Effect of Epidural Anesthesia and Analgesia on Perioperative Outcome: A Randomized, Controlled Veterans Affairs Cooperative Study Thoracic Epidural versus Intravenous Patient-controlled Analgesia after Cardiac Surgery: A Randomized Controlled Trial on Length of Hospital Stay and Patient-perceived Quality of Recovery Epidural anaesthesia and analgesia and outcome of major surgery: a randomised trial Prospective, randomized, controlled trial of thoracic epidural or patient-controlled opiate analgesia on perioperative quality of life. [Postoperative analgesia: comparing continuous epidural catheter infusion of local anesthetic and opioid and continuous wound catheter infusion of local anesthetic]. Effects of two different anesthesia-analgesia methods on incidence of postoperative delirium in elderly patients undergoing major thoracic and abdominal surgery: study rationale and protocol for a multicenter randomized controlled trial Comparison of effects of epidural bupivacaine and intravenous meperidine analgesia on patient recovery following elective abdominal aortic surgery Epidural Anesthesia and Analgesia in High‐risk Surgical Patients Perioperative epidural analgesia and outcome after major abdominal surgery in high-risk patients. Randomized clinical trial of local infiltration plus patient-controlled opiate analgesia vs. epidural analgesia following liver resection surgery. Comparison of Intravenous or Epidural Patient-controlled Analgesia in the Elderly after Major Abdominal Surgery Double-masked Randomized Trial Comparing Alternate Combinations of Intraoperative Anesthesia and Postoperative Analgesia in Abdominal Aortic Surgery Postoperative Wound Oxygen Tension with Epidural or Intravenous Analgesia: A Prospective, Randomized, Single-blind Clinical Trial Thoracic epidural analgesia or intravenous morphine analgesia after thoracoabdominal esophagectomy: a prospective follow-up of 201 patients. Intraoperative Epidural Analgesia Combined with Ketamine Provides Effective Preventive Analgesia in Patients Undergoing Major Digestive Surgery [No reduction in postoperative complications by the use of catheterized epidural analgesia following major abdominal surgery]. Impact on postoperative pain of long‐lasting pre‐emptive epidural analgesia before total hip replacement: a prospective, randomised, double‐blind study
Objective To test the hypothesis that epidural anesthesia and postoperative epidural analgesia decrease the incidence of death and major complications during and after four types of intraabdominal surgical procedures . Summary Background Data Even though many beneficial aspects of epidural anesthesia have been reported , clinical trials of epidural anesthesia for outcome of surgical patients have shown conflicting results . Methods The authors studied 1,021 patients who required anesthesia for one of the intraabdominal aortic , gastric , biliary , or colon operations . They were assigned r and omly to receive either general anesthesia and postoperative analgesia with parenteral opioids ( group 1 ) or epidural plus light general anesthesia and postoperative epidural morphine ( group 2 ) . The patients were monitored for death and major complications during and for 30 days after surgery , as well as for postoperative pain , time of ambulation , and length of hospital stay . Results Overall , there was no significant difference in the incidence of death and major complications between the two groups . For abdominal aortic surgical patients , unlike the other three types of surgical patients , the overall incidence of death and major complications was significantly lower in group 2 patients ( 22 % ) than in group 1 patients ( 37 % ) , stemming from differences in the incidence of new myocardial infa rct ion , stroke , and respiratory failure between the two groups . Overall , group 2 patients received significantly less analgesic medication but had better pain relief than group 1 patients . In group 2 aortic patients , endotracheal intubation time was 13 hours shorter and surgical intensive care stay was 3.5 hours shorter . Conclusions The effect of anesthetic and postoperative analgesic techniques on perioperative outcome varies with the type of operation performed . Overall , epidural analgesia provides better postoperative pain relief . Epidural anesthesia and epidural analgesia improve the overall outcome and shorten the intubation time and intensive care stay in patients undergoing abdominal aortic operations Background : Perioperative thoracic epidural analgesia reduces stress response and pain scores and may improve outcome after cardiac surgery . This prospect i ve , r and omized trial was design ed to compare the effectiveness of patient-controlled thoracic epidural analgesia with patient-controlled analgesia with intravenous morphine on postoperative hospital length of stay and patients ’ perception of their quality of recovery after cardiac surgery . Methods : One hundred thirteen patients undergoing elective cardiac surgery were r and omly assigned to receive either combined thoracic epidural analgesia and general anesthesia followed by patient-controlled thoracic epidural analgesia or general anesthesia followed by to patient-controlled analgesia with intravenous morphine .  