Effect Of Postoperative Epidural Analgesia Research Articles

Epidural Local Anesthetics Versus Opioid-Based Analgesic Regimens for Postoperative Gastrointestinal Paralysis, Vomiting, and Pain After Abdominal Surgery: A Cochrane Review.

The aim of this review was to compare the effects of postoperative epidural analgesia with local anesthetics to postoperative systemic or epidural opioids in terms of return of gastrointestinal transit, postoperative pain control, postoperative vomiting, incidence of gastrointestinal anastomotic leak, hospital length of stay, and cost after abdominal surgery. Trials were identified by computerized searches of the Cochrane Central Register of Controlled Trials (CENTRAL) (2014, Issue 12), Medical Literature Analysis and Retrieval System Online (MEDLINE) (from 1950 to December, 2014) and Excerpta Medica dataBASE (EMBASE) (from 1974 to December 2014) and by checking the reference lists of trials retained. We included parallel randomized controlled trials comparing the effects of postoperative epidural local anesthetic with regimens based on systemic or epidural opioids. The quality of the studies was rated according to the Cochrane tool. Two authors independently extracted data. We judged the quality of evidence according to the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) working group scale. Based on 22 trials including 1138 participants, an epidural containing a local anesthetic will decrease the time required for return of gastrointestinal transit as measured by time required to observe the first flatus after an abdominal surgery standardized mean difference (SMD) -1.28 (95% confidence interval [CI], -1.71 to -0.86; high quality of evidence; equivalent to 17.5 hours). The effect is proportional to the concentration of local anesthetic used. Based on 28 trials including 1559 participants, we also found a decrease in time to first feces (stool): SMD -0.67 (95% CI, -0.86 to -0.47; low quality of evidence; equivalent to 22 hours). Based on 35 trials including 2731 participants, pain on movement at 24 hours after surgery is also reduced: SMD -0.89 (95% CI, -1.08 to -0.70; moderate quality of evidence; equivalent to 2.5 on a scale from 0 to 10). Based on 22 trials including 1154 participants, we did not find a difference in the incidence of vomiting within 24 hours: risk ratio 0.84 (95% CI, 0.57-1.23); low quality of evidence. Based on 17 trials including 848 participants we did not find a difference in the incidence of gastrointestinal anastomotic leak: risk ratio 0.74 (95% CI, 0.41-1.32; low quality of evidence). Based on 30 trials including 2598 participants, epidural analgesia reduces length of hospital stay for an open surgery: SMD -0.20 (95% CI, -0.35 to -0.04; very low quality of evidence; equivalent to 1 day). Data on cost were very limited. An epidural containing a local anesthetic, with or without the addition of an opioid, accelerates the return of the gastrointestinal transit (high quality of evidence). An epidural containing a local anesthetic with an opioid decreases pain after an abdominal surgery (moderate quality of evidence). An epidural containing a local anesthetic does not affect the incidence of vomiting or anastomotic leak (low quality of evidence). For an open surgery, an epidural containing a local anesthetic would reduce the length of hospital stay (very low quality of evidence).

Epidural local anaesthetics versus opioid-based analgesic regimens for postoperative gastrointestinal paralysis, vomiting and pain after abdominal surgery.

