Benefits Of Epidural Analgesia Research Articles

Procedural Aspects of Epidural Catheter Placement: A Prospective Observational Study of 173 Epidural Catheter Insertions

The risks and benefits of epidural analgesia have been studied extensively, but information regarding many other aspects of epidural catheter insertion is limited. The authors aimed to add information regarding procedural pain, procedure duration, failure rates, and the effect of experience to the ongoing discussion on this procedure. A prospective observational study. A Danish tertiary hospital. Patients scheduled to undergo video-assisted thoracic surgery. Epidural catheter insertion in 173 patients undergoing video-assisted thoracic surgery for lung cancer. The authors recorded the time required for the epidural insertion procedure, the attempts used, insertion level, access use, patient position, placement technique used, and the designation of the physician placing the catheter. Furthermore, the authors asked the patients to evaluate the expected procedural pain, and after the procedure the authors asked them to evaluate the actual level of pain experienced. Six and 24 months after discharge, the authors examined persistent sequelae by using questionnaire assessments. The median procedure duration was 13 minutes, with 75% of the catheters placed within 22 minutes. Actual procedure-related pain (mean score [M]=3.5, SD=2.0) was significantly (p < 0.0001) less than that expected before the procedure (M=4.9, SD=2.0). The patients' expected pain, attempts required for successful catheter placement, and approach used to access the epidural space significantly affected the actual procedure-related pain (p=0.001, p ≤ 0.003, and p=0.023, respectively). Persistent pain and sensory disturbances were observed in 11% and 4% of the patients, respectively, after 6 months and in 6% and 4% of the patients, respectively, after 2 years. In this study, the authors examined several lesser-known aspects of epidural procedures. The use of epidural analgesia as part of the pain management plan after surgery requires a more complex evaluation instead of merely discussing the possibility of procedural infections, hematomas, or neurologic injuries. The procedure time, patients' expected and experienced pain related to the procedure, and the potential long-term side effects should be a part of the decision-making process.

Sociodemographic Factors Associated with Request for Labor Epidural Analgesia in a Tertiary Obstetric Hospital in Vietnam.

This study is aimed at examining the sociodemographic factors associated with the utilization of labor epidural analgesia at a large obstetric and gynecology hospital in Vietnam. This was a cross-sectional study of women who underwent vaginal delivery in September 2018 at the Hanoi Obstetrics and Gynecology Hospital. The utilization of epidural analgesia during labor was determined. Univariate and multivariate regression models were applied to evaluate the association between patient demographic and socioeconomic factors and request for labor epidural analgesia. A total of 417 women had vaginal deliveries during the study period. 207 women utilized epidural analgesia for pain relief during labor, and 210 did not. Parturients older than 35 years of age (OR 2.84, 95% CI 1.11-8.17), multiparous women (OR 2.8 95% CI 1.85-4.25), women living from an urban area, women with higher income (OR 6.47, 95% CI 2.59-19.23), and women with higher level of education were more likely to utilize labor epidurals. Factors related to a parturient request for epidural analgesia during labor at our tertiary obstetric hospital included age greater than 35 years, multiparity, and high income and education levels. Educational outreach to women about the benefits of epidural analgesia can target women who do not share these demographic characteristics.

Epidural analgesia for postoperative pain: Improving outcomes or adding risks?