Postoperative length of stay , time to eligibility for hospital discharge , pain and sedation scores , degree of ambulation , lung volumes , and organ morbidities were evaluated . A vali date d quality of recovery score was used to measure postoperative health status . Results : Length of stay and time to eligibility for hospital discharge were similar between the groups . Study groups differed neither in postoperative global quality of recovery score nor in five dimensions of quality of recovery score . Time to extubation was shorter ( P < 0.001 ) and consumption of anesthetics was lower in the patient-controlled thoracic epidural analgesia group . Pain relief , degree of sedation , ambulation , and lung volumes were similar between the study groups . There was a trend for lower incidences of pneumonia ( P = 0.085 ) and confusion ( P = 0.10 ) in the patient-controlled thoracic epidural analgesia group , whereas cardiac , renal , and neurologic outcomes were similar between the groups . Conclusions : In elective cardiac surgery , thoracic epidural analgesia combined with general anesthesia followed by patient-controlled thoracic epidural analgesia offers no major advantage with respect to hospital length of stay , quality of recovery , or morbidity when compared with general anesthesia alone followed by to patient-controlled analgesia with intravenous morphine BACKGROUND Epidural block is widely used to manage major abdominal surgery and postoperative analgesia , but its risks and benefits are uncertain . We compared adverse outcomes in high-risk patients managed for major surgery with epidural block or alternative analgesic regimens with general anaesthesia  in a multicentre r and omised trial . METHODS 915 patients undergoing major abdominal surgery with one of nine defined comorbid states to identify high-risk status were r and omly assigned intraoperative epidural anaesthesia and postoperative epidural analgesia for 72 h with general anaesthesia ( site of epidural selected to provide optimum block ) or control . The primary endpoint was death at 30 days or major postsurgical morbidity . Analysis by intention to treat involved 447 patients assigned epidural and 441 control . FINDINGS 255 patients ( 57.1 % ) in the epidural group and 268 ( 60.7 % ) in the control group had at least one morbidity endpoint or died ( p=0.29 ) . Mortality at 30 days was low in both groups ( epidural 23 [ 5.1 % ] , control 19 [ 4.3 % ] , p=0.67 ) . Only one of eight categories of morbid endpoints in individual systems ( respiratory failure ) occurred less frequently in patients managed with epidural techniques ( 23 % vs 30 % , p=0.02 ) . Postoperative epidural analgesia was associated with lower pain scores during the first 3 postoperative days . There were no major adverse consequences of epidural-catheter insertion . INTERPRETATION Most adverse morbid outcomes in high-risk patients undergoing major abdominal surgery are not reduced by use of combined epidural and general anaesthesia and postoperative epidural analgesia . However , the improvement in analgesia , reduction in respiratory failure , and the low risk of serious adverse consequences suggest that many high-risk patients undergoing major intra-abdominal surgery will receive substantial benefit from combined general and epidural anaesthesia intraoperatively with continuing postoperative epidural analgesia BACKGROUND Perioperative epidural analgesia provides continuous pain control and may have advantages over parenteral opiate administration . This study assessed the impact of epidural analgesia on quality of life ( QOL ) of patients undergoing major surgery . METHODS Sixty patients undergoing thoracic or thoraco-abdominal surgery were studied prospect ively . Patients were r and omly assigned to receive either thoracic epidural analgesia or patient-controlled i.v . opiate analgesia ( PCA ) after operation .  Visual analogue pain and sedation scores were recorded for the period of the study . QOL health surveys at 24 h ( SF-8 acute form ) and at 1 week ( SF-36 ) were recorded . Results were examined by uni- and multivariate analyses corrected for the effect of multiple comparisons . RESULTS Mean pain scores were significantly lower in the epidural group at most time points . Physical and mental scores in the epidural group were significantly better than the PCA group for both SF-8 and SF-36 QOL health surveys ( P<0.001 ) . CONCLUSIONS Epidural analgesia with local anaesthetic and opioid improves QOL and delivers better analgesia compared with PCA in patients undergoing major thoraco-abdominal surgery BACKGROUND AND OBJECTIVES Continuous wound infusion has been investigated as a method of postoperative pain control and its