Research and Opinion in Anesthesia & Intensive Care

: 2017  |  Volume : 4  |  Issue : 3  |  Page : 117--123

Does combined general–epidural anesthesia reduce the risk for surgical site infections in radical cystectomy?

Hoda Shokri 
 Department of Anaesthesiology, Ain Shams University, Cairo, Egypt

Correspondence Address:
Hoda Shokri
Department of Anaesthesiology, Ain Shams University, Cairo, 11772


Background Radical cystectomy is an aggressive surgical procedure associated with the highest morbidity and mortality of all commonly performed urological procedures. It has been assumed that regional anesthesia may reduce infectious complications. Objective This aim of this study was to compare whether general anesthesia (GA) combined with epidural anesthesia reduces the incidence of superficial and deep surgical site infections, chest infection, mortality rate, and length of hospital stay. Patients and methods In this prospective randomized parallel group study, 150 patients between 50 and 65 years of age who were scheduled for elective radical cystectomy were randomly divided into two groups: the GA-only group (n=75), which received GA-alone, and the Epi–GA group (n=75), which received both GA and epidural anesthesia. Demographic and clinical data, such as age, sex, and BMI, and surgical data, such as duration of surgical procedure and number of whole blood units given, were recorded. Postoperative data such as superficial and deep surgical site infections, chest infection diagnosed by the consultant over 10 days’ duration, mortality rate, and duration of hospital stay were recorded. Results Demographic, clinical, and surgical data were similar among the study groups. There was no significant difference between the study groups as regards the incidence of superficial and deep surgical site infections, chest infection, and mortality rate. The duration of hospital stay was significantly shorter in the Epi–GA group compared with the GA-only group. Conclusion Our study showed that combined GA and epidural anesthesia offers no advantage over GA alone with regard to the incidence of infectious complications within 10 days postoperatively, but it significantly reduced the length of hospital stay.

How to cite this article:
Shokri H. Does combined general–epidural anesthesia reduce the risk for surgical site infections in radical cystectomy?.Res Opin Anesth Intensive Care 2017;4:117-123

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Shokri H. Does combined general–epidural anesthesia reduce the risk for surgical site infections in radical cystectomy?. Res Opin Anesth Intensive Care [serial online] 2017 [cited 2018 May 20 ];4:117-123
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Full Text


Surgical site infections (SSIs) are one of the most serious and important anesthetic and surgical complications [1]. The medical and financial burdens of SSIs are so serious that any modification of the surrounding circumstances would deserve attention [2].

Radical cystectomy is a lengthy surgical procedure associated with the highest morbidity and mortality and a high risk for infectious complications in all commonly performed urological cancer treatment procedures, especially in the elderly [3].

Cigarette smoking causes inhibited wound healing and microvascular obstruction resulting from platelet aggregation, decreased blood flow to the skin, and increased nonfunctioning hemoglobin. In addition, smoking has been found to compromise the immune system and the respiratory system [4].

Neuroaxial anesthesia, either spinal or epidural anesthesia, reduces the surgical stress response. It has been assumed that neuroaxial anesthesia may reduce complications and improve surgical outcomes by blocking the noxious afferent inputs and decreasing the surgery-related complications [5].

These effects of neuroaxial anesthesia precisely on the immune response might have a profound impact on the incidence of infectious complications.

Neuroaxial anesthesia decreases the risk for infection through vasodilatation and consequent improvement in tissue oxygenation [6].

This aim of this study was to predict whether general anesthesia (GA) combined with epidural anesthesia reduces the incidence of the postoperative infectious complications diagnosed by the consultant or depending on accurate clinical and laboratory criteria over 10-day postoperative period, mortality rate, and hospital stay after radical cystectomy compared with GA alone.

 Patients and methods

After approval from the Ethical committee of Ain Shams University, this prospective randomized double-blinded parallel group trial included 150 patients between 50 and 65 years of age with physical status I and II according to the American Society of Anesthesiologists (ASA) who were scheduled for elective radical cystectomy. This study was conducted at Ain Shams University Hospital from January 2014 to June 2016.