Current evidence shows that the benefits of epidural analgesia (EA) are not as impressive as believed in the past, while the risks of adverse effects and serious complications are greater than previously estimated. There are many reasons for the decreasing role of epidural technique in clinical practice (table). Indeed, EA can cause harm and hinder early mobilization in enhanced recovery after surgery (ERAS) programmes. Some ERAS interventions are complex, confusing, sometimes contradictory and apparently unimplementable. In spite of much hype and after almost 25 years, the originator of the concept has described the current status of ERAS as 'far from good'. Outpatient surgery setup has been a remarkable success for many major surgical procedures, and it predates ERAS and appears to be a simpler and better model for reducing postoperative morbidity and hospitalization times. Systematic reviews of comparative studies have shown that less invasive and safer but equally effective alternatives to EA are available for almost all major surgical procedures. These include: paravertebral block, peripheral nerve blocks, catheter wound infusion, periarticular local infiltration analgesia, preperitoneal catheters and transversus abdominis plane block. Increasingly, these non-EA methods are being used as surgeon-delivered regional analgesia (RA) techniques. This encouraging trend of active surgeon participation, with anaesthesiologist collaboration, will undoubtedly improve the decades-old twin problems of underused RA techniques and undertreated postoperative pain. The continued use of EA at any institution can only be justified by results from its own audits; however, regrettably only very few institutions perform such regular audits.

Trends in the use and outcomes of perioperative epidural analgesia among medicare patients undergoing hepatic and pancreatic surgery

Background: Peri-operative pain management around the time of hepato-pancreatic (HP) surgery has been debated. In particular, utilization of epidural analgesia (EA) remains controversial as the benefit of EA is poorly defined. The objective of the current study was to describe trends, as well as identify factors associated with EA use. In addition, we sought to characterize peri-operative outcomes relative to EA use among Medicare patients undergoing HP procedures. Methods: Medicare patients who underwent HP surgery between 2013–2015 were identified using the Standard Analytic Files. In-hospital outcomes were compared among patients who had EA versus did not have EA (non-EA). Logistic regression was utilized to identify factors associated with EA receipt, as well as to assess possible associations of EA use with in-hospital morbidity and mortality, prolonged length of stay (LOS), blood transfusion, as well as overall Medicare expenditures. Results: Among 20,562 patients, 7,392 (35.9%) and 13,170 (64.1%) patients underwent a liver or pancreas procedure, respectively. Overall, only 1,362 (6.7%) patients had EA; EA use was more predominant among patients who had a pancreatic resection (liver: n = 435, 32%; pancreas: n=927, 68%; p = 0.001). In addition, younger patients (OR/10years 1.21, 95%CI 1.10–1.34), white patients (OR 1.55, 95%CI 1.18–2.02), as well as patients undergoing an open rather than a minimally invasive procedure (OR 1.44, 95%CI 1.17-1.78) were more likely to have EA (all p < 0.05). While the unadjusted incidence of complications (EA: 32.8% vs. non-EA: 34.6%) and 30-day mortality (EA: 3.8% vs. non-EA: 5.6%) were slightly lower among EA patients, LOS was longer by an average of one day (EA: 8 days, IQR 6-13 vs. 7 days, IQR 5-12)(all p<0.05). On multivariate analysis, after controlling for competing risk factors, while there was no difference among EA versus non-EA patients with regard to complications (OR 1.05, 95%CI 0.93–1.19), EA patients had a higher odds of a longer LOS (OR 1.16, 95%CI 1.03–1.30). In addition, while median Medicare payments for liver surgery were comparable among EA versus non-EA patients (EA: $19,500, IQR $15,800-24,600 vs. non-EA: $19,300, IQR $15,300-29,700; p = 0.85), median expenditures were slightly higher for EA patients undergoing a pancreatic procedure (EA: $23,600, IQR $17,900-37,300 vs. non-EA: $22,000, IQR $16,800-36,400; p = 0.001). Conclusion: EA utilization among Medicare patients undergoing HP is low as only about 1 in 15 patients had EA. EA utilization was associated with specific patient- and procedure factors. While EA use was not associated with morbidity, it was associated with an average additional one day LOS and slightly higher Medicare expenditures among patients undergoing pancreatic surgery.

Is It Time to Reconsider Postoperative Epidural Analgesia in Patients Undergoing Elective Ventral Hernia Repair?: An AHSQC Analysis.

