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Epidural Analgesia

Growing evidence suggests so

BMJ 1999;319:530-531 ( 28 August )

Major surgery induces profound physiological changes in the perioperative period, characterised by increases in sympathoadrenal and other neuroendocrine activity and also increased cytokine production. Because epidural anaesthesia can attenuate this "stress response" to surgery, improve the quality of postoperative analgesia in comparison with systemic opioids, and hasten recovery of gut function, it has been suggested that conducting surgery under epidural anaesthesia (either as the sole anaesthetic or in combination with general anaesthesia) may reduce perioperative morbidity and mortality compared with general anaesthesia alone.1

Indeed, in a study of high risk patients undergoing major vascular surgery those who received combined general and epidural anaesthesia with postoperative epidural analgesia had significantly lower cardiac morbidity than those receiving general anaesthesia alone with postoperative systemic opioid analgesia.2 Unfortunately, subsequent studies have failed to confirm this finding. This uncertainty probably relates to the design, small size, and inadequate number of relevant studies for a meta-analysis of outcome; hence investigators in Australia are currently undertaking a large, multicentre study to address this question.

Though the effects of epidural anaesthesia on mortality and cardiac morbidity have been disappointing so far, the evidence that epidural anaesthesia decreases thromboembolic, pulmonary, and gastrointestinal postoperative complications is much more encouraging. A meta-analysis showed a significant reduction in venous thromboembolism in patients undergoing surgery for hip fracture under regional (epidural or spinal) anaesthesia compared with general anaesthesia, but showed only a marginally better effect on early mortality.3 Another meta-analysis of randomised controlled trials on the influence of different anaesthetic and postoperative analgesic regimens on pulmonary outcome found that thoracic epidural anaesthesia and analgesia using opioids and local anaesthetics was associated with a decreased incidence of atelectasis, pulmonary infections, and hypoxaemia compared with systemic opioids.4 Perhaps surprisingly, there were no differences in physiological lung volumes. The mechanism by which thoracic epidural anaesthesia improves pulmonary morbidity is unclear but may be related to improved analgesia and alertness, allowing patients to sigh, cough, and change position more easily. Diaphragmatic dysfunction, a consequence of reflex muscle spasm after surgery, may also be attenuated by thoracic epidural anaesthesia, hence improving pulmonary function.5



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