Gastrointestinal paralysis, nausea and vomiting and pain are major clinical problems following abdominal surgery. Anaesthetic and analgesic techniques that reduce pain and postoperative nausea and vomiting (PONV), while preventing or reducing postoperative ileus, may reduce postoperative morbidity, duration of hospitalization and hospital costs. This review was first published in 2001 and was updated by new review authors in 2016. To compare effects of postoperative epidural analgesia with local anaesthetics versus postoperative systemic or epidural opioids in terms of return of gastrointestinal transit, postoperative pain control, postoperative vomiting, incidence of anastomotic leak, length of hospital stay and costs after abdominal surgery. We identified trials by conducting computerized searches of the Cochrane Central Register of Controlled Trials (CENTRAL) (2014, Issue 12), MEDLINE (from 1950 to December 2014) and EMBASE (from 1974 to December 2014) and by checking the reference lists of trials retained. When we reran the search in February 2016, we added 16 potential new studies of interest to the list of 'Studies awaiting classification' and will incorporate these studies into formal review findings during the next review update. We included parallel randomized controlled trials comparing effects of postoperative epidural local anaesthetic versus regimens based on systemic or epidural opioids. We rated the quality of studies by using the Cochrane 'Risk of bias' tool. Two review authors independently extracted data and judged the quality of evidence according to the GRADE (Grades of Recommendation, Assessment, Development and Evaluation Working Group) scale. We included 128 trials with 8754 participants in the review, and 94 trials with 5846 participants in the analysis. Trials included in the review were funded as follows: charity (n = 19), departmental resources (n = 8), governmental sources (n = 15) and industry (in part or in total) (n = 15). The source of funding was not specified for the other studies.Results of 22 trials including 1138 participants show that an epidural containing a local anaesthetic will decrease the time required for return of gastrointestinal transit as measured by time to first flatus after an abdominal surgery (standardized mean difference (SMD) -1.28, 95% confidence interval (CI) -1.71 to -0.86; high quality of evidence; equivalent to 17.5 hours). The effect is proportionate to the concentration of local anaesthetic used. A total of 28 trials including 1559 participants reported a decrease in time to first faeces (stool) (SMD -0.67, 95% CI -0.86 to -0.47; low quality of evidence; equivalent to 22 hours). Thirty-five trials including 2731 participants found that pain on movement at 24 hours after surgery was also reduced (SMD -0.89, 95% CI -1.08 to -0.70; moderate quality of evidence; equivalent to 2.5 on scale from 0 to 10). From findings of 22 trials including 1154 participants we did not find a difference in the incidence of vomiting within 24 hours (risk ratio (RR) 0.84, 95% CI 0.57 to 1.23; low quality of evidence). From investigators in 17 trials including 848 participants we did not find a difference in the incidence of gastrointestinal anastomotic leak (RR 0.74, 95% CI 0.41 to 1.32; low quality of evidence). Researchers in 30 trials including 2598 participants noted that epidural analgesia reduced length of hospital stay for an open surgery (SMD -0.20, 95% CI -0.35 to -0.04; very low quality of evidence; equivalent to one day). Data on costs were very limited. An epidural containing a local anaesthetic, with or without the addition of an opioid, accelerates the return of gastrointestinal transit (high quality of evidence). An epidural containing a local anaesthetic with an opioid decreases pain after abdominal surgery (moderate quality of evidence). We did not find a difference in the incidence of vomiting or anastomotic leak (low quality of evidence). For open surgery, an epidural containing a local anaesthetic would reduce the length of hospital stay (very low quality of evidence).

Effects of postoperative epidural analgesia on recurrence-free and overall survival in patients with nonsmall cell lung cancer

Study ObjectiveTo determine whether postoperative epidural analgesia is associated with better recurrence-free survival and overall survival after lung cancer surgery. DesignRetrospective study. SettingAcademic hospital. MeasurementsData of patients with stage 1, stage 2, and stage 3 nonsmall cell lung cancer, who underwent tumor resection surgery, were studied. Patient data were grouped into three different postoperative pain management interventions: intravenous patient-controlled analgesia, patient-controlled epidural analgesia, and their combination. Univariate and multicovariate Cox proportional hazards models were applied to assess the effects of covariates of interest on overall survival and recurrence-free survival. Main ResultsThe type of postoperative analgesia used for patients who underwent surgery for nonsmall cell lung cancer did not affect recurrence-free survival or overall survival. However, certain variables, including age ≥ 65 years, male gender, body mass index ≥ 25 kg/m2, ASA physical status 4, and the need for preoperative blood transfusions, pneumonectomy, and postoperative radiation, were associated with decreased recurrence-free survival and overall survival. ConclusionsThe type of postoperative analgesia used after surgery for nonsmall cell lung cancer is not associated with better 2-year or 5-year recurrence-free survival or overall survival rates.

