Protective Effects of Epidural Analgesia on Pulmonary Complications After Abdominal and Thoracic Surgery

Abstract

To review the impact of epidural vs systemic analgesia on postoperative pulmonary complications.Data Sources: Search of databases (1966( to March 2006 and bibliographies.Study Selection: Inclusion criteria were randomized comparison of epidural vs systemic analgesia lasting 24 hours or longer postoperatively and reporting of pulmonary complications, lung function, or gas exchange. Fiftyeight trials (5904 patients) were included.Data Extraction: Articles were reviewed and data extracted. Data were combined using fixed-effect and random-effects models.Data Synthesis: The odds of pneumonia were decreased with epidural analgesia (odds ratio [OR], 0.54; 95% confidence interval [CI], 0.43-0.68), independent of site of surgery or catheter insertion, duration of analgesia, or regimen. The effect was weaker in trials that used patient-controlled analgesia in controls (OR, 0.64; 95% CI, 0.49-0.83) compared with trials that did not (OR, 0.30; 95% CI, 0.18-0.49) and in larger studies (OR, 0.62; 95% CI, 0.47-0.81) compared with smaller studies (OR, 0.37; 95% CI, 0.23-0.58). From 1971-2006, the incidence of pneumonia with epidural analgesia remained about 8% but decreased from 34% to 12% with systemic analgesia (P Ͻ.001); consequently, the relative benefit of epidural analgesia decreased also. Epidural analgesia reduced the need for prolonged ventilation or reintubation, improved lung function and blood oxygenation, and increased the risk of hypotension, urinary retention, and pruritus. Technical failures occurred in 7%. Conclusion:Epidural analgesia protects against pneumonia following abdominal or thoracic surgery, although this beneficial effect has lessened over the last 35 years because of a decrease in the baseline risk.

Guidelines for Perioperative Care in Elective Colonic Surgery: Enhanced Recovery After Surgery (ERAS®) Society Recommendations

“…A regional anaesthetic block used in addition to general anaesthesia during surgery can minimise the need for postoperative intravenous opiates, thereby allowing rapid awakening from anaesthesia which can facilitate early enteral intake and mobilisation on the day of surgery. In open surgery, the use of epidural analgesia has proven to be superior to opioid-based alternatives for several important outcomes [81], including pain [82], PONV [83] and complications [84]. In laparoscopic surgery, emerging data indicate that alternative methods such as spinal anaesthesia, intravenous lidocain and patient-controlled anaesthesia (PCA) may be equally effective [80].…”

“…Using low-dose concentrations of local anaesthetic combined with a short-acting opiate appears to offer the best combination of analgesia while minimising the risk of motor block and hypotension due to sympathetic blockade. Several meta-analyses have shown improved outcomes with TEA compared with opioid-based analgesia, including pain, complications, PONV and insulin resistance [81][82][83][84][85]. Hypotension induced by sympathetic block should be treated with vasopressors provided the patient is not hypovolaemic.…”

Enhanced Recovery After Surgery (ERAS) for gastrointestinal surgery, part 1: pathophysiological considerations

“…Blockade of these pathways by epidural anaesthesia and local anaesthetic blocks prevents the increase in circulating counter‐regulatory hormones, thereby minimising insulin resistance and limiting protein catabolism48 and hyperglycaemia 49. The physiological effects of epidural anaesthesia may serve as a rationale for improved respiratory and cardiovascular outcomes after general, urological and vascular procedures as reported by meta‐analyses and randomised controlled trials 50, 51…”

Hepatectomy without Endotracheal General Anesthesia: A Safe Procedure?

“…An increasing number of publications provide evidence for improved pulmonary function when using EDA, 5 and vulnerable patients such as severe chronic obstructive pulmonary diseases patients could certainly benefit from this protective effect. However, the advantage of EDA for upper abdominal procedures has been established exclusively in procedure combining EDA with GA.…”