Epidural pain relief versus systemic opioid-based pain relief for abdominal aortic surgery.
BACKGROUND
Epidural analgesia offers greater pain relief compared to systemic opioid-based medications, but its effect on morbidity and mortality is unclear.


OBJECTIVE
To assess the benefits and harms of postoperative epidural analgesia in comparison with postoperative systemic opioid-based pain relief for adult patients who underwent elective abdominal aortic surgery.


METHODS
We searched the Cochrane Central Register of Controlled Trials via OVID (CENTRAL) (The Cochrane Library, Issue 3, 2004); OVID MEDLINE (1966 to July 2004); and EMBASE (1980 to June 2004). We assessed non-English language reports and contacted researchers in the field. We did not seek unpublished data.


METHODS
We included all randomized controlled trials comparing postoperative epidural analgesia and postoperative systemic opioid-based analgesia for adult patients who underwent elective open abdominal aortic surgery.


METHODS
Two authors independently assessed trial quality and extracted data. We contacted study authors for additional information and data.


RESULTS
Thirteen studies involving 1224 patients met our inclusion criteria; 597 patients received epidural analgesia and 627 received systemic opioid analgesia. The epidural analgesia group showed significantly lower visual analogue scale for pain on movement (up to postoperative day three), regardless of the site of epidural catheter and epidural formulation. Postoperative duration of tracheal intubation and mechanical ventilation was significantly shorter by about 20% in the epidural analgesia group. The overall incidence of cardiovascular complication; myocardial infarction; acute respiratory failure (defined as an extended need for mechanical ventilation); gastrointestinal complication; and renal insufficiency was significantly lower in the epidural analgesia group, especially in trials that used thoracic epidural analgesia.


CONCLUSIONS
Epidural analgesia provides better pain relief (especially during movement) for up to three postoperative days. It reduces the duration of postoperative tracheal intubation by roughly 20%. The occurrence of prolonged postoperative mechanical ventilation, overall cardiac complication, myocardial infarction, gastric complication and renal complication was also reduced by epidural analgesia, especially thoracic. However, current evidence does not confirm the beneficial effect of epidural analgesia on postoperative mortality and other types of complications.
Nishimori
M
M
Massachusetts General Hospital, MGH Anesthesia Statistics Research Laboratory, 101 Merrimac Street, Suite 610,Boston, MA 02114, USA. Minansm@aol.com
Ballantyne
J C
JC
Low
J H S
JH
D000328:Adult; D015360:Analgesia, Epidural / Q000009:adverse effects / Q000379:methods*; D000701:Analgesics, Opioid / Q000009:adverse effects / Q000627:therapeutic use*; D001012:Aorta, Abdominal / Q000601:surgery*; D002423:Cause of Death; D006801:Humans; D007442:Intubation, Intratracheal; D010149:Postoperative Pain / Q000517:prevention & control*; D011183:Postoperative Complications / Q000401:mortality
D000701:Analgesics, Opioid