the study, the authors aimed to assess the potential immuno-modulatory benefits of epidural analgesia in combination with general anaesthesia. The adjunct of epidural analgesia to general anaesthesia is an important topic, as previous studies have shown beneficial effects of epidural block on patient outcomes2 and immuno- modulatory response to surgery3. The present study investigated selected changes in immune response before, during and after (up to day 4) upper abdominal surgery in groups who either did or did not receive an epidural block as part of their immediate anaesthetic care. However, the authors fail to discuss the effects of post-operative analgesia, in the control group (Group G), which did not receive an intra-operative epidural block. Furthermore, there is no mention of when the epidural catheter is sited in the control group. This is important because in the Methods section, the authors state that the control group did indeed receive post-operative epidural analgesia. Thus, treatments in the two patient groups converge immediately after surgery limiting the conclusions that can be drawn from the study data collected post-operatively. The comparison of post- operative results between the groups may therefore be significantly affected. Additionally, in the discussion, the authors acknowledge the importance of the post-operative period on neutrophil response but fail to clarify why their results are different from previous studies.4 This study purports to assess both the immediate and delayed inflammatory response to upper abdominal surgery. However, any post-operative effects of surgery on immune response are potentially obscured by the use of post- operative epidural analgesia in both patient groups. From the study by Kawasaki and colleagues1, conclusions on the immuno-modulatory effect of epidural analgesia cannot be extrapolated into the post-operative period. Peter Faber Andrew Klein Papworth Hospital NHS Trust, Papworth Everard Cambridge CB23 3RE, U.K. E-mail : faber@doctors.org.uk 1. Kawasaki T, Ogata M, Kawasaki C, Okamoto K, Sata T. Effects of epidural anaesthesia on surgical stress-induced immunosuppression during upper abdominal surgery. Br J Anaesth 2007; 98: 196-03 2. Tziavrangos E, Schug SA. Regional anaesthesia and perioperative outcome. Curr Opin Anaesthesiol 2006; 19:521-5 3. Tonnesen E, Wahlgreen C. Influence of extradural and general anaesthesia on natural killer cell activity and lymphocyte subpopulations in patients undergoing hysterectomy. Br J Anaesth 1988;60:500-7 4. Redmond HP, Watson RW, Houghton T, et al. Immune function in patients undergoing open vs laparoscopic cholecystectomy. Arch Surg 1994;129:1240-6 Conflict of Interest:None declared |
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Masanori Ogata
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Editor- We would like to thank Dr. Shivanand L Chaven for the important questions and interesting comments regarding our article. We also would like to apologize our inadequate description about method and dispel your misunderstandings. Firstly, we mainly maintained patient's hemodynamics by adjusting concentration of the inhalation anesthetics during an operation in GA group. However, regarding a few patients who had persistent hypertension or tachycardia during an operation, we used pentazocine i.v. at the time. Secondly, epidural catheter was placed in the patients of even GA group at a vertebral interplace between T6 and T9 before induction, but we did not use any epidural local anesthetics or opioid during an operation. After the extubation, we immediately injected bolous dose of epidural anaesthesia (5ml of 1% mepivacain) and followed continuous epidural infusion of mepivacaine 1% at 5mlh-1 along with fentanyl 20μgh-1 for 4 days. At the postoperative round, none patient even in GA group complained unsatisfactory pain by this method. Masanori Ogata University of Occupational & Environmental Health,Japan E-mail:mogata@med.uoeh-u.ac.jp Conflict of Interest:None declared |
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Shivanand L Chavan, Specialist Registrar Birmingham Children's Hospital,Birmingham
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Editor- I was interested to read the study by Kawasaki and colleagues[1] and would like congratulate them on their excellent research work.However, reading through the article, I had few questions unanswered;Firstly, according to the authors, any further use of opioid apart from fentanyl at induction was avoided because of their immune modulator effects. Does that mean that the patients in GA group did not require any other form of intra operative analgesia for an upper abdominal procedure of more than four hours(mean duration of procedure 250.5 mins)?. Secondly, in the Materials and Methods, the authors mention starting epidural mepivacaine 1% at 5 ml h–1 along with fentanyl 20 µg h–1 in both groups, but the patients in GA group did not have any epidural sited. Is this a printing error? Or did the patients in GA group had an epidural sited at the end of the procedure? Finally, there is no mention about the postoperative pain relief in patients in GA group as the duration of the study was well into post operative period. Even though the authors have worked extensively on the immunological markers, this study fails to provide basic anaesthetic care. I wonder whether this study will get ethical committee approval in United kingdom. 1.Kawasaki T, Ogata M, Kawasaki K, Okamoto K, Sata T. Effects of epidural anaesthesia on surgical stress-iduced immunosuppression during upper abdominal surgery. Br J Anaesth 2007;98:196-03 Conflict of Interest:None declared |
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