We aimed to evaluate the association of epidural analgesia (EA) with hospital length of stay (LOS), wound morbidity, postoperative complications, and patient-reported outcomes in patients undergoing ventral hernia repair (VHR). EA has been shown to reduce LOS in certain surgical populations. The LOS benefit in VHR is unclear. Patients having VHR performed in the Americas Hernia Society Quality Collaborative (AHSQC) were separated into 2 comparable groups matched on several confounding factors using a propensity score algorithm: one group received postoperative EA, and the other did not. The groups were then evaluated for hospital LOS, 30-day wound morbidity, other complications, and 30-day patient-reported outcomes using pain and hernia-specific quality-of-life instruments. A 1:1 match was achieved and the final analysis included 763 patients receiving EA and 763 not receiving EA. The EA group had an increased LOS (5.49 vs 4.90 days; P < 0.05). The rate of wound events was similar between the groups. There was an increased risk of having any postoperative complication associated with having EA (26% vs 21%; P < 0.05). Pain intensity-scaled scores were significantly higher (worse) in the EA group versus the non-EA group (47.6 vs 44.0; P = 0.04). The LOS benefit of EA noted for other operations may not apply to patients undergoing VHR. Further study is necessary to determine the beneficial role of invasive pain management procedures in this group of patients with an extremely common disease state.

Effects of Epidural Analgesia on Recovery After Open Colorectal Surgery

The use of epidural analgesia (EA) has been suggested as an integral part of an enhanced recovery program for colorectal surgery. However, the effects of EA on postoperative outcomes and hospital length of stay remain controversial. Data from the American College of Surgeons National Surgical Quality Improvement Program database for 2014 and 2015 were queried for adult patients who underwent elective open colorectal surgery. We included only cases with general anesthesia as the main anesthetic. Cases with other types of anesthesia were excluded. A 1:3 matched sample of EA versus non-EA cases was created based on propensity scores. The primary outcome of interest was the occurrence of major cardiopulmonary complications within 7 days of the surgery. Secondary outcome measures were hospital length of stay and 30-day mortality. A total of 24,927 patients were included in the analysis. EA was utilized in 15.02% (n = 3745). The cumulative risk over the study period for major cardiopulmonary complications was 2.52% (n = 627). There were no statistically significant differences in the rate of postoperative complications (relative risk 0.91, 95% CI 0.66–1.27, P = 0.59), length of stay (median [interquartile range], EA 6 [5–9] versus non-EA 6 [4–9] days, P = 0.36), and 30-day mortality rate (relative risk 0.71, 95% CI 0.42–1.20, P = 0.20) between the two propensity-matched cohorts. In conclusion, our study revealed that the benefits of EA in patients undergoing open colorectal surgery are limited, as it does not influence immediate postoperative cardiopulmonary complications or hospital length of stay.

Traumatic flail chest injuries and the benefits of epidural analgesia

Traumatic flail chest injuries and the benefits of epidural analgesia

Short and Long-Term Outcomes of Epidural or Intravenous Analgesia after Esophagectomy: A Propensity-Matched Cohort Study.

Background and ObjectivesAs a well-established technique for postoperative pain relief, the benefits of epidural analgesia (EDA) have been under debate recently. This study aimed to determine whether EDA could improve perioperative outcomes and survival in patients undergoing esophagectomy.MethodsFrom January 2010 to December 2012, 587 consecutive cases undergoing McKeown-type esohpageactomy were retrospectively identified from a prospectively maintained database.ResultsAfter propensity-matching, incorporating baseline characteristics, 178 cases were included in each group, and patients characteristics distributions were well-balanced between two groups. Compared with intravenous analgesia, the use of EDA significantly decreased the incidence of pneumonia from 32% to 19.7% (P = 0.008), and anastomotic leakage from 23.0% to 14.0% (P = 0.029). The change in CRP level of EDA group was significantly decreased (preoperative, 6.2 vs. 6.2; POD 1, 108.1 vs. 121.3; POD 3, 131.5 vs. 137.8; POD 7, 69.3 vs. 82.1 mg/L; P = 0.044). EDA patients had a significantly longer duration of indwelling urinary catheter (P<0.001), and lower levels in both systolic (P = 0.001) and diastolic blood pressure (P<0.001). There weren't significant differences in overall survival (log-rank P = 0.47) and recurrence (Gray-test P = 0.46) between two groups.ConclusionsThese findings revealed that EDA could attenuate inflammatory response and reduce the incidence of pneumonia and anastomotic leakage after esophagectomy, at the price of delayed urinary catheter removal and lower blood pressure. EDA remains an important component of multimodal perioperative management after esophagectomy.