Effects of postoperative epidural analgesia on prolactin level and neonatal neurobehavioral scores after caesarean section

Objective To investigate the effect of postoperative epidural analgesia on prolactin level and neonatal neurological and adaptive capacity scores(NACS) after caesarean section.Methods Sixty healthy primipara after caesarean section under combined spinal epidural anesthesia were randomly divided into three groups(n=20).Received epidural analgesia with complex of butorphanol (0.006％) and 1evobupivacaine(0.15％) in group B,those with morphine(0.004％) and levobupivacaine(0.15％) in group M.Group C was given conventional postoperative analgesia with meperidine injection.The visual analog scales (VAS) and the adverse effects were observed at 4,8,12,24 and 48 h after operation.Detect the prolactin (PRL) level in serum before operation,after operation 24 h and 48 h separately by electrochemiluminescence immunoassay.Keep note of the first lactation time.NACS was recorded at 24,48 and 72 h.Results The VAS was significantly lower in group B [4 h:( 1.1±0.7),8 h:(1.2±1.2),12 h:( 1.7±1.1),24 h:(1.4±1.5),48 h:(1.0±0.9)] and group M [4 h:(1.1±0.9),8 h:(1.3±1.9),12 h:(1.6±1.2),24h:(1.3±1.3),48 h:(1.0±0.7)] than that in group C [4 h:(2.2±1.3),8 h:(4.3±1.7),12 h:(4.7±1.5),24 h:(3.6±1.3),48 h:(2.4±1.1)] at all time points (P＜0.05).The adverse effects of pruritus,nausea and vomiting were significantly more in group M (25％,30％,respectively)than that in group B (5％,0％,respectively)(P＜0.05).The first lactation time of the group B (26±8) h and M (26±9) h were distinctively earlier than that of the group C (35±10) h (P＜0.05).The PRL concentration in serum of the group B [(357±62),(387±63) μg/L,respectively] and group M [(367±64),(392±61) μg/L,respectively] at 24,48 h after operation were higher than that of the group C [(299±93),(327±74) μg/L,respectively](P＜0.05).There was no significant difference NACS among the 3 groups.Conclusions Combined with butorphanol levobupivacaine,epidural analgesia in parturient after cesarean section can provide effective analgesia,with less pruritus,nausea and vomiting,and promoting lactation without untoward reaction on NACS. Key words: Butorphanol ; Caesarean section; Epidural analgesia; Prolactin; Neonatal

The effect of postoperative epidural analgesia in women possessing severe gestational hypertension undergoing cesarean delivery

Introduction: The purpose of this study was to examine the clinical usefulness of postoperative epidural analgesia in patients possessing severe gestational hypertension after Cesarean delivery. Methods: We reviewed the obstetric records of 99 patients possessing severe gestational hypertension undergoing singleton Cesarean delivery at ≥ 22 weeks’ gestation. Thirty patients were received continuous epidural analgesia with 0.2% ropivacaine for pain relief after Cesarean delivery with spinal anesthesia, 69 patients were not received epidural analgesia after Cesarean delivery with spinal anesthesia. Results: During the preoperative period, there were no measurable differences in the diastolic blood pressure between the 2 groups (108 vs± 7 vs. 106 mmHg ± 10 mmHg, p = 0.29). The diastolic blood pressure at 2 and 4 hours after Cesarean section in the epidural analgesia group were significantly lower than those in the non-epidural group (2 hours after Cesarean section: 88 vs ± 13 vs. 95 mmHg ± 8 mmHg, p < 0.01; 4 hours after Cesarean section: 92 vs ± 15 vs. 102 mmHg ± 9 mmHg, p < 0.01). Conclusions: The current results indicated that the postoperative epidural analgesia can inhibit the rise in diastolic blood pressure in patients possessing severe gestational hypertension after Cesarean delivery. This electronic document is a “live” template. The various components of your paper [title, text, heads, etc.] are already defined on the style sheet, as illustrated by the portions given in this document.