efficacy has been demonstrated when compared to saline infusion . The objective of this study was to compare the quality of postoperative analgesia , the use of opioids as rescue analgesia , patient satisfaction , and the incidence of complications between epidural catheter infusion of local anesthetic and opioids and continuous wound infusion of local anesthetic . METHODS Thirty-eight patients undergoing elective laparotomy under general anesthesia , r and omly divided into two groups , participated in this study . Group I ( GI ) received postoperative patient-controlled epidural analgesia ( PCEA ) with continuous infusion of ropivacaine and fentanyl , while Group II ( GII ) receive postoperative patient-controlled continuous wound catheter infusion of ropivacaine . In the postoperative period , the following parameters were assessed : quality of analgesia through the Visual Analogue Scale ; use of rescue opioids ; and adverse effects driving patient satisfaction . RESULTS Decreased pain at rest and with movements ( p < 0.05 ) and lower consumption of rescue opioids ( p < 0.05 ) were observed in GI in all intervals evaluated , as well as greater patient satisfaction in the post anesthesia care unit ( PACU ) . The incidence of complications was similar in both groups except for pruritus which prevailed in GI between 6 ( p < 0.05 ) and 24 ( p < 0.001 ) postoperative hours . CONCLUSIONS Postoperative analgesia with opioids and local anesthetics via PCEA was superior to the patient-controlled local anesthetic infusion into surgical wound . The incidence of side effects was similar in both groups Background Delirium is a common complication in elderly patients after surgery and associated with increased morbidity and mortality . Studies suggest that deep anesthesia and intense pain are important precipitating factors of postoperative delirium . Neuraxial block is frequently used in combination with general anesthesia for patients undergoing major thoracic and abdominal surgery . Compared with general anesthesia alone and postoperative intravenous analgesia , combined epidural-general anesthesia and postoperative epidural analgesia decreases the requirement of general anesthetics during surgery and provided better pain relief after surgery . However , whether combined epidural-general anesthesia plus epidural analgesia is superior to general anesthesia plus intravenous analgesia in decreasing the incidence of postoperative delirium remains unknown . Methods / design This is a multicenter , open-label , r and omized , parallel-controlled clinical trial . One thous and eight hundred elderly patients ( age range 60–90 years ) who are scheduled to undergo major thoracic or abdominal surgery are r and omized to receive either general anesthesia plus postoperative intravenous analgesia or combined epidural-general anesthesia plus postoperative epidural analgesia . The primary outcome is the 7-day incidence of postoperative delirium . Secondary outcomes include the duration of postoperative delirium , the intensity of pain during the first three days after surgery , the 30-day incidences of postoperative non-delirium complications , the length of stay in hospital after surgery and 30-day all-cause mortality . Discussion Results of the present study will provide information to guide clinical practice in choosing appropriate anesthesia-analgesia method for elderly patients undergoing major thoracic and abdominal surgery . Trial registration The study is registered on Clinical Trials.gov NCT01661907 and Chinese Clinical Trial Registry ChiCTR-TRC-12002371 Background The efficacy of epidural anesthesia and analgesia in management of perioperative stress has been established . Perioperative pain management strategies decrease surgical complications and aid recovery . In this study , we aim ed to document and compare the efficacy of epidural bupivacaine and intravenous meperidine on recovery of patients with elective abdominal aortic surgery performed under general anesthesia . Material / Methods Patients undergoing elective abdominal aortic surgery between February 2009 and November 2011 were studied prospect ively . Patients were r and omized into epidural bupivacaine ( n=40 ) and intravenous meperidine ( n=40 ) groups regarding postoperative analgesia strategy . The preoperative demographic characteristics , perioperative outcomes , postoperative adverse effects of analgesia strategy , time to initiate oral intake , sedation scores , visual analogue scale results , and mobility scores were compared . Results The mean ages of the patients were 61.7±8.1 in the epidural group and 59.4±9.7 in the intravenous group ( p>0.05 ) . The preoperative demographic characteristics of the patients were comparable between the groups . There were no statistically significant differences between groups regarding anesthesia times , intubation times , intensive care unit stay , hospital length of stay , postoperative vomiting , and postoperative cardiac , renal , and cerebral complications . Postoperative nausea was more prevalent in the meperidine group ( p<0.05 ) . In the epidural group , time to begin oral intake was shorter , sedation scores and visual analogue scale results were lower , and mobility scores were higher ( p<0.05 each ) . Conclusions Epidural analgesia allowed earlier recovery compared to intravenous analgesia in patients undergoing elective abdominal aortic surgery , but did not affect postoperative outcomes and complications The authors conducted a r and omized controlled clinical trial to evaluate the effect of epidural anesthesia and postoperative analgesia ( EAA ) on postoperative morbidity in a group of high-risk surgical patients . A total of 53 patients were admitted to the study , 28 received EAA , and 25 received st and ard anesthetic and analgesic techniques without EAA . Surgical “ risk ” was evaluated preoperatively and found to be comparable in the two groups . When compared to control patients , patients who received EAA had a reduction in the overall postoperative complication rate ( P = 0.002 ) and in the incidence of cardiovascular failure ( P = 0.007 ) and major infectious complications ( P = 0.007 ) . Urinary cortisol excretion , a marker of the stress response , was significantly diminished during the first 24 postoperative hours in the group receiving EAA ( P = 0.025 ) . Finally , hospital costs were significantly reduced for patients who received EAA ( P = 0.02 ) . The authors conclude that EAA exerted a significant beneficial effect on operative outcome in a group of high risk surgical patients In a primary analysis of a large recently completed r and omized trial in 915 high-risk patients undergoing major abdominal surgery , we found no difference in outcome between patients receiving perioperative epidural analgesia and those receiving IV opioids  , apart from the incidence of respiratory failure . Therefore , we performed a selected number of predetermined subgroup analyses to identify specific types of patients who may have derived benefit from epidural analgesia . We found no difference in outcome between epidural and control groups in subgroups at increased risk of respiratory or cardiac complications or undergoing aortic surgery , nor in a subgroup with failed epidural block ( all P > 0.05 ) . There was a small reduction in the duration of postoperative ventilation ( geometric mean [ SD ] : control group , 0.3 [ 6.5 ] h , versus epidural group , 0.2 [ 4.8 ] h ; P = 0.048 ) . No differences were found in length of stay in intensive care or in the hospital . There was no relationship between frequency of use of epidural analgesia in routine practice outside the trial and benefit from epidural analgesia in the trial . We found no evidence that perioperative epidural analgesia significantly influences major morbidity or mortality after major abdominal surgery OBJECTIVES Epidural analgesia is recommended for the provision of analgesia following major abdominal surgery . Continuous local anaesthetic wound infiltration may be an effective alternative . A prospect i ve r and omized trial was undertaken to compare these two methods following open liver resection . The primary outcome was length of time required to fulfil criteria for discharge from hospital . METHODS Patients undergoing open liver resection were r and omized to receive either epidural ( EP group ) or local anaesthetic wound infiltration plus patient-controlled opiate analgesia ( WI group ) for the first 2 days postoperatively . All other care followed a st and ardized enhanced recovery protocol .  Time to fulfil discharge criteria , pain scores , physical activity measurements and complications were recorded . RESULTS Between August 2009 and July 2010 , 65 patients were r and omized to EP ( n = 32 ) or WI ( n = 33 ) . The mean time required to fulfil discharge criteria was 4.5 days ( range : 2.5 - 63.5 days ) in the WI group and 6.0 days ( range : 3.0 - 42.5 days ) in the EP group ( P = 0.044 ) . During the first 48 h following surgery , pain scores were significantly lower in the EP group both at rest and on movement . Resting pain scores within both groups were rated as mild ( range : 0 - 3 ) . There was no significant difference between the groups in time to first mobilization or overall complication rate ( 48.5 % in the WI group vs. 58.1 % in the EP group ; P = 0.443 ) . CONCLUSIONS Local anaesthetic wound infiltration combined with patient-controlled opiate analgesia reduces the length of time required to fulfil criteria for discharge from hospital compared with epidural analgesia following open liver resection . Epidural analgesia provides superior analgesia , but does not confer benefits in terms of faster mobilization or recovery Background Patient-controlled analgesia ( PCA ) with intravenous morphine and patient-controlled epidural analgesia ( PCEA ) , using an opioid either alone or in combination with a local anesthetic , are two major advances in the management of pain after major surgery . However , these techniques have been evaluated poorly in elderly people . This prospect i ve , r and omized study compared the effectiveness on postoperative pain and safety of PCEA and PCA after major abdominal surgery in the elderly patient . Methods Seventy patients older than 70 yr of age and undergoing major abdominal surgery were assigned r and omly to receive either combined epidural analgesia and general anesthesia followed by postoperative PCEA , using a mixture of 0.125 % bupivacaine and sufentanil ( PCEA group ) , or general anesthesia followed by PCA with intravenous morphine ( PCA group ) .  