title: The effect of intraoperative thoracic epidural anesthesia and postoperative analgesia on bowel function after colorectal surgery Spinal anaesthesia or general anaesthesia for emergency hip surgery in elderly patients. Effects of Thoracic Epidural Anesthesia on Systemic Hemodynamic Function and Systemic Oxygen Supply‐Demand Relationship Thoracic epidural versus patient-controlled analgesia in elective bowel resections. Anaesthetic techniques for surgical correction of fractured neck of femur A Prospective Randomised Trial Comparing Spinal Anaesthesia using Hyperbaric Cinchocaine with General Anaesthesia for Lower Limb Vascular Surgery Long-term outcome after repair of fractured neck of femur. Comparison of subarachnoid and general anaesthesia. Mental function and morbidity after acute hip surgery during spinal and general anaesthesia Postoperative Analgesia with Intramuscular Morphine at Fixed Rate Versus Epidural Morphine or Sufentanil and Bupivacaine in Patients Undergoing Major Abdominal Surgery [Comparative study of general and spinal anesthesia in elderly women in hip surgery]. The effects of epidural anesthesia on the neuroendocrine response to major surgical stress: a randomized prospective trial. Prospective, Randomized Trial Comparing General with Spinal Anesthesia for Cesarean Delivery in Preeclamptic Patients with a Nonreassuring Fetal Heart Trace [Patient-controlled analgesia versus epidural analgesia using bupivacaine or morphine following major abdominal surgery. No difference in postoperative morbidity]. Spinal or General Anesthesia for Surgery of the Fractured Hip? A Prospective Study of Mortality in 578 Patients Epidural Anesthesia and Analgesia in High‐risk Surgical Patients Ropivacaine epidural anesthesia and analgesia versus general anesthesia and intravenous patient-controlled analgesia with morphine in the perioperative management of hip replacement. Ropivacaine Hip Replacement Multicenter Study Group. Thoracolumbar epidural anaesthesia and isoflurane to prevent hypertension and tachycardia in patients undergoing abdominal aortic surgery. Perioperative epidural analgesia and outcome after major abdominal surgery in high-risk patients. Effects of Perioperative Analgesic Technique on Rate of Recovery after Colon Surgery Randomized Comparison of General and Regional Anesthesia for Cesarean Delivery in Pregnancies Complicated by Severe Preeclampsia Perioperative ischaemia in aortic surgery: combined epidural/ general anaesthesia and epidural analgesia vs general anaesthesia andiv analgesia Cardiac Outcome after Peripheral Vascular Surgery: Comparison of General and Regional Anesthesia Postoperative pain and pulmonary complications: Comparison of three analgesic regimens The effect of bupivacaine and morphine on pain and bowel function after colonic surgery Double-masked Randomized Trial Comparing Alternate Combinations of Intraoperative Anesthesia and Postoperative Analgesia in Abdominal Aortic Surgery Perioperative Morbidity in Patients Randomized to Epidural or General Anesthesia for Lower Extremity Vascular Surgery Anaesthesia for surgical correction of fractured femoral neck A comparison of three techniques Prospective, multi-centre trial of mortality following general or spinal anaesthesia for hip fracture surgery in the elderly. Epidural Analgesia and Intravenous Patient-Controlled Analgesia Result in Similar Rates of Postoperative Myocardial Ischemia After Aortic Surgery Postoperative Confusion after Anesthesia in Elderly Patients with Femoral Neck Fractures Effect of Epidural Anesthesia and Analgesia on Perioperative Outcome: A Randomized, Controlled Veterans Affairs Cooperative Study Perioperative myocardial ischaemia in patients undergoing surgery for fractured hip randomized to incremental spinal, single-dose spinal or general anaesthesia. Combined Epidural and General Anaesthesia versus General Anaesthesia for Abdominal Aortic Surgery: A Prospective Randomised Trial [Effect of continuous postoperative analgesia with peridural bupivacaine on intestinal motility following colorectal resection]. Epidural Bupivacaine-Morphine Analgesia versus Patient-controlled Analgesia following Abdominal Aortic Surgery: Analgesic, Respiratory, and Myocardial Effects
