Combined Epidural-General Anesthesia vs General Anesthesia Alone for Elective Abdominal Aortic Aneurysm Repair

Bardia, Amit; Sood, Akshay; Mahmood, Feroze; Orhurhu, Vwaire; Mueller, Ariel; Montealegre-Gallegos, Mario; Shnider, Marc; Ultee, Klaas H.J.; Schermerhorn, Marc L.; Matyal, Robina

doi:10.1001/jamasurg.2016.2733

Cited by 71 publications

(26 citation statements)

References 23 publications

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“…11,12 Recent retrospective data suggest that, in abdominal aortic surgery, the addition of an epidural to GA improves the 5 yr survival compared to GA alone. 15 The risk of GA varies directly with American Society of Anesthesiologists physical status, but there is no clear evidence that using RA in high-risk patients influences outcome. 16 PNB avoids the haemodynamic compromise of CNB, and theoretically may be safer than CNB or GA in high-risk patients, but there is only anecdotal evidence to support this, albeit as experts PNB would be our choice.…”

Section: Mortalitymentioning

confidence: 99%

Regional anaesthesia and outcomes

2018

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Regional anaesthesia (RA) reduces acute pain, chronic pain after some surgical procedures, postoperative nausea and vomiting, and pulmonary complications. RA can reduce length of stay and improve operating department throughput. Although RA confers short-term functional benefits, these are generally not sustained. Combined general anaesthesia and epidural analgesia may increase the incidence of adverse cardiac events. Some studies have shown RA to be associated with a reduction in cancer recurrence, bloodtransfusion requirements, surgical site infections, ICU admission, and mortality; however, these associations must be treated cautiously.

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Section: Mortalitymentioning

confidence: 99%

Regional anaesthesia and outcomes

2018

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“…7,20e22 Recently, Bardia et al have suggested that combined epidural with GA vs. GA alone was associated with significantly lower mortality and morbidity in patients undergoing elective abdominal aneurysm open repair. 6,23 However, TAAA surgery is more complex and presents unique features which may account for the different results observed. Furthermore, the present data concerning the incidence of neurological complications are encouraging, as no case of epidural haematoma was recorded in a context in which patients require systemic intra-operative heparinisation and are at high risk of developing peri-operative coagulopathy secondary to massive bleeding and need for transfusions.…”

Section: Discussionmentioning

confidence: 99%

“…EA also improved outcomes after major surgery, 4,5 including open abdominal aortic aneurysm (AAA) repair. 6 Compared to AAA repairs, TAAA surgery is a longer and more complex intervention, with a higher risk of complications due to major involvement of the cardiovascular and pulmonary systems. Left thoracotomy is associated with both greater pain and pulmonary complications than AAA.…”

Section: Introductionmentioning

confidence: 99%

Epidural Analgesia in Open Thoraco-abdominal Aortic Aneurysm Repair

Monaco

Pieri

Barucco

et al. 2019

European Journal of Vascular and Endovascular Surgery

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Thoracic epidural analgesia is effective in reducing post-operative pain with no effect on major post-operative complications. The use of thoracic epidural analgesia, if not contraindicated, might be considered in clinical practice in open thoraco-abdominal aortic aneurysm repair, as it could improve peri-operative management and promote recovery. Objective: Epidural analgesia improves pain control and outcomes of abdominal aortic aneurysm procedures, while the effect of thoracic epidural analgesia on thoraco-abdominal aortic aneurysm (TAAA) repair is unknown. The aim of the study was to evaluate thoracic epidural analgesia effects in patients undergoing open TAAA repair in terms of pain control and clinically relevant outcomes. Methods: This was a retrospective study of a prospectively collected database. Patients undergoing open TAAA repair between January 2009 and December 2016. Results: Four hundred and fifty-nine consecutive patients were included. Thoracic epidural analgesia was used in 409 (89%) of cases. On multivariable analysis, patients who received thoracic epidural analgesia experienced reduced post-operative pain (odds ratio [OR] 0.003, 95% confidence interval [CI] 0.0007e0.009; p < .001), a lower rate of acute kidney injury (AKI; OR 0.39, 95% CI 0.21e0.71 [p ¼ .002]), atrial fibrillation (OR 0.47, 95% CI 0.23e0.95; p ¼ .04), acute myocardial infarction (AMI; OR 0.189, 95% CI 0.05e0.64; p ¼ .008), and paraplegia (OR 0.31, 95% CI 0.157e0.615; p ¼ .001) compared with the conventional analgesia (CA) group. After propensity score matching, 43 patients in the CA group were compared with 43 in thoracic epidural analgesia group. On case match analysis thoracic epidural analgesia showed a significant reduction in postoperative pain (p < .001) and no differences in the incidence of AKI, atrial fibrillation, AMI, and paraplegia. In the thoracic epidural analgesia group there were no epidural haematomas. Conclusion: Thoracic epidural analgesia was effective in reducing post-operative pain with no effect on major post-operative complications. The use of thoracic epidural analgesia, if not contraindicated, might be considered in clinical practice, even in patients undergoing open TAAA repair. Whether a better postoperative management enhances patient's recovery in this setting remains to be tested.

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“…Eine aktuelle Cochrane-Analyse beschreibt eine Reduktion der Häufigkeit von postoperativen Myokardinfarkten, von respiratorischen Komplikationen, gastrointestinalen Blutungen und der Schmerzintensität [11]. In einer retrospektiven Analyse von mehr als 1500 BAA-Operationen konnte eine Abnahme von respiratorischen Komplikationen, dialysepflichtigem Nierenversagen, Darmischämien und Re-Operationen beobachtet werden [12].…”

Section: Gefäßchirurgieunclassified

CONTRA: Postoperative Epiduralanalgesie – der Goldstandard?

Gerbershagen¹

2018

Anästhesiol Intensivmed Notfallmed Schmerzther

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As strategy for postoperative pain therapy, epidural analgesia (EDA) is superior to systemic opiate analgesia after abdominal and thoracic surgery. In addition, EDA may significantly reduce the incidence of complications in some large operations, such as, e.g. cardiac (myocardial infarction, atrial fibrillation) and pulmonary complications (pneumonia, atelectasis), and even reduce mortality. Intestinal motility can also be improved. However, these positive effects do not appear in all interventions and not to the same degree. Therefore, for benefit-risk assessment, it is important to know both the operation-specific benefits and disadvantages of EDA. In the meantime, the distinctly different complication rates of epidural bleeding and abscesses after EDA are also known for different surgical interventions. In large open abdominal interventions, open thorax operations, and especially open abdominal aortic surgeries, EDA reduces pain and complications. It should be noted that the positive effects of EDA have so far hardly been directly compared with those of intraoperative lidocaine administration.

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Combined Epidural-General Anesthesia vs General Anesthesia Alone for Elective Abdominal Aortic Aneurysm Repair

Cited by 71 publications

References 23 publications

Regional anaesthesia and outcomes

Regional anaesthesia and outcomes

Epidural Analgesia in Open Thoraco-abdominal Aortic Aneurysm Repair

CONTRA: Postoperative Epiduralanalgesie – der Goldstandard?

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