title: Benefits and risks of epidural analgesia in cardiac surgery.
abstract: BACKGROUND
  Epidurals provide excellent analgesia for cardiac surgery and may reduce complications. However, their use has been tempered because of concern of the rare, but serious complication of epidural haematoma. The aim of this meta-analysis was to assess the effect of epidural on survival and the risk estimate of epidural haematoma.
  
  
  METHODS
  A systematic review of the literature (Pubmed, Embase, Scopus and the Cochrane Register) and a meta-analysis of the available randomized and case-matched studies were performed to estimate the effect on survival. An international, directed and viral anonymous survey was performed to identify the incidence of haematomas with a corresponding estimate of the number of epidurals performed.
  
  
  RESULTS
  Of 66 randomized and case-matched studies, 57 trials including 6383 patients reported the incidence of all-cause mortality at the longest follow up available, with a significant reduction with epidurals (59/3123 [1.9%] vs 108/3260 [3.3%] in the control arm, RR 0.65 [95% CI 0.48-0.86], P=0.003, NNT=70). No epidural haematoma was reported in these 66 trials (3320 epidurals). All other literature revealed nine haematomas in 13,100 patients. Through the anonymous, web-based, viral, international survey, we identified 16 further, non-published, epidural haematomas from 72,400 positioned epidurals. Therefore, a total of 25 haematomas have been identified from an estimate of 88,820 positioned epidurals, producing an estimated risk of 1:3552 (95% CI 1:2552-1:5841).
  
  
  CONCLUSIONS
  The use of epidural analgesia in cardiac surgery is associated with a reduction in mortality (NNT=70), and with an estimated risk of epidural haematoma of 1:3552.
authors.affiliation: Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute Vita-Salute San Raffaele University, Via Olgettina 60, Milan 20132, Italy landoni.giovanni@hsr.it.
authors.forename: G
authors.initials: G
authors.lastname: Landoni
authors.affiliation: Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute.
authors.forename: F
authors.initials: F
authors.lastname: Isella
authors.affiliation: Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute.
authors.forename: M
authors.initials: M
authors.lastname: Greco
authors.affiliation: Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute Vita-Salute San Raffaele University, Via Olgettina 60, Milan 20132, Italy.
authors.forename: A
authors.initials: A
authors.lastname: Zangrillo
authors.affiliation: Anaesthesia and Pain Management Unit, The Royal Melbourne Hospital Department of Surgery, The University of Melbourne, The Royal Melbourne Hospital, Level 6 Clinical Medical Research Building, Melbourne, VIC 3050, Australia.
authors.forename: C F
authors.initials: CF
authors.lastname: Royse
mesh_terms: D015360:Analgesia, Epidural / Q000009:adverse effects; D006348:Cardiac Surgical Procedures; D006801:Humans; D016032:Randomized Controlled Trials as Topic; D018570:Risk Assessment; D016019:Survival Analysis
keywords: anaesthesia; epidural; myocardial infarction; spinal epidural hematoma; survival rate; thoracic surgery