Pain intensity was tested three times daily using a visual analog scale . Postoperative evaluation included mental status , cardiorespiratory and gastrointestinal functions , and patient satisfaction scores . Results Pain relief was better at rest ( P = 0.001 ) and after coughing ( P = 0.002 ) in the PCEA group during the 5 postoperative days . Satisfaction scores were better in the PCEA group . Although incidence of delirium was comparable in the PCA and PCEA groups ( 24%vs . 26 % , respectively ) , mental status was improved on the fourth and fifth postoperative days in the PCEA group . The PCEA group recovered bowel function more quickly than did the PCA group . Cardiopulmonary complications were similar in the two groups . Conclusion After major abdominal surgery in the elderly patient , patient-controlled analgesia , regardless of the route ( epidural or parenteral ) , is effective . The epidural route using local anesthetics and an opioid provides better pain relief and improves mental status and bowel activity Background Improvement in patient outcome and reduced use of medical re sources may result from using epidural anesthesia and analgesia as compared with general anesthesia and intravenous opioids , although the relative importance of intraoperative versus postoperative technique has not been studied . This prospect i ve , double-masked , r and omized clinical trial was design ed to compare alternate combinations of intraoperative anesthesia and postoperative analgesia with respect to postoperative outcomes in patients undergoing surgery of the abdominal aorta . Methods One hundred sixty-eight patients undergoing surgery of the abdominal aorta were r and omly assigned to receive either thoracic epidural anesthesia combined with a light general anesthesia or general anesthesia alone intraoperatively and either intravenous or epidural patient-controlled analgesia postoperatively ( four treatment groups ) . Patient-controlled analgesia was continued for at least 72 h. Protocol s were used to st and ardize perioperative medical management and to preserve masking intraoperatively and postoperatively . A uniform surveillance strategy was used for the identification of prospect ively defined postoperative complications . Outcome evaluation included postoperative hospital length of stay , direct medical costs , selected postoperative morbidities , and postoperative recovery milestones . Results Length of stay and direct medical costs for patients surviving to discharge were similar among the four treatment groups . Postoperative outcomes were similar among the four treatment groups with respect to death , myocardial infa rct ion , myocardial ischemia , reoperation , pneumonia , and renal failure . Epidural patient-controlled analgesia was associated with a significantly shorter time to extubation ( P = 0.002 ) . Times to intensive care unit discharge , ward admission , first bowel sounds , first flatus , tolerating clear liquids , tolerating regular diet , and independent ambulation were similar among the four treatment groups . Postoperative pain scores were also similar among the four treatment groups . Conclusions In patients undergoing surgery of the abdominal aorta , thoracic epidural anesthesia combined with a light general anesthesia and followed by either intravenous or epidural patient-controlled analgesia , offers no major advantage or disadvantage when compared with general anesthesia alone followed by either intravenous or epidural patient-controlled analgesia Background Adequate tissue oxygen tension is an essential requirement for surgical-wound healing . The authors tested the hypothesis that epidural anesthesia and analgesia increases wound tissue oxygen tension compared with intravenous morphine analgesia . Methods In a prospect i ve , r and omized , blind clinical study , the authors allocated patients having major abdominal surgery ( n = 32 ) to receive combined general and epidural anesthesia with postoperative patient-controlled epidural analgesia ( epidural group , n = 16 ) , or general anesthesia alone with postoperative patient-controlled intravenous analgesia ( intravenous group , n = 16 ) . An oxygen sensor and a temperature sensor were placed subcutaneously in the wound before closure . Wound oxygen tension ( Pwo2 ) and temperature were measured continuously for 24 