title: Safety and efficacy of combined epidural/general anesthesia during major abdominal surgery in patients with increased intracranial pressure: a cohort study.
abstract: BACKGROUND
  The increased intracranial pressure can significantly complicate the perioperative period in major abdominal surgery, increasing the risk of complications, the length of recovery from the surgery, worsening the outcome. Epidural anesthesia has become a routine component of abdominal surgery, but its use in patients with increased intracranial pressure remains controversial. The goal of the study was to evaluate the safety and efficacy of epidural anesthesia, according to monitoring of intracranial pressure in patients with increased intracranial pressure.
  
  
  METHODS
  The study includes 65 surgical patients who were routinely undergone the major abdominal surgery under combined epidural/general anesthesia. Depending on the initial ICP all patients were divided into 2 groups: 1 (N group) - patients with the normal intracranial pressure (≤12 mm Hg, n = 35) and 2 (E group) - patients with the elevated intracranial pressure (ICP > 12 mm Hg, n = 30). During the surgery we evaluated ICP, blood pressure, cerebral perfusion pressure (CPP). The parameters of recovery from anesthesia and the effectiveness of postoperative analgesia were also assessed.
  
  
  RESULTS
  In N group ICP remained stable. In E group ICP decreased during anesthesia, the overall decline was 40% at the end of the operation (from 15 to 9 mm Hg (P <0.05)). The correction of MAP with vasopressors to maintain normal CPP was required mainly in patients with increased ICP (70% vs. 45%, p <0.05). CPP declined by 19% in N group. In E group the CPP reduction was 23%, and then it remained stable at 60 mm Hg. No significant differences in time of the recovery of consciousness, effectiveness of postoperative analgesia and complications between patients with initially normal levels of ICP and patients with ICH were noted.
  
  
  CONCLUSIONS
  The combination of general and epidural anesthesia is safe and effective in patients with increased intracranial pressure undergoing elective abdominal surgery under the condition of maintaining the arterial pressure. Its use is not associated with the increase in intracranial pressure during the anesthesia, but it needs an intraoperative monitoring of ICP in order to prevent CPP reduction.
authors.affiliation: Kuban State Medical University, Sedin st.,4, Krasnodar, 350063, Russian Federation. pobeda_zib@mail.ru.
authors.forename: Igor
authors.initials: I
authors.lastname: Zabolotskikh
authors.affiliation: Kuban State Medical University, Sedin st.,4, Krasnodar, 350063, Russian Federation. nikitkax@mail.ru.
authors.forename: Nikita
authors.initials: N
authors.lastname: Trembach
mesh_terms: D000005:Abdomen / Q000601:surgery*; D000368:Aged; D000767:Anesthesia, Epidural / Q000009:adverse effects / Q000379:methods*; D000768:Anesthesia, General / Q000009:adverse effects / Q000379:methods*; D001794:Blood Pressure / Q000502:physiology; D015331:Cohort Studies; D005260:Female; D006801:Humans; D019586:Intracranial Hypertension / Q000150:complications* / Q000503:physiopathology; D007427:Intracranial Pressure / Q000502:physiology; D008297:Male; D016343:Monitoring, Intraoperative / Q000379:methods