Epidural analgesia during labour – maternal understanding and experience – informed consent

Women obtain information on epidural analgesia from various sources. For epidural for pain relief in labour this is provided by the anaesthetist as part of the consenting process. There is much discussion about the inadequacy of this consenting process; we report on women's knowledge, experience and recall of this process at a regional hospital with a 24-h epidural service. Fifty-four women were interviewed within 72 h of a vaginal birth. 91% of the women had acquired information from friends, relatives and antenatal classes. Lack of recall of benefits of epidural analgesia accounted for 26 (38%) and 25 (26%) of the responses, respectively. Similarly in terms of amount of pain relief they could expect, 13 (21%) could not remember and 13 (21%) thought that it may not work. We suggest use of varying methods of disseminating information and wider utilisation of anaesthetists in the antenatal educational programmes.

Minimally invasive postoperative analgesia for pain relief after minimally invasive surgical procedures: the role of local anesthetic infusion

Surgery is increasingly moving toward minimally invasive procedures that lead to less tissue injury, less operative stress for the patient and less postoperative pain, allowing for patients to have a faster recovery than after conventional surgical approaches. Colorectal surgery is now widely performed by laparoscopy and is one of the most well-documented examples of this concept of ‘‘minimally invasive surgery.’’ Anesthetic and analgesic strategies should evolve accordingly. All of the items that need to be controlled in order to make patients suitable for faster hospital discharge are mentioned in the Enhanced Recovery After Surgery (ERAS) Program, established by European experts involved in this process [1]. Although epidural analgesia (EA) remains one of the cornerstones of the ERAS program, the risks and benefits of this technique should be reevaluated in light of the development of multimodal analgesia, and other loco-regional alternative techniques, as well as recent pathophysiological concepts. Indeed, several studies have reported a very small benefit of EA after laparoscopic colorectal surgery [2, 3]. Furthermore, interesting recent data have emphasized the involvement of visceral nociceptive input, especially afferent fibers in the peritoneum, in the stress and pain response, induced by abdominal surgery [4]. It has been suggested that at least a part of these visceral afferents are transmitted directly along the vagal nerve, without passing through the spinal pathway, which raises some questions about the ability of EA to control them. This is supported by clinical trials showing that direct intraperitoneal [5] or preperitoneal wound infusions [6] would provide additional benefits when used in combination with epidural analgesia. From this perspective, the study by Moore et al. [7] evaluating the use of surgical site catheter analgesia for pain relief after laparoscopic colorectal resection is meaningful. A continuous infusion of 8 ml/h ropivacaine 0.5 % was delivered through an epidural catheter placed between muscular and subcutaneous layers for 72 h. It is shown that this form of analgesia did not have significant beneficial effects on pain relief or opiate consumption, when compared to placebo. Factors that could explain how these negative results may have occurred were investigated by Rowlingson [8] some years ago, and it should be kept in mind that a large component of pain after laparoscopic abdominal surgery originates from surgical wound [9]. Catheter location is one of the most important issues to consider, with placement under the fascia being more effective than more superficial positions [10]. Epidural catheters are fenestrated over a very short length, so that the assumption made by the authors about the homogeneous diffusion of the local anesthetic solution between muscular and cutaneous layers is very unlikely. However, in accordance with the previous reports [11, 12], an improvement in respiratory function was noted in the group that received the ropivacaine infusion. This strongly suggests that wound infusion might still have beneficial effects on mobilization pain and/or neurogenic diaphragmatic dysfunction. Nevertheless, pain relief after laparoscopic colorectal resection remains a critical issue because of our wish to provide patients with the most effective analgesic technique with the best tolerance and safety profiles. Blockade of intercostal nerves with a transversus abdominis plane (TAP) block has the ability to control the somatic component of pain and thereby to reduce opiate consumption M. Beaussier (&) Department of Anesthesia and Intensive Care, St-Antoine Hospital, Assistance Publique, Hopitaux de Paris, Universite Pierre et Marie Curie, Paris 6, France e-mail: marc.beaussier@sat.aphp.fr