abstract: PURPOSE : Colorectal surgery is associated with postoperative ileus , which contributes to delayed discharge . This study was design ed to investigate the effect of thoracic epidural anesthesia and analgesia on gastrointestinal function after colorectal surgery under st and ardized controlled postoperative care . METHODS : Forty-two patients diagnosed with either colonic cancer , diverticulitis , polyps , or adenoma , and scheduled for elective colorectal surgery , were r and omly assigned to either postoperative patient-controlled analgesia ( PCA ) with intravenous morphine ( n=21 ) or epidural analgesia with a mixture of bupivacaine and fentanyl ( n=21 ) . Postoperative early oral feeding and assistance to mobilization were offered to all patients . Pain visual analog scale ( 1–100 mm ) , passage of flatus and bowel movements , length of hospital stay , and readiness for discharge were recorded . RESULTS : Pain visual analog scale ( visual analog scale , 1–100 mm ) at rest , on coughing , and daily on mobilization was significantly lower in the epidural group compared with the patient-controlled analgesia group . Median values for the visual analog scale group were 7 ( 95 percent confidence interval , 2–18 ) mm , 19 ( 95 percent confidence interval , 4–38 ) mm , and 10 ( 95 percent confidence interval , 5–33 ) mm , respectively , and , for the patient-controlled analgesia group , were 24 ( 95 percent confidence interval , 18–51 ) mm , 59 ( 95 percent confidence interval , 33–74 ) mm , and 40 ( 95 percent confidence interval , 29–79 ) mm , respectively ( P<0.01 ) . Intake of protein and calories and time out of bed were similar in both groups . Mean time intervals ± st and ard deviation from surgery to first flatus and first bowel movement occurred earlier in the epidural group , 1.9±0.6 days and 3.1±1.7 days , respectively , compared with patient-controlled analgesia , 3.6±1.5 days and 4.6 ± 1.6 days , respectively ( P<0.01 ) . Postoperative complications occurred in 33 percent of the patient-controlled analgesia group and 28 percent of the epidural group . There was no significant difference in length of hospital stay between the two groups with a mean of 7.3±3.7 days in the patient-controlled analgesia group and 8.5±4.2 days in the epidural group . Readiness for discharge was similar in both groups . CONCLUSION : Thoracic epidural analgesia has distinct advantages over patient-controlled analgesia morphine in providing superior quality of analgesia and shortening the duration of postoperative ileus . However , discharge home was not faster , indicating that other perioperative factors influence the length of hospital stay One hundred and thirty-two elderly patients undergoing emergency hip surgery  were r and omly allocated to receive subarachnoid block ( SAB ) or general anaesthesia ( GA ) . Using the 125.I fibrinogen uptake test , deep vein thrombosis was found to occur in 17 of 37 patients in the SAB group and 30 of 39 patients in the GA group ( P 0.05 ) . Blood loss was 513 ml ( + /- SEM 44 ) in the SAB group and 714 ml ( + /- SEM 67 ) in the GA group ( P less than 0.01 ) . Hypoxaemia was present preoperatively ( mean PaO2 9.2 kPa ) . Immediately following general anaesthesia , the mean fall in PaO2 was 0.86 kPa compared with preoperative values but only 0.16 kPa following subarachnoid block ( P less than 0.01 ) . At 24 hours postoperatively the fall in PaO2 was similar in both groups and recovered only slowly during the first week . Twelve patients died , three in the SAB group and nine in the GA group . This difference in mortality was not statistically significant The effects of thoracic epidural anesthesia ( TEA ) on total body oxygen supply-dem and ratio are complex due to potential influences on both O2 delivery ( & OV0422;O2 ) and consumption ( & OV0312;O2 ) . One hundred and five patients undergoing abdominal aortic surgery were r and omly assigned to one of three groups to compare the cardiovascular and metabolic responses associated with ( 1 ) thoracic epidural anesthesia plus light general anesthesia ( group TEA ) ; ( 2 ) general anesthesia with halothane ( group