Effect of postoperative epidural analgesia on morbidity and mortality after lung resection in Medicare patients

Effect of postoperative epidural analgesia on morbidity and mortality after lung resection in Medicare patients

Correlation of postoperative epidural analgesia on morbidity and mortality after colectomy in Medicare patients

Study Objective To examine, with a large database, the effect of postoperative epidural analgesia (vs systemic analgesia) on mortality after colectomy is unclear. Design Retrospective cohort (database) design. Setting Medicare beneficiaries undergoing elective colectomy. Patients We examined a cohort of 12 817 patients obtained from a 5% nationally random sample of Medicare beneficiaries from 1997 to 2001 who underwent elective partial excision of the large intestine. Interventions Patients were divided into two groups depending on the presence or absence of billing for postoperative epidural analgesia (Current Procedural Terminology code 01996). Measurements The primary outcomes assessed were death at 7 and 30 days after the procedure. The rates of major morbidity were also compared. Multivariate regression analysis incorporating race, gender, age, comorbidities, hospital size, hospital teaching status, and hospital technology status was performed to determine whether the presence of postoperative epidural analgesia had an independent effect on mortality or major morbidity. Main Results Multivariate regression analysis revealed that there was no difference between the groups with regard to overall major morbidity; however, the presence of epidural analgesia was associated with a significantly lower odds of death at 7 days (odds ratio, 0.35; 95% confidence interval, 0.21-0.59; P < 0.0001) and 30 days (odds ratio, 0.54; 95% confidence interval, 0.42-0.70; P < 0.0001) after surgery. Conclusions The presence of postoperative epidural analgesia may decrease the odds of death after elective colectomy; however, the mechanism of such a benefit is not clear from our analysis.

Effect of postoperative epidural analgesia on morbidity and mortality after lung resection in Medicare patients

Study ObjectiveTo perform an analysis of the Medicare claims database in patients undergoing lung resection to determine whether there is an association between postoperative epidural analgesia and mortality. DesignRetrospective cohort (database) design. SettingUniversity hospital. MeasurementsWe examined a cohort of 3501 patients obtained from a 5% nationally random sample of 1997 to 2001 Medicare beneficiaries who underwent nonemergency segmental excision of the lung (International Classification of Diseases, 9th Revision, Clinical Modification codes 32.3 and 32.4). Patient data were divided into two groups depending on the presence or absence of billing for postoperative epidural analgesia (Current Procedural Terminology code 01996). The primary outcomes assessed were death at 7 and 30 days after the procedure. The rates of major morbidity (acute myocardial infarction, angina, cardiac dysrhythmias, heart failure, pneumonia, pulmonary edema, respiratory failure, deep venous thrombosis, pulmonary embolism, sepsis, acute renal failure, somnolence, acute cerebrovascular event, transient organic syndrome, and paralytic ileus) were also compared. Multivariate regression analysis incorporating race, gender, age, comorbidities, hospital size, hospital teaching status, and hospital technology status was performed to determine whether the presence of postoperative epidural analgesia had an independent effect on mortality or major morbidity. Main ResultsMultivariate regression analysis showed that the presence of epidural analgesia was associated with a significantly lower odds of death at 7 days (odds ratio, 0.39; 95% confidence interval, 0.19-0.80; P = 0.001) and 30 days (odds ratio, 0.53; 95% confidence interval, 0.35-0.78; P = 0.002) after surgery. There was no difference between the groups with regard to overall major morbidity. ConclusionsPostoperative epidural analgesia may contribute to lower odds of death after segmental excision of the lung, although the mechanism of such a benefit is not clear from our analysis.