h. Other variables affecting wound tissue oxygenation and visual analogue scale ( VAS ) pain scores were also documented . Results Despite epidural patients having lower body temperatures at the end of surgery ( 35.7 ± 0.3 ) versus 36.3 ± 0.5 ° C , P = 0.004 ) , they had significantly higher mean Pwo2 over the 24 h period , compared with the intravenous group ( 64.4 ± 14 vs. 50.7 ± 15 ) mmHg , mean ( SD ) , 95 % CI difference , −22 to −5 , P = 0.002 ) . Area under the Pwo2 −24 h time curve was also significantly higher in the epidural group ( 930 ± 278 vs. 749 ± 257 ) mmHg × h , 95 % CI difference −344 to −18 , P = 0.03 ) . VAS pain scores at rest and moving were significantly lower in the epidural group at all times . Conclusion Epidural anesthesia and postoperative analgesia for major abdominal surgery increases wound tissue oxygen tension compared with general anesthesia and intravenous morphine analgesia OBJECTIVE Thoracoabdominal esophagectomy is a major surgical procedure that carries significant postoperative morbidity and mortality . Because the choice of analgesic technique may influence outcome , the impact of thoracic epidural or intravenous analgesia was investigated after esophagectomy . DESIGN Prospect i ve observational study during January 1996 until January 2002 . SETTING University hospital . PARTICIPANTS All patients undergoing thoracoabdominal esophagectomy during the 6-year period . INTERVENTIONS Patients were prospect ively monitored during a 6-year period . Duration of surgery , intraoperative blood loss , fluid administration , postoperative intubation time , intensive care unit ( ICU ) stay , pain relief and related side effects , postoperative complications , hospital stay , and in-hospital and long-term mortality were compared in relation with the analgesic technique . MEASUREMENTS AND MAIN RESULT Thoracic epidural analgesia with bupivacaine/morphine was used in 166 patients , and intravenous morphine analgesia was used in 35 patients .  Postoperative intubation time and ICU stay were similar in both groups . Patients with epidural analgesia experienced less pain . Sedation , respiratory depression , hallucinations , and confusion were more common in the intravenous morphine group . Postoperative weight did not differ between the groups , despite fluid replacement that was higher in the epidural group during the first 24 hours . The in-hospital mortality rate was 0.5 % . CONCLUSIONS No differences in morbidity/mortality rates depending on analgesic treatment were observed in patients undergoing thoracoabdominal esophagectomy . Thoracic epidural analgesia provided better pain relief with fewer opioid-related side effects than intravenous morphine analgesia . However , postoperative epidural analgesia was associated with more technical difficulties Background : As a broader definition of preemptive analgesia , preventive analgesia aims to prevent the sensitization of central nervous system , hence the development of pathologic pain after tissular injury . To demonstrate benefits from preventive treatment , objective measurement of postoperative pain such as wound hyperalgesia and persistent pain should be evaluated . The current study assessed the role and timing of epidural analgesia in this context . Methods : In a r and omized , double-blinded trial , 85 patients scheduled to undergo neoplastic colonic resection were included . All the patients received a thoracic epidural catheter , systemic ketamine at a antihyperalgesic dose , and general anesthesia . Continuous infusion of analgesics belonging to the same class was administered by either intravenous or epidural route before incision until 72 h after surgery . Patients were allocated to four groups to receive intraoperative intravenous lidocaine – sufentanil – clonidine or epidural bupivacaine – sufentanil – clonidine followed postoperatively by either intravenous ( lidocaine – morphine – clonidine ) or epidural ( bupivacaine – sufentanil – clonidine ) patient-controlled analgesia .  Postoperative pain scores ( visual analog scale ) , analgesic consumption , wound area of punctuate hyperalgesia , residual pain , and analgesics needed from 2 weeks until 12 months were recorded . Results : Analgesic requirements , visual analog scale scores , and area of hyperalgesia were significantly higher in the intravenous treatment group ( intravenous – intravenous ) , and more patients reported residual pain from 2 weeks until 1 yr ( 28 % ) . Although postoperative pain measurements did not differ , postoperative epidural treatment ( intravenous – epidural ) was less effective to prevent residual pain at 1 yr ( 11 % ; P = 0.2 with intravenous – intravenous group ) than intraoperative one ( epidural – epidural and epidural – intravenous groups ) ( 0 % ; P = 0.01 with intravenous – intravenous group ) . Conclusion : Combined with an antihyperalgesic dose of ketamine , intraoperative epidural analgesia provides effective preventive analgesia after major digestive