Exclusion criteria were as follows: refusal to participate in the study, history of pre-existing infectious conditions, including pneumonia or sepsis, infection at the puncture site, coagulopathies, hypersensitivity to drugs used for analgesia, diabetes or two perioperative glucose readings higher than 126 mg/day, and alcohol abuse. After obtaining written informed consent from every patient, patients were randomly divided into two groups with an allocation ratio of 1 : 1: the GA-only group (n=75) received GA alone, and the Epi–GA group (n=75) received both GA and epidural anesthesia. The randomization sequence was concealed in sealed envelopes by an investigator not involved with the clinical management or data collection.

Preanesthetic evaluation of patients, followed by preoperative investigations including complete blood count, renal profile, liver profile, coagulation profile, and ECG, was performed.

In the induction room, the anesthesiologist secured an 18 G cannula and midazolam (1 mg) was administered to reduce the fear and anxiety of the patient.

All patients received Ringer’s acetate solution (15 ml/kg) intravenously on arrival at the operating room. During all procedures, patients of both groups were subjected to invasive and noninvasive blood pressure monitoring, pulse oximetry, ECG, and monitoring of end-tidal CO2, which was maintained within 35–40 mmHg.

Both study groups received standardized GA involving preoxygenation with 100% oxygen for 3 min and induction with fentanyl (3 µg/kg) followed by thiopental (5 mg/kg) until loss of consciousness, followed by atracurium 0.5 mg/kg to facilitate endotracheal intubation. Anesthesia was maintained using isoflurane with minimal alveolar concentration (1.2%) in oxygen and air mixture (1 : 1). All patients were mechanically ventilated with fresh gas flow of 5 l, tidal volume of 8–10 ml/kg, and respiratory rate of 12 breaths/min, which were then adjusted to maintain normocapnea and normoxia with oxygen saturation of 98% or more.

In the Epi–GA group, the patient was positioned in the sitting position. With all aseptic precautions, the skin was cleaned with povidone iodine, the L2–L3 space was identified, and the skin was infiltrated with 3 ml of 2% lignocaine to numb the skin. Thereafter, an 18 G Tuohy needle (Romsons epidural needle; Romsons Scientific & Surgical Industries Pvt. Ltd, Agra, Uttar Pradesh, India) was inserted, and the epidural space was located by the loss-of-resistance to saline technique. A test dose of 3 ml of 2% lignocaine with adrenaline was administered and the patients were observed for 5 min to exclude any intravascular or intrathecal injection. The patients were then administered 18 ml of 0.25% bupivacaine to achieve a sensory block up to the T8 level, and then top-up doses of bupivacaine 0.25% (8 ml/h) were administered. Subsequently, the patients received standardized GA similar to the GA group but minimal alveolar concentration of isoflurane was set at 0.8%. Central venous line was inserted in the right internal jugular vein, and central venous pressure was regularly measured. Baseline arterial blood gases analysis was performed, and then it was checked every hour. All patients were warmed with a warming mattress and warm Ringer acetate was infused throughout the procedure to maintain normothermia. Fluids were administered according to the fluid chart and guided by central venous pressure level and the number of blood units given guided by calculation of maximum allowable blood loss.

In both groups, at the end of surgical procedure, the volatile anesthetic agent was discontinued and residual neuromuscular blocking agent was antagonized with intravenous prostigmine (0.04 mg/kg) and atropine (0.02 mg/kg).

The lungs were manually ventilated until resumption of spontaneous ventilation.

After fulfilling the criteria of complete recovery, patients were transferred to the ICU.

Measured parameters

Primary outcome measures included the mortality rate.

Secondary outcome measures included the incidence of SSIs and chest infection diagnosed by the consultant over 10 days’ duration postoperatively as well as length of hospital stay.

NSQIP Definition of Major Infection Outcome Variables [7]:Superficial SSI is defined as the infection involving the skin or subcutaneous tissue of the incision and at least one of the following criteria: purulent drainage, organisms isolated, or at least one of the following − pain or tenderness, localized swelling, redness, or hotness.Deep SSI is defined as the infection related to the operation involving the deep soft tissues of the incision and at least one of the following criteria: purulent drainage, spontaneous dehisces or deliberate dehisces by a surgeon, an abscess, or other pieces of evidence of infection.