Effects of epidural administration of local anaesthetics or morphine on postoperative nitrogen loss and catabolic hormones

To examine the effects of postoperative epidural analgesia with local anaesthetics or morphine on the excess nitrogen loss after upper abdominal surgery and to assess the roles of catabolic hormones in the nitrogen loss, urinary excretion of nitrogen and catecholamines and plasma concentrations of cortisol and glucagon were measured in three groups of patients undergoing elective gastrectomy. Group G patients received the operation under general anaesthesia, and their postoperative pain was relieved by intermittent injections of analgesics. Group PE received prolonged epidural analgesia with local anaesthetics during and after surgery. Group EM received epidural analgesia intra-operatively and epidural morphine postoperatively. Urinary nitrogen excretion during the first three postoperative days was significantly less in the PE and EM groups than in the G group, and the PE group excreted slightly less nitrogen than the EM group. In the G group, urinary excretion of adrenaline increased mainly on the day of operation, and noradrenaline chiefly on postoperative days. These catecholamine responses were almost completely abolished in the PE group, and significantly inhibited in the EM group. Plasma cortisol response was most remarkable shortly after the operation and then decreased in all groups, but was significantly lower in the two epidural groups than in the G group throughout the study. Plasma glucagon increased postoperatively in all groups, and the increase was less pronounced in both epidural groups than in the G group. These results suggested that an elevated sympathetic activity, represented by increased noradrenaline excretion and elicited by painful nociceptive and sympathetic nervous afferents, is responsible for the postoperative nitrogen loss which is mediated by glucagon and cortisol.

Effect of Postoperative Epidural Analgesia on Rehabilitation and Pain after Hip Fracture Surgery

Hip fracture surgery usually carries a high demand for rehabilitation and a significant risk of perioperative morbidity and mortality. Postoperative epidural analgesia may reduce morbidity and has been shown to facilitate rehabilitation in elective orthopedic procedures. No studies exist on the effect of postoperative epidural analgesia on pain and rehabilitation after hip fracture surgery. Sixty elderly patients were included in a randomized, double-blind study comparing 4 days of continuous postoperative epidural infusion of 4 ml/h bupivacaine, 0.125%, and 50 mug/ml morphine versus placebo. Both patient groups received balanced analgesia and intravenous nurse-controlled analgesia with morphine. All patients followed a well-defined multimodal rehabilitation program. Pain, ability to participate in four basic physical functions, and any factors restricting participation were assessed on the first 4 postoperative days during physiotherapy. Epidural analgesia provided superior dynamic analgesia during all basic physical functions, and patients were significantly less restricted by pain, which was the dominating restricting factor in the placebo group. Motor blockade was not a restricting factor during epidural analgesia. Despite improved pain relief, scores for recovery of physical independence were not different between groups. Postoperative epidural analgesia after hip fracture surgery provides superior analgesia attenuating pain as a restricting factor during rehabilitation without motor dysfunction. However, superior analgesia did not translate into enhanced rehabilitation. Future studies with multimodal rehabilitation are required to establish whether superior analgesia can be translated into enhanced rehabilitation and reduced morbidity in hip fracture patients.

The effect of postoperative epidural analgesia vs NCA morphine on pain and rehabilitation after surgery for hip fracture: A randomized, doubleblinded, placebo-controlled study

Foss, N. B.; Kristensen, B. B.; Kristensen, M. T.; Jensen, P S.; Kehlet, H. Author Information

Effect of postoperative epidural analgesia on morbidity and mortality following surgery in medicare patients

Because of the uncertainty and limitations in available randomized controlled trials, we performed an analysis of the Medicare claims database to determine whether an association exists between postoperative epidural analgesia and mortality. A 5% nationally random sample of Medicare beneficiaries from 1997 to 2001 was analyzed to identify patients undergoing segmental excision of the lung (International Statistical Classification of Diseases, Ninth Revision, Clinical Modification codes 32.3 and 32.4), complete pneumonectomy (code 32.5), partial excision of large intestine (codes 45.73 and 45.76), anastomosis of the esophagus (codes 42.5 and 42.6), total knee replacement/revision (codes 81.54 and 81.55), total/radical abdominal hysterectomy (codes 68.4 and 68.6), partial/radical pancreaticoduodenectomy (codes 52.5 and 52.7), partial/complete nephrectomy (codes 55.4 and 55.5), partial/complete cystectomy (codes 57.6 and 57.7), hepatotomy/lobectomy of the liver (codes 50.0 and 50.3), partial/total gastrectomy (codes 43.5 to 43.9), and radical retropubic prostatectomy (codes 60.4 and 60.5). Patients were divided into 2 groups, depending on the presence or absence of postoperative epidural analgesia. The rate of major morbidity and death at 7 and 30 days after surgery were compared. Multivariate regression analyses incorporating race, gender, age, comorbidities, hospital size, hospital teaching status, and hospital technology status were performed. The presence of epidural analgesia was associated with a significantly lower odds of death at 7 days (odds ratio [OR], 0.52; 95% confidence interval [CI], 0.38 to 0.73; P = .0001) and 30 days (OR, 0.74; 95% CI, 0.63 to 0.89; P = .0005) after surgery; however, no difference was seen between the groups with regard to overall major morbidity, with the exception of an increase in pneumonia at 30 days for the epidural group (OR, 1.91;[95% CI, 1.09 to 3.34; P = .02). Postoperative epidural analgesia may contribute to lower odds of death after surgery.

