title: Double-masked randomized trial comparing alternate combinations of intraoperative anesthesia and postoperative analgesia in abdominal aortic surgery.
abstract: BACKGROUND
  Improvement in patient outcome and reduced use of medical resources 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 prospective, double-masked, randomized clinical trial was designed 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 randomly 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. Protocols were used to standardize perioperative medical management and to preserve masking intraoperatively and postoperatively. A uniform surveillance strategy was used for the identification of prospectively 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 infarction, 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.
authors.affiliation: Department of Anesthesia and Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland 21287-8711, USA. enorris@jhmi.edu
authors.forename: E J
authors.initials: EJ
authors.lastname: Norris
authors.forename: C
authors.initials: C
authors.lastname: Beattie
authors.forename: B A
authors.initials: BA
authors.lastname: Perler
authors.forename: E A
authors.initials: EA
authors.lastname: Martinez
authors.forename: C L
authors.initials: CL
authors.lastname: Meinert
authors.forename: G F
authors.initials: GF
authors.lastname: Anderson
authors.forename: J A
authors.initials: JA
authors.lastname: Grass
authors.forename: N T
authors.initials: NT
authors.lastname: Sakima
authors.forename: R
authors.initials: R
authors.lastname: Gorman
authors.forename: S C
authors.initials: SC
authors.lastname: Achuff
authors.forename: B K
authors.initials: BK
authors.lastname: Martin
authors.forename: S L
authors.initials: SL
authors.lastname: Minken
authors.forename: G M
authors.initials: GM
authors.lastname: Williams
authors.forename: R J
authors.initials: RJ
authors.lastname: Traystman
mesh_terms: D000368:Aged; D016058:Analgesia, Patient-Controlled; D000767:Anesthesia, Epidural; D000768:Anesthesia, General; D000771:Anesthesia, Intravenous; D001012:Aorta, Abdominal / Q000601:surgery*; D001794:Blood Pressure / Q000187:drug effects; D004311:Double-Blind Method; D004737:Enflurane; D005260:Female; D005283:Fentanyl; D017052:Hospital Mortality; D006760:Hospitalization / Q000191:economics*; D006801:Humans; D007432:Intraoperative Period; D007902:Length of Stay; D008297:Male; D010149:Postoperative Pain / Q000517:prevention & control*; D011184:Postoperative Period
chemical_list: D004737:Enflurane; D005283:Fentanyl