Chest infection has the following criteria:Criterion 1: rales or dullness to percussion on physical examination of the chest in addition to one of the following: new onset of purulent sputum, organism isolated from blood culture, tracheal specimen, or bronchial specimen.Criterion 2: chest radiography finding and one of the following: new onset of purulent sputum, organism isolated (from blood culture, tracheal specimen, bronchial specimen, or from respiratory secretions), or histopathologic evidence of pneumonia.

Statistical analysis

The number of patients was chosen on the basis of the relative precision of 50%, confidence level of 90%, expected prevalence of the outcome in absence group of 7%, odds ratio of 0.8, and ratio of the absence group to the presence group of 1. The expected sample size was 150 patients, 75 in each group. A P-value of less than 0.05 was considered significant.

The collected data were coded, tabulated, and statistically analyzed using statistical package for the social sciences, version 17 (SPSS Inc., Chicago, Illinois, USA).

Numerical parametric data were expressed as mean±SD, whereas categorical data were expressed as number and percentage.

Parametric data were compared using the independent t-test in cases of two independent groups, and the χ2-test was used to compare the categorical data.

We also conducted regression analysis in which binary logistic regression models can be fitted using either the logistic regression procedure or the multinomial logistic regression procedure. Each procedure has options not available in the other. An important theoretical distinction is that the Logistic regression procedure produces all predictions, residuals, influence statistics, and goodness-of-fit tests using data at the individual case level, regardless of how the data are entered and whether or not the number of covariate patterns is smaller than the total number of cases, whereas the multinomial logistic regression procedure internally aggregates cases to form subpopulations with identical covariate patterns for the predictors, producing predictions, residuals, and goodness-of-fit tests based on these subpopulations. If all predictors are categorical or any continuous predictors take on only a limited number of values − so that there are several cases at each distinct covariate pattern − the subpopulation approach can produce valid goodness-of-fit tests and informative residuals, whereas the individual case level approach cannot.


All patients completed the study. Patients’ characteristics and surgical data were similar among the study groups, as shown in [Table 1].{Table 1}

All data were presented as mean±SD, but ASA physical status and sex were presented as percentage.

There was no significant difference between the study groups as regards the incidence of superficial and deep SSIs, chest infection within 10 days postoperatively, and the mortality rate ([Table 2]).{Table 2}

The length of hospital stay was significantly shorter in the Epi–GA group compared with the GA-only group ([Table 3]).{Table 3}

Logistic regression analysis of superficial SSI showed that the length of surgical procedure and age were associated with a higher incidence of superficial SSI, but anesthesia type or smoking was not associated with a significant incidence of superficial site infection ([Table 4]).{Table 4}

Logistic regression analysis of deep SSI showed that neither the length of surgical procedure nor smoking or age or the length of surgical procedure was associated with significant incidence of deep SSI ([Table 5]).{Table 5}

Logistic regression analysis of chest infection showed that only the length of surgical procedure was associated with a higher incidence of chest infection ([Table 6]).{Table 6}

Logistic regression analysis of mortality showed that only the age was associated with a higher incidence of mortality ([Table 7]).{Table 7}


The financial burdens of SSIs [8] may be critical enough to ask whether a change in practice can lower the occurrence of the infectious complications seen. There are very few studies attempting to compare the risk for SSI among patients undergoing procedures under GA and those undergoing procedures under combined epidural anesthesia and GA.

Our study showed that the incidence of postoperative SSIs, chest infection, and mortality rate were similar in both study groups undergoing radical cystectomy, whereas there was a significant decrease in the length of hospital stay.

Multiple previous studies reported that epidural anesthesia combined with GA in patients provided excellent postoperative analgesia, which lowered the incidence of SSI. Severe pain causes an autonomic response, which results in vasoconstriction and reduced peripheral perfusion [6].

Proposed mechanisms through which epidural anesthesia carries a lower risk for SSI compared with GA is yet to be explored [9].

Neuroaxial anesthesia modifies the inflammatory response to surgery, reducing nonspecific generalized responses and allowing the immune system to concentrate better on the critical task of fighting bacteria.

Wu and colleagues conducted a retrospective study of Medicare patients and showed that the use of epidural analgesia might contribute to an increase in 30 days pneumonia risk with an odds ratio of 1.91 (95% confidence interval).