Effect of Postoperative Epidural Analgesia on Morbidity and Mortality Following Surgery in Medicare Patients

Effect of Postoperative Epidural Analgesia on Morbidity and Mortality Following Surgery in Medicare Patients

Effect of postoperative epidural analgesia on morbidity and mortality after total hip replacement surgery in medicare patients

Background and Objectives: The effect of postoperative epidural analgesia (vs. systemic analgesia) on patient outcomes is unclear. Available randomized controlled trials (RCTs) have focused on the intraoperative period and not properly examined the effect of postoperative epidural analgesia (EA) on outcomes. Methods: A 5% nationally random sample of Medicare beneficiaries from 1994 to 1999 was analyzed to identify patients undergoing total hip arthroplasty (Common Procedural Terminology [CPT] code 27130, 27132, 27134, 27137, 27138). Patients were divided into 2 groups depending on the presence or absence of postoperative EA based on the CPT coding (01996). The rate of major morbidity (acute myocardial infarction, deep venous thrombosis, pulmonary embolism, angina, respiratory failure, heart failure, cardiac dysrhythmias, pneumonia, pulmonary edema, sepsis, acute renal failure, paralytic ileus, acute cerebrovascular event) and death at 7 and 30 days after the procedure were compared. Multivariate regression analysis was performed to determine if the presence of postoperative (EA) had an independent effect on mortality or major morbidity. Data were reported as an odds ratio with 95% confidence intervals (CI) when appropriate. Results: The unadjusted 7- and 30-day death rate was significantly lower for EA versus no EA (1.9/1000 [95% CI: 0.2-3.6] vs. 3.9/1000 [95% CI: 3.0-6.2] at 7 days [ P = .04] and 5.8/1000 [95% CI: 2.9-8.7] vs. 9.9/1000 [95% CI: 8.6-11.3] at 30 days [ P = 0.01]). However, multivariate regression analysis revealed that there was no difference between the groups with regard to mortality or major morbidity with the exception of an increase in deep venous thrombosis in patients who received EA. Conclusions: The use of postoperative EA was not associated a lower incidence of mortality and major morbidity in Medicare patients undergoing total hip arthroplasty. However, the results should be interpreted with caution because of limitations in using the Medicare claims data for analysis. Further trials using other properly conducted and designed studies (e.g., RCTs) would be ideal to validate these results.

Effect of postoperative epidural analgesia on patient outcomes

The overall benefits of perioperative epidural anesthesia and analgesia for decreasing morbidity and mortality is controversial. However, perioperative epidural anesthesia and analgesia will attenuate detrimental perioperative pathophysiology, which, in turn, may diminish the incidence of adverse patient outcomes. There are increasing experimental and clinical data to support the use of perioperative epidural anesthesia and analgesia for decreasing postoperative pulmonary, gastrointestinal, and cardiovascular complications. One of the primary reasons that the “regional versus general anesthesia” question has not been answered is due to the significant methodological issues present in every available trial, which affect the interpretation and limit the applicability of the trial results. A major issue in the overall interpretation of results from trials examining the effect of postoperative epidural analgesia on patient outcomes is that “epidural analgesia” is commonly viewed as a generic term. There are clinical and outcome implications for various inputs into what constitutes “epidural analgesia,” including the duration of epidural analgesia, analgesic contents (eg, local anesthetics versus opioids), and location of catheter placement. We will examine these issues along with the role of epidural analgesia in the multimodal approach for patient recovery.

