Why we starting siting epidurals in high-risk laparotomies

MP Yeager, DD Glass, RK Neff, T Brinck-Johnsen. Epidural Anesthesia and Analgesia in High-risk Surgical Patients Anesthesiology 1987; 66:729-736

RHH Journal Club. December 8th, 2011. Dr Ilias Kanellopoulos

Full-text article  (if available)

Does the use of epidural anaesthesia for postoperative analgesia improve outcomes in high-risk surgical patients?

Aim

Comparison of epidural anesthesia and analgesia with general anesthesia and standard analgesic techniques in a selected group of patients at high risk for postoperative morbidity, in their overall outcome

Study design

Single center. Double bind. RCT

Dartmouth-Hitchcock Medical Center, Hanover, New Hampshire (1987)

Materials and methods

Patient selection: >18y / no contraindication for epidural catheter / intrathoracic, intraabdominal, major (non-cerebral) vascular surgery / scheduled  preoperatively to receive postoperative care in ICU (due pre-existing disease(s), magnitude of the anticipated surgical procedure, or both)

Allocation:

Group I: Intubated and ventilated. Light general anesthesia. Epidural anesthesia and postoperative analgesia

Group II: Intubated and ventilated. General anesthesia. Parenteral postoperative analgesia with opioid

Outcome variables for analysis: mortality; morbidity (organ failure, infectious complication, re-operation); endocrine response (free cortisol); cost utilization

Validity

  • existence of specific eligibility criteria
  • randomization: table of random numbers
  • appropriate statistical analysis
  • blinded
  • numbers of patients involved: 53
  • confounding factors considered
  • follow up completed but due to high mortality of group II (4/25), study was stopped

Results

Patients in epidural group had reduced postoperative complication rate, frequency of postoperative cardiovascular failure and frequency of postoperative infectious complications. The postoperative cost utilization was higher in non-epidural group. Use of EAA in high risk surgical patients is associated with decreased postoperative morbidity and improved operative outcome.

Take home message

Efficacy of a study doesn’t establish effectiveness in clinical practice. The size of the referring trial is too small for making a major change in anesthetic practice. More trials, with larger number of patients are needed in order to confirm benefits and establish the use of epidural anesthesia and analgesia in a wider clinical practice.

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