Effect of epidural blockade on indicators of splanchnic perfusion and gut function in critically ill patients with peritonitis: a randomised comparison of epidural bupivacaine with systemic morphine.
OBJECTIVE
(a) To measure gastric tonometry values in critically ill patients with peritonitis and to assess the impact of epidural analgesia on these values. (b) To assess the impact of epidural analgesia on gastro-intestinal motility by abdominal ultrasound and paracetamol absorption. (c) To observe any change in clinical outcome that may result from the use of epidural analgesia in such patients.


METHODS
A double-blinded, prospective, randomised and controlled study of general intensive therapy unit (ITU) patients.


METHODS
Twenty-one patients admitted with peritonitis and adynamic small bowel following abdominal surgery were randomly allocated to receive either intravenous morphine or epidural bupivacaine for analgesia.


RESULTS
Gastric intramucosal pH (pHig) and the mucosal:arterial PCO2 gradient (Pg-PaCO2) were measured at admission and after 24 h of analgesia. Analysis of mean changes in tonometry values showed a rise in Pg-PaCO2 and a fall in pHig in the morphine group and a significant difference between groups in the Pg-PaCO2 trends (p = 0.024). Significant improvements in the ultrasound appearance of the small bowel were observed in the epidural group (p = 0.0037, Mann-Whitney U test of median changes in a locally developed scoring system). There were no significant differences between the groups in any of the variables derived from the paracetamol absorption test (n = 10); both groups showed persistently delayed gastric outflow throughout the study period.


CONCLUSIONS
Epidural analgesia resulted in improvements in gastric mucosal perfusion and the ultrasound appearance of the small bowel, indicating potential clinical benefit in a group of patients in whom epidural catheterisation is traditionally contraindicated.
Spackman
D R
DR
Department of Anaesthesia, St Thomas's Hospital, London, UK. david.spackman@gstt.sthames.nhs.uk
McLeod
A D
AD
Prineas
S N
SN
Leach
R M
RM
Reynolds
F
F
D015360:Analgesia, Epidural; D000779:Anesthetics, Local / Q000008:administration & dosage* / Q000494:pharmacology; D002045:Bupivacaine / Q000008:administration & dosage* / Q000494:pharmacology; D004311:Double-Blind Method; D005260:Female; D005753:Gastric Mucosa; D005769:Gastrointestinal Motility / Q000187:drug effects; D006801:Humans; D006863:Hydrogen-Ion Concentration; D007262:Infusions, Intravenous; D007421:Intestine, Small / Q000000981:diagnostic imaging; D016014:Linear Models; D008297:Male; D008365:Manometry; D008875:Middle Aged; D009020:Morphine / Q000008:administration & dosage; D010538:Peritonitis / Q000188:drug therapy*; D011446:Prospective Studies; D013152:Splanchnic Circulation / Q000187:drug effects; D018709:Statistics, Nonparametric; D014463:Ultrasonography
D000779:Anesthetics, Local; D009020:Morphine; D002045:Bupivacaine