Effect of Postoperative Epidural Analgesia on Morbidity and Mortality After Total Hip Replacement Surgery in Medicare Patients

Effect of Postoperative Epidural Analgesia on Morbidity and Mortality After Total Hip Replacement Surgery in Medicare Patients

Complications and side effects associated with epidural bupivacaine/morphine analgesia

Abstract Postoperative analgesia is a responsibility that physicians should fulfil in every patient. It is not only an act of kindness, but also an improved clinical outcome may be derived from this service when epidural techniques are used. However, complications and side effects may occur with postoperative epidural analgesia. Thus, there have been concerns among some clinicians regarding the use of local anaesthetics and opioids for epidural analgesia in the surgical wards where monitoring of patients is not as strict as it is in critical care or step down units. A review of the literature reflects a low incidence of side effects and complications in the surgical wards where the nursing staff have been trained in the early recognition of potential complications and the treatment of side effects. Many issues remain to be addressed via further research efforts. However, we believe that the current knowledge on potential complications and side effects of postoperative epidural analgesia and their treatment, allow for the safe epidural delivery of combinations of local anaesthetics and opioids in a wide range of postoperative patients. We also present the protocols that we currently use in our Acute Pain Treatment Service for the management of these complications and side effects.

Reply

Department of Anaesthesia; Deaconess Hospital; Harvard Medical School; Boston, Massachussets 02215-9985.In Reply:--We emphasize that the scope of our study and subsequent conclusions [1]were limited to patients undergoing infrainguinal peripheral vascular surgery (PVS). Trials cited [2,3]by de Leon-Casasola and Lema as evidence that postoperative analgesia impacts cardiac outcome studied other surgical populations, including intraabdominal procedures.Our data offer little encouragement to those who wish to improve cardiac outcome after PVS by providing postoperative epidural analgesia. Within the epidural group, 40% received 3 mg in 10 ml epidural morphine during surgery. Generally, a second bolus was given immediately before catheter removal at 24 h after surgery. Therefore, epidural analgesia would have been expected to be in the range of 36-48 h. This is well into the period when poor cardiac outcome becomes evident. The myocardial infarction rate for the epidural morphine group was 4.9% versus 3.6% and 3.7%, respectively, for the patients who received general or spinal, both with postoperative parenteral opioids. As we pointed out in our discussion of these results, patients undergoing lower extremity PVS probably do not experience the same intensity of postoperative pain as do patients undergoing other types of surgery, such as intraabdominal procedures. Any beneficial effects of postoperative epidural analgesia may, therefore, be rendered inconsequential.In this era of severe cost constraints, we reduced costs by making various changes, such as shortening length of stay, but we continue to use arterial and pulmonary artery catheters in most of our PVS patients. Having established morbidity and mortality rates achieved with intensive perioperative monitoring, we believe that the onus is on those who deviate from this practice to show similar or better results.As de Leon-Casasola and Lema correctly point out, our study design had no protocol to guide participating anesthesiologists and surgeons in the use of vasoactive drugs and fluids. There was no "tune-up" or "hemodynamic optimization" before surgery, as was described by others. [4]More than 100 anesthesiologists (residents and staff) and surgeons were involved directly in the care of our study patients. Each physician used their own judgment in the use of hemodynamic data. It is hard to imagine how such a large group of practitioners could introduce a consistent and significant bias into the methods.Robert H. Bode, Jr., M.D.; Keith P. Lewis, M.D.; Eric T. Pierce, Ph.D., M.D.; Department of Anaesthesia; Deaconess Hospital; Harvard Medical School; Boston, Massachusetts 02215-9985(Accepted for publication April 18, 1996.)