Introduction
CESA (combined general and epidural anesthesia) is a composite technique in which general anesthesia is used to keep the patient unconscious during surgery, and epidural anesthesia is used to manage pain both during and after the procedure. The epidural catheter placement allows the patients to have continued pain relief after surgery, which will help them sleep, breathe, and move more conveniently. CESA is the most common type of anesthesia for significant abdominal and thoracic (chest) procedures. An anesthesiologist may leave the epidural catheter in place for several days after the surgery to assist with pain control.
CEGA (combined GA-Epidural anesthesia) could bring together the advantages of both techniques while allowing no adverse effects. Adding an epidural to general anesthesia can reduce the hemodynamic changes associated with pneumoinsufflation by lowering systemic vascular resistance (SVR), mean arterial blood pressure (MAP), and maintaining cardiac index, in addition to the requirements for various anesthetic agents. In addition, epidural anesthesia can effectively prevent the nerve conduction pathway of noxious simulations. It reduces the stress response during the procedure by suppressing the sympathetic response, presumably accomplished by obstructing sympathetic afferent pathways.
Thus, general anesthesia combined with precautionary epidural analgesia may result in a lower stress status for laparoscopic surgeries while improving hemodynamics. It also dramatically enhances the surgical field by causing bowel contraction due to blockage of the sympathetic system. It can also be utilized in individuals with severe chronic obstructive pulmonary disease (COPD) and chronic asthma for a smooth and quick postoperative recovery. In the immediate postpartum period, epidural analgesia could improve respiratory function, reduce perioperative cardiac comorbidities, improve patient health and quality of life, and allow early ambulation and bowel function recovery.
What Is the Underlying Mechanism for CEGA?
The following are possible mechanisms by which combined epidural-general anesthesia protects intraoperative patients.
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Firstly, it is more effective at alleviating acute pain and pain-related negative impacts.
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Secondly, thoracic epidural anesthesia may enhance the balance of myocardial oxygen consumption and supply and alleviate gut injury.
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Thirdly, it alleviates the hyperactivation of the neuroendocrine, metabolic, and inflammatory responses following surgery.
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Finally, patients undergoing adrenalectomy for adrenal functional tumors may benefit from the epidural blockade in conjunction with general anesthesia.
What Is the Effect of CESA on Colon Cancer Patients?
Regional anesthesia has been shown to improve cancer outcomes compared to general anesthesia. Thoracic epidural anesthesia and analgesia are frequently used to manage intraoperative and postoperative pain during colon cancer surgery. Together, general anesthesia and epidural anesthesia can suppress immunity by immediately affecting the immune system or the sympathetic nervous system. Moreover, numerous studies have shown that intraoperative monitoring of the depth of the anesthesia is crucial for achieving successful surgery and quick recovery. Different cytokines and effector molecules, such as tumor necrosis factor (TNF-α), interleukin (IL)-4, IL-6, and IL-10, as well as stress hormones, are secreted by immunocompetent cells and mediate anti-tumor immunity and body defense.
What Is the Effect of CESA on Laparoscopic Cholecystectomy Patients?
For retroperitoneal laparoscopic surgeries, general anesthesia combined with precautionary epidural analgesia can improve the surgical environment and lower stress.
Luchetti M et al. demonstrated that combined epidural general anesthesia (CEGA) could control pain caused by carbon dioxide-induced peritoneal irritation, providing intra and postoperative analgesia and pain-free and rapid recovery in laparoscopic cholecystectomy.
Yun-song et al. utilized epidural anesthesia as preemptive analgesia in retroperitoneal laparoscopic adrenalectomy and discovered a reduction in the need for anesthetic agents and other vasoactive drugs, resulting in a faster recovery. As a result, in the presence of epidural anesthesia, the need for anesthetic medicines is minimized, allowing for a speedy recovery and extubation at the completion of the procedure.
What Is the Role of CESA on Stress?
The nerve conduction pathway of noxious stimulation can be effectively blocked by epidural anesthesia. Thus, general anesthesia combined with preemptive epidural analgesia can provide a less stressful environment for laparoscopic surgeries while reducing hemodynamic responses. In addition, for stress reduction, other vasoactive drugs are minimized in epidural anesthesia, such as Esmolol, Metoprolol, and Nicardipine.
What Is the Effect of Cesa on Thoracic Surgery?
Q DM et al. and Vera Von Dassow et al. demonstrated that cumulative general anesthesia and epidural anesthesia reduce stress during thoracic surgery. Q DM et al. also reported that cortisol concentration was significantly lower in the combined epidural general anesthesia (CEGA) group compared to the plain general anesthesia (GA) group, and cortisol is the primary steroid hormone responsible for stress response.
What Is the Dose of Propofol Required Intraoperatively During CESA?
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The epidural anesthesia administered before induction of anesthesia reduces the need for propofol. The need for anesthetic drugs is concentrated in the presence of epidural anesthesia; the patient awakens quickly and is extubated at the end of the surgery.
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Yun-song et al. used epidural anesthesia as preemptive analgesia in retroperitoneal laparoscopic adrenalectomy. They noticed the reduced use of anesthetic agents and other vasoactive drugs to blunt the stress response.
What Is the Role of CESA on the Recovery Score?
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The nerve conduction route of noxious simulations can be successfully blocked by epidural anesthesia.
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Thus, general anesthesia coupled with preemptive epidural analgesia can create a less stressful environment for laparoscopic procedures while also reducing hemodynamic reactions.
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In patients undergoing CESA, recovery was usually painless and quick. In addition, using an epidural catheter allowed us to effectively manage pain caused by peritoneal irritation, resulting in superior intra and postoperative analgesia.
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CESA was accomplished without using intravenous opioids and with no increase in detrimental effects or changes in hemodynamics or respiratory stability.
What Is the Role of CESA in hysterectomy?
CESA had little to no effect on patients' hemodynamics and could maintain blood pressure stability, which was especially beneficial for hypertensive patients. In addition, it has a better anesthetic effect in hysterectomy (surgical removal of the uterus), has little influence on patients' circulatory response, and can reduce stress.
Conclusion
The combined regional and general anesthesia technique is simple and easy to use. Its benefits include lower healthcare expenses for high-risk surgeries, and enhanced patient stability. It also reduces surgical stress-related impairment of anti - carcinogenic immune responses and accelerates intestinal function recovery.