Epidural Technique for Postoperative Pain

Epidural analgesia is a well-established technique that has commonly been regarded as the gold standard in postoperative pain management. However, newer, evidence-based outcome data show that the benefits of epidural analgesia are not as significant as previously believed. There are some benefits in a decrease in the incidence of cardiovascular and pulmonary complications, but these benefits are probably limited to high-risk patients undergoing major abdominal or thoracic surgery who receive thoracic epidural analgesia with local anaesthetic drugs only. There is increasing evidence that less invasive regional analgesic techniques are as effective as epidural analgesia. These include paravertebral block for thoracotomy, femoral block for total hip and knee arthroplasty, wound catheter infusions for cesarean delivery, and local infiltration analgesia techniques for lower limb joint arthroplasty. Wound infiltration techniques and their modifications are simple and safe alternatives for a variety of other surgical procedures. Although pain relief associated with epidural analgesia can be outstanding, clinicians expect more from this invasive, high-cost, labour-intensive technique. The number of indications for the use of epidural analgesia seems to be decreasing for a variety of reasons. The decision about whether to continue using epidural techniques should be guided by regular institutional audits and careful risk-benefit assessment rather than by tradition. For routine postoperative analgesia, epidural analgesia may no longer be considered the gold standard.

Perioperative Analgesia for Patients Undergoing Open Liver Resection: Epidural or Paravertebral?

Open liver resection is a painful surgery, and patients clearly benefit from regional anesthesia for pain management in the perioperative period. However, it is still unclear which regional block technique is superior in these patients. Epidural Analgesia in Open Liver Resection Although simple liver resection is increasingly done laparoscopically, patients with large liver masses or previous abdominal surgery often undergo an open liver resection. This requires a long right subcostal incision, the associated pain of which may carry significant morbidity in the post-operative period. The best-studied regional technique in abdominal as well as thoracic procedures is thoracic epidural block. Decreasing nociceptive input via epidural analgesia reduces activation of sympathetic outflow, thus reducing surgical stress, which negatively impacts many organ systems (1). Epidural analgesia decreases pain-related tachycardia and hypertension, which could cause perioperative myocardial ischemia. Furthermore, thoracic and upper abdominal nociceptive input activates reflex inhibition of diaphragmatic excursion and increased expiratory intercostal and abdominal muscle tone, leading to increased atelectasis and risk of pneumonia. One study of 915 major abdominal surgical patients revealed that epidural analgesia both decreased pain scores in the first three postoperative days and decreased rates of respiratory failure (2). Interestingly, a handful of studies have also documented a positive impact of epidural analgesia on the coagulation profile, which prevents post-operative thromboembolic complications (1). Other benefits include a decrease in stress-induced gastrointestinal disruption and immunosuppression. Moreover, in patients undergoing open liver resection, epidural technique resulted not only in improved analgesia, but also in decreased postoperative morphine consumption (3), the latter of which is an additional benefit of epidural analgesia, given the potentially deleterious side effects associated with intravenous (IV) opioids (i.e., respiratory depression, decreased gastrointestinal motility). Indeed, epidural analgesia was sufficient for 80% of patients undergoing open liver resection in another study, with only 20% of patients requiring additional analgesia with IV opioids (4).

