Safety and Efficacy of Combined Epidural/General Anesthesia During Major Abdominal Surgery in Patients With Increased Intracranial Pressure

A Cohort Study

Igor Zabolotskikh; Nikita Trembach


BMC Anesthesiol. 2015;15(76) 

In This Article


Increased intracranial pressure (ICP) is a common state in surgical practice and it is mainly associated with the pathology of cerebral venous circulation, which significantly alters cerebral hemodynamics.[1,2] Meanwhile, it can significantly complicate the perioperative period, increasing the risk of complications, the length of recovery from the surgery, worsening the outcome.[1] Total intravenous anesthesia with propofol and fentanyl worked well in the abdominal surgery, providing a smooth and rapid postoperative recovery, at the same time, this type of anesthesia is more preferable in the presence of increased ICP as compared with inhaled anesthetics.[3,4] Epidural anesthesia has become a routine component of abdominal surgery because it provides a high quality of analgesia and promotes early mobilization of patients, including patients at high risk for perioperative complications. Nevertheless, according to some authors, it can lead to an increase in intracranial pressure in patients with reduced craniocerebral compliance.[5] An injection of both a local anesthetic and any solution may lead to an increase in ICP, which is associated with compression of the dural sac; thus, the increase is transient and not associated with properties of the local anesthetic.[6] Thereby, an increase in ICP was considered a contraindication to the use of epidural anesthesia over a long period of time, despite the small number of studies.[7] There is no conclusive evidence of a negative influence of epidural anesthesia on the perioperative period in patients with increased intracranial pressure, so, it makes this contraindication disputable, especially with a slow bolus injection of a local anesthetic, and all the more in case of its prolonged infusion.[8] Epidural anesthesia with 0.2 % ropivacaine solution administering as a continuous infusion has been successfully used in patients with a traumatic brain injury.[9] There are some reports about the safety and efficacy of epidural anesthesia in obstetric practice in patients with increased intracranial pressure.[10] As for the major abdominal surgery, where epidural anesthesia is almost the "gold standard" of anesthesia, its effect on ICP and the course of the perioperative period has not been studied well. Lack of investigations on this subject is due, primarily, to the fact that, despite its importance, the problem of evaluating of intracranial pressure in anesthesiology is currently far from being solved. Methods that we have in our disposal cannot be used routinely because these methods are either too invasive or not informative at all. In this regard, the method of ophtalmodynamometry (ODM) of the central retinal vein has an undoubted advantage. It allows us to perform a noninvasive and accurate evaluation of the intracranial pressure.[11] This method has been well proven in clinical practice.[12]

Objective: To evaluate the safety and efficacy of epidural anesthesia, according to monitoring of intracranial pressure in patients with increased intracranial pressure.