surgery This study was design ed to assess whether intra- and postoperative epidural analgesia would diminish the overall rate of postoperative complications after major abdominal operations when compared to a st and ard anesthetic and postoperative analgesic regimen . A total of 214 patients undergoing infrarenal aortic bypass operations , gastric resection , gastrectomy , Whipple 's operation , or duodenum-preserving pancreatic resection were r and omly divided into two groups . Patients in the epidural group ( n = 98 ) were operated on under light general anesthesia ( midazolam , low-dose fentanyl , N2O/O2 , pancuronium bromide ) . In addition , a mixture of bupivacaine ( 0.25 % ) and fentanyl ( 2 micrograms/ml ) was infused ( 6 - 10 ml/h ) via a thoracic epidural catheter intra- and postoperatively for 76:1.45 h ( logarithmic normal distribution ) . Patients in the control group ( n = 116 ) were operated on under a st and ard general anesthesia ( midazolam , fentanyl , N2O/O2 , isoflurane , pancuronium-bromide ) . Piritramid was injected for postoperative pain relief , either i.v . ( recovery room , intensive care unit ) or i.m . ( surgical ward ) . In the epidural group the quality of analgesia and ability to cough were significantly better ( 2 P less than 0.0071 ) than in the control group ( four observations each on the 1st and 2nd postoperative days ) . Heart rate and mean arterial pressure were lower in the epidural group at the same points of observation ( 2 P less than 0.01 ) , as was the plasma glucose on the 1st postoperative day . The time up to the first postoperative defecation was shorter in the epidural group ( 79:1.51 h ) as compared to the control group ( 93:1.38 h ; 2 P less than 0.0167 ) . The time to hospital discharge was equal in both groups ( epidural group 19:1.6 days , control group 18:1.6 days ) . ( ABSTRACT TRUNCATED AT 250 WORDS Clinical studies on pre‐emptive analgesia have produced inconsistent results . We conducted a clinical study investigating the effect of long‐lasting pre‐emptive epidural analgesia on consumption of analgesics and acute pain .  Forty‐two patients scheduled for elective hip replacement for osteo‐arthritis were r and omly assigned to receive , on the day before operation , either 5 ml.h−1 ropivacaine 0.2 % ( study group , n = 21 ) or 5 ml.h−1 saline ( control group , n = 21 ) . Postoperative analgesia was achieved in both groups by patient‐controlled epidural analgesia ( PCEA ) with ropivacaine 0.2 % . The main outcome measure was consumption of local anaesthetics . Additional parameters included visual analogue pain scale ( VAS ) scores , consumption of rescue analgesics , requests for PCEA boluses , and side‐effects . The pre‐operative parameters and pain scores were similar in the two groups . Epidural blocks provided sufficient operative analgesia in all patients . Pre‐emptive analgesia was continued for 11–20 h and led to significantly decreased pain scores before surgery . The consumption of local anaesthetics was decreased postoperatively in the study group ( 194 mg vs. 284 mg in the postoperative period ) . Furthermore , bolus requests occurred more frequently in the control group . VAS scores did not differ significantly between groups . Long‐lasting ‘ pre‐emptive ’ epidural analgesia decreases postoperative pain with improved pain control
The majority of evidence favors an ability of epidural analgesia to reduce postoperative cardiovascular and pulmonary complications only after major vascular surgery or in high-risk patients .
This finding may become irrelevant because of rapid conversion of major surgery to minimally invasive techniques ( e.g. , endoluminal abdominal aortic repair ) that carry less risk of complications .
There is also consistent evidence that epidural analgesia with local anesthetics is associated with faster resolution of postoperative ileus after major abdominal surgery .
Again , this finding may also become irrelevant with the adoption of laparoscopic techniques and multimodal fast-track programs for abdominal surgery .
There is no current evidence that perineural analgesia , continuous wound catheters using local anesthetics , IV patient-controlled analgesia with opioids , or addition of multimodal systemic analgesics have any clinical ly significant beneficial effect on postoperative complications .
CONCLUSIONS : Overall , there is insufficient evidence to confirm or deny the ability of postoperative analgesic techniques to affect major postoperative mortality or morbidity .
This is primarily due to typically insufficient subject numbers to detect differences in currently low incidences of postoperative complications
BACKGROUND : Few individual clinical trials have had sufficient subject numbers to definitively determine the effects of postoperative analgesia on major outcomes .
Epidural analgesia with local anesthetics has the greatest theoretical potential to affect major outcomes and has been the most thoroughly investigated technique .