Birth Technology and Maternal Roles in Birth: Knowledge and Attitudes of Canadian Women Approaching Childbirth for the First Time

To describe Canadian nulliparous women's attitudes to birth technology and their roles in childbirth. A large convenience sample of low-risk women expecting their first birth was recruited by posters in laboratories, at the offices of obstetricians, family physicians, and midwives, at prenatal classes, and through web-based advertising and invited to complete a paper or web-based questionnaire. Of the 1318 women completing the questionnaire, 95% did so via the web-based method; 13.2% of respondents were in the first trimester, 39.8% were in the second trimester, and 47.0% in the third. Overall, 42.6% were under the care of an obstetrician, 29.3% a family physician, and 28.1% a registered midwife. The sample included mainly well-educated, middle-class women. The planned place of giving birth ranged from home to hospital, and from rural centres to large city hospitals. Eighteen percent planned to engage a doula. Women attending obstetricians reported attitudes more favourable to the use of birth technology and less supportive of women's roles in their own delivery, regardless of the trimester in which the survey was completed. Those women attending midwives reported attitudes less favourable to the use of technology at delivery and more supportive of women's roles. Family practice patients' opinions fell between the other two groups. For eight of the questions, "I don't know" (IDK) responses exceeded 15%. These IDK responses were most frequent for questions regarding risks and benefits of epidural analgesia, Caesarean section, and episiotomy. Women in the care of midwives consistently used IDK options less frequently than those cared for by physicians. Regardless of the type of care provider they attended, many women reported uncertainty about the benefits and risks of common procedures used at childbirth. When grouped by the type of care provider, in all trimesters, women held different views across a range of childbirth issues, suggesting that the three groups of providers were caring for different populations with different attitudes and expectations.

Epidural Analgesia and Cancer Recurrence: Timing Matters

We thank our colleagues for their interest regarding our recent work.1In response to their inquiries, recurrence in our study was defined as any (local or metastatic) detection of colon cancer after primary resection. In the commonwealth of Virginia, treating physicians are required by law to report the cancer status of all patients. The University of Virginia Cancer Center, Charlottesville, tracks this data. Therefore, we are fortunate to have access to long-term follow-up cancer recurrence data on a large number of patients. However, we fully acknowledge that any retrospective study, including ours, is limited by (1) the accuracy of the available medical records, which may include missing data, and (2) difficulty controlling bias and confounding factors that could influence cancer recurrence (e.g ., α and β blockers, statins, nonsteroidal antiinflammatory drugs, cyclooxygenase inhibitors).We agree with Dr. Tiouririne that intraoperative use of epidural analgesia (i.e ., to supplement general anesthetics) may have different effects on cancer recurrence than epidural analgesia used only postoperatively. As Christopherson et al. 2note, a variety of factors influence cancer recurrence. For example, cancer stage and grade are almost always the best predictors of recurrence. Although our analysis corrected for major factors, our statistical modeling was, of course, restricted to the available data.Both letters assert that our findings contradict those of Christopherson et al. 2However, this interpretation of our results is inaccurate; neither we nor Christopherson et al. 2found an overall (primary hypothesis) benefit of epidural analgesia. Unplanned post hoc subgroup analyses—including our observation that cancer recurrence was reduced in older patients who received epidural analgesia—are notoriously unreliable. Indeed, such analyses, when statistically significant at 0.05, have only a 57% chance of being replicated in an identical clinical trial.3Although the idea that regional analgesia may reduce the incidence of cancer recurrence is exciting, it remains a hypothesis at this time—a question that can be answered only with prospective randomized clinical trials. Fortunately, several such studies are already in progress.* University of Virginia Health System, Charlottesville, Virginia. en3x@virginia.edu

Methodological Quality of Randomized Controlled Trials of Postoperative Epidural Analgesia