It is worthy of mention that Wu et al. [10] included variable surgical procedures such as abdominal hysterectomy and nephrectomy.

The inclusion of both thoracic and lumbar epidural anesthesia among these procedures, which were different from our type of anesthesia, partially explains the difference between the results of the current study and the study by Wu and colleagues.

Guay et al. [11] showed that adding neuroaxial blockade to GA had no effect on the risk for infectious complications such as pneumonia or 30-day mortality rate compared with GA alone, and this is in agreement with the results of our study.

Danielle et al. [12] found that the addition of epidural anesthesia to GA was not associated with a reduced risk for major medical complications and all causes of mortality after different elective surgical procedures when compared with GA alone.

Kopp et al. [13] found no significant difference in the incidence of SSI in patients undergoing total joint arthroplasty under GA versus neuroaxial anesthesia and they also concluded that the use of peripheral nerve block did not affect the incidence of SSI.

These three studies are in agreement with the results of our study.

Rodgers et al. [14] reported one-third reduction in the mortality rate when neuroaxial anesthesia, either spinal or epidural anesthesia, was combined with GA, and it significantly lowered the risk of developing pneumonia precisely in orthopedic surgeries. However, further studies were needed to determine whether the reduction in mortality and morbidity rates were resulting from the use of neuroaxial anesthesia in nonorthopedic surgeries such as urologic and vascular surgeries [14].

Their results are in disagreement with our results; this can be attributed to the heterogenous nature of surgical procedure and its duration. However they could not find any significant effects of regional anesthesia on other surgical procedures.

Craig et al. [15] concluded that there was no association between the anesthetic technique and the rate of SSI. Duration of anesthesia and an ASA status of at least three significantly reduce the rate of SSI [15].

Chang et al. [16] found that, in total hip or knee replacement under GA, the incidence of SSI was significantly higher compared with epidural or spinal anesthesia.

Helwani et al. [17] showed that the length of hospital stay was significantly shorter among patients undergoing total hip arthroplasty (primary and revision) with regional anesthesia (spinal or epidural) compared with GA. However, the mortality rate was similar in both groups. These findings are in agreement with the results of our study [17].

A meta-analysis by Parker et al. [18] on a total of 1125 patients did not conclude any reduction in risk for pneumonia using neuroaxial anesthesia (spinal or epidural) in hip fracture surgery among adults.

The National Nosocomial Infection Surveillance risk index has been used to predict the risk for SSI in many operative procedures such as radical cystectomy. The risk index score ranges from 0 to 3 according to the following risk factors: ASA of at least 3, an operation classified dirty or clean, and a procedure lasting more than 3 h, which results in difficult control of intraoperative body temperature [19].

A previous study showed that the procedure duration was the most common of the three traditional factors of the National Healthcare Safety Network risk index parameters. ASA score was the next most common surgical performance. Age, which was not included in the risk index, was the third most commonly selected factor [20].

Most patients undergoing major surgery experience perioperative hyperglycemia, whether or not they are diabetic. Perioperative hyperglycemia in nondiabetic individuals has only recently been found as an important risk factor for adverse events following major events such as major surgery [21].

This study suffered from a few limitations that should be addressed. First, we did not record intraoperative or postoperative parameters such as body temperature and postoperative glycemic level but we continued warming the patients with warming mattress and using warm fluids. In this study, diabetic patients were excluded. Postoperative fluid management and fluid maintenance intraoperatively were not separately evaluated, because our proposal was that the study represented a real clinical practice.

We assumed that the effects of all these factors were evenly distributed between groups. We recommend further studies to study the effect of these factors on the incidence of SSIs.

Our study did not include patients readmitted with a principal diagnosis of SSIs after 10 days postoperatively.

Future prospective studies are needed to confirm these findings.


Combined GA and epidural anesthesia offers no advantage over general anesthesia alone with regard to the incidence of infectious complications, especially within 10 days postoperatively as well as mortality rate, but it significantly reduced hospital stay duration.


The author thank her dear anesthesia colleagues in the Anesthesia Department of Ain Shams University.

Financial support and sponsorship


Conflicts of interest

None declared.


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