title: Epidural analgesia and arterial reconstructive surgery to the leg: effects on fibrinolysis and platelet degranulation.
abstract: It has been suggested that the incidence of early graft occlusion after arterial reconstructive surgery to the leg may be decreased by epidural analgesia. This effect may be mediated by the suppression of the usual cortisol response to surgery, which results in increased circulating plasminogen activator inhibitor-1 with consequent adverse effects on fibrinolysis. To investigate this and other potential mechanisms, 30 patients undergoing arterial reconstructive surgery to the leg were randomized to receive either general anaesthesia or general anaesthesia plus epidural analgesia. Post-operative analgesia was provided by morphine infusion or epidural analgesia, respectively. Blood samples were collected at 0, 2, 4, 6, 12 and 24 h, and 2, 3 and 5 days and analysed for cortisol, plasminogen activator inhibitor-1 antigen, interleukin-6 and beta thromboglobulin. The incidence of graft-related and systemic complications was recorded for 30 days. Only one patient developed early graft occlusion that required embolectomy and eventually amputation. There were no significant changes from control values in either group of patients in circulating cortisol, plasminogen activator inhibitor-1 and beta thrombogobulin (a marker for platelet degranulation). Interleukin-6 values increased significantly in both groups after 4 h and remained elevated until day 3. There were no significant differences between the groups in any variable measured. We conclude that any effect of epidural analgesia on early graft patency is unlikely to be mediated by fibrinolysis or platetlet degranulation.
authors.affiliation: Department of Anaesthesia and Intensive Care Medicine, St George's Hospital Medical School, London, UK.
authors.forename: S A
authors.initials: SA
authors.lastname: Bew
authors.forename: A E
authors.initials: AE
authors.lastname: Bryant
authors.forename: J P
authors.initials: JP
authors.lastname: Desborough
authors.forename: G M
authors.initials: GM
authors.lastname: Hall
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D015360:Analgesia, Epidural; D000768:Anesthesia, General; D000779:Anesthetics, Local / Q000494:pharmacology; D001792:Blood Platelets / Q000187:drug effects* / Q000502:physiology; D019917:Blood Vessel Prosthesis Implantation / Q000379:methods*; D002045:Bupivacaine / Q000494:pharmacology; D015550:Cell Degranulation / Q000187:drug effects; D005260:Female; D005342:Fibrinolysis / Q000187:drug effects*; D006083:Graft Occlusion, Vascular / Q000517:prevention & control; D006801:Humans; D007866:Leg / Q000098:blood supply*; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications; D012086:Reoperation
chemical_list: D000779:Anesthetics, Local; D002045:Bupivacaine