The overall benefits of epidural analgesia are controversial, in part because of the varying quality of methodology in published randomized controlled trials (RCTs). We performed a systematic review of available RCTs to examine the methodological quality of epidural analgesia trials. Current instruments for evaluating the quality of methodology are generic; thus, we also developed a specific assessment tool named Epidural Analgesia Trial Checklist (EATC). The National Library of Medicine's PubMed database was searched (1966 to January 2006) for RCTs of epidural analgesia. All RCTs that had epidural infusion analgesia in at least 1 study arm and as primary intervention for randomization were included. Two independent reviewers were given blinded full-text paper versions of each article and reviewed all articles for inclusion in this study. Study characteristics were extracted from accepted RCTs, and reviewers completed the standardized 7-item Jadad score, 22-item Consolidated Standards of Reporting Trials (CONSORT) checklist, and 8-item EATC for evaluation of methodological quality. A total of 321 articles met all inclusion criteria. The overall median (first, third quartiles) Jadad, CONSORT, and EATC scores were 2 (1, 3), 10 (8, 11), and 4 (3, 6) (of maximum scores of 5, 22, and 8), respectively. For all assessments, we found significantly higher methodological study quality for articles with a larger study population size, those written by a first author affiliated with an anesthesiology department, and studies published after release of the CONSORT statement with a significant overall increase in methodological quality over time. There was no effect on methodological quality with regard to region of publication or number of centers. There was relatively high interrater agreement when using the EATC (κ = 0.92). The items most frequently lacking from the studies captured using the EATC were appropriate description/definition of adverse effects (11.8% of all studies properly reported this), proper presentation of visual analog scale (VAS) pain scores (31.2%), and assessment of VAS pain both at rest and with activity (39.9%). Methodology scores for epidural analgesia RCTs have improved over time. The EATC seems to correlate well with other commonly used generic assessments for methodological RCT quality and be useful for assessing methodological quality of epidural RCTs. Future epidural analgesia RCTs should focus on improving appropriate description/definition of adverse effects, proper presentation of VAS pain scores, and assessment of VAS pain both at rest and with activity.

Could benefits of epidural analgesia following oesophagectomy be measured by perceived perioperative patient workload?

A controversy exists whether beneficial analgesic effects of epidural analgesia over intravenous analgesia influence the rate of post-operative complications and the length of hospital stay. There is some evidence that favours epidural analgesia following major surgery in high-risk patients. However, there is a controversy as to whether epidural analgesia reduces the intensive care resources following major surgery. In this study, we aimed at comparing the post-operative costs of intensive care in patients receiving epidural or intravenous analgesia. Clinical data and rates of post-operative complications were extracted from a previously reported trial following thoraco-abdominal oesophagectomy. Cost data for individual patients included in that trial were retrospectively obtained from administrative records. Two separate phases were defined: costs of pain treatment and the direct cost of intensive care. Higher calculated costs of epidural vs. intravenous pain treatment, 1,037 vs. 410 Euros / patient, were outweighed by lower post-operative costs of intensive care 5,571 vs. 7,921 Euros / patient (NS). Higher costs and better analgesic effects of epidural analgesia compared with intravenous analgesia do not reduce total costs for post-operative care following major surgery.

A reply

Dr Scott has raised some interesting issues and I think these are worth exploring. Firstly, I refer Dr Scott to a review done the same year on the same topic with very similar references [1] to the one that he has quoted. It found very little benefit of epidural analgesia in colorectal surgery. The authors in the reference quoted by Dr Scott state that they were unable to comment on the increase or decrease in anastomotic dehiscence using thoracic epidural analgesia and also comment on the fact that many of the proposed benefits to epidural analgesia were unable to be proven [2]. So we do not believe that the evidence that he has provided supports the safety or efficacy of epidural analgesia in patients who have had colorectal surgery. Regarding the use of the study by Gould et al. [3], we chose this as it is the only study that we are aware of that has clearly demonstrated the relationship between cardiac output, blood pressure and gastro-intestinal tract perfusion. Gould et al. clearly showed that gut perfusion is not related to cardiac output but is related to an increase in perfusion pressure. Most therapies used to treat epidural induced hypotension are based on either fluid loading or decreasing the epidural infusion rate. Fluid loading will optimise cardiac output but will do very little to improve vascular resistance and relying on pain driven catecholamines to increase the blood pressure seems somewhat perverse. It is, of course, very difficult for us to comment on Dr Scott’s 3500 cardiac patients who have had thoracic epidural analgesia. As far as we are aware he has not published any data regarding these patients. This is not the group that we were addressing and they will have different levels of post operative monitoring and therapy to standard laparotomy patients. Without knowing Dr Scott’s definitions, therapy and completeness of the data set, it is impossible to draw any conclusions on the safety of epidurals from his data. The review quoted earlier found an odds ratio of 13.5 for hypotension with epidural analgesia compared to opioid techniques [1]. We would therefore say there is quite a high level of concern. Thirdly we reiterate our point made in the editorial about the MASTER study. We did not say it was a perfect study. We said that it was the most credible study in this area that has been performed. It demonstrates a number of important points but most significantly, how difficult it is to provide adequate epidural analgesia in these patients. Regarding the significant reduction in pulmonary morbidity and pain, we commented in our editorial that there was a statistically significant reduction in pain scores, but that in both groups the pain scores were low. We still feel that a reduction in pain score of 1 cm on a visual analogue score was not clinically significant. Our comment on the MASTER study being a victim of its own success refers to the fact that it is very difficult to prove benefit in terms of pain scores if your background pain score is so low. Failure rates for post-operative epidurals are high. The failure rate in the MASTER study was 42.5%. This is in the context of a study with enthusiasts involved. It is difficult to see that it will be any less in the UK. The study that you quoted suggesting a 20% failure rate in UK hospitals is not reflective of normal UK practice [4]. This survey was performed when patients with epidural analgesia were routinely admitted to High Dependency Unit for post operative care. This, as you pointed out, is no longer the case. The authors also only looked at epidural analgesia for 48 h which we consider to be inadequate. We therefore stand by our figures of 50% of epidurals failing and possibly even higher. We do however agree with Dr Scott that if you are going to provide an epidural service you must have the ability to adequately assess the effect of your epidural analgesia, strive for total dynamic analgesia and be able to rapidly resite or adjust the epidural. This is both costly and time consuming to provide this service on a 24 h basis. Considering both the decrease in the numbers and experience of junior trainees, it is likely that this role is going to fall to consultants. We are not sure that the cost of providing this service is justified.

The role of the anaesthetist in the management of the pre-eclamptic patient

Recent literature on the anaesthetist's role in the management of the patient with severe pre-eclampsia is reviewed, with particular emphasis on the role of regional anaesthesia. Laboratory findings in pre-eclamptic women include increased levels of markers of oxidative stress and circulating tyrosine kinase 1, and inflammatory activation of leucocytes. Magnesium sulphate is the most effective agent for seizure prophylaxis. The optimal pharmacological agents for acute control of blood pressure remain controversial. The benefits of epidural analgesia in labour are well established. Single-shot spinal anaesthesia for caesarean section is safe in the absence of contraindications. Successful use of combined spinal-epidural anaesthesia has been described. Most studies on maternal haemodynamics have employed heart rate and blood pressure data as surrogate measures of cardiac output. Noninvasive cardiac output studies provide further insight into the haemodynamic response during neuraxial techniques for caesarean section. The value of regional anaesthesia cannot be over-emphasized. Recent research into spinal anaesthesia for caesarean section suggests a lower susceptibility to hypotension and probably less impairment of cardiac output than in healthy parturients. Noninvasive cardiac output measurement may also have advantages in critical care management.

Thoracic epidural analgesia for coronary artery surgery. A bridge too far?

Thoracic epidural analgesia for coronary artery surgery. A bridge too far?

Comparative benefits of epidural analgesia following hysterectomy and colonic resection

Comparative benefits of epidural analgesia following hysterectomy and colonic resection