H ) ; and ( 3 ) neuroleptanalgesia ( group NLA ) . Values of cardiac index ( CI ) and & OV0422;O2 were less intra operatively in the TEA group than in the H or NLA groups , while & OV0312;O2 values were similar . & OV0312;O2 during recovery was greater in both the TEA and NLA groups than in the H group . Consequently the oxygen supply-dem and ratio ( & OV0422;O2/&OV0312;O2 ) was less in the TEA group throughout the perioperative period and about 30 % below baseline values during early recovery . At comparable & OV0312;O2 , CI and mixed venous O2 saturation were always less in the TEA group than in the NLA group . Heart rate was slowest intra operatively during TEA , and stroke work was less with TEA than with NLA . As cardiac filling pressure and systemic vascular resistance did not differ among the three groups , reduced adaptation of CI to tissue O2 needs during TEA was attributed to negative inotropic and chronotropic effects of the sympathetic blockade . We conclude that in patients undergoing abdominal aortic surgery , TEA has no apparent advantage over general anesthesia BACKGROUND This study was undertaken to determine if thoracic epidural analgesia is of practical benefit after bowel resection . METHODS Patients were prospect ively r and omized to receive either a  thoracic epidural or patient-controlled analgesia for pain control after bowel resection . A st and ardized postoperative protocol was instituted after surgery . RESULTS Pain scores were significantly lower in the epidural group . Return of bowel function , and interval to discharge was not different between groups . Cost and complication rates were significantly higher in the epidural group . CONCLUSIONS Although pain scores were significantly lower in the epidural group , this did not translate into a quicker return of bowel function or earlier discharge of the patient . Furthermore , the epidural group had a significantly higher complication rate and cost . Therefore , while thoracic epidural analgesia provides superior pain control , it does not offer a significant advantage over patient-controlled analgesia in return of bowel function after bowel resection Fifty-five patients presenting with fractured neck of femur were r and omly allocated to either a st and ard general anaesthetic or spinal block in the lateral position combined with light sedation . The comparability of the two groups was established . There was little difference in the intra-operative course of postoperative morbidity in the two groups . There was a statistically significant difference in post-operative mortality between two groups , the general anaesthetic group showing a much higher mortality than the spinal group One hundred and one patients were r and omly allocated to have their peripheral vascular surgery performed under general anaesthesia ( 51 patients ) or spinal anaesthesia ( 50 patients ) .  Intraoperative haemodynamic changes were markedly different between the two groups with a higher incidence of hypotension in the spinal group ( 72 % vs 31 % ) and a higher incidence of hypertension in the general anaesthesia group ( 22 % vs 0 % ) . Blood loss was significantly less in the spinal group ( 560 , SD 340 , ml vs 792 , SD 440 , ml ) . Postoperatively three patients from the general anaesthesia group died from causes unrelated to the anaesthesia , and one had a myocardial infa rct . Two patients in the spinal group had myocardial infa rcts , both had been treated for bradycardia and hypotension intraoperatively , and one died . There was a significantly higher incidence of postoperative chest infection in the general anaesthesia group ( 33 % vs 16 % ) . There was no significant difference between the groups in the incidence of postoperative confusion , or lower limb amputation rate or need for further surgery prior to hospital discharge One hundred and forty-eight patients undergoing " pin- and -plate " repair of fractured neck of femur received either subarachnoid blockade or general anaesthesia .  The patients were followed up for 1 year after surgery . At the end of the year , 34 % had died and 50 % had returned home . Twelve per cent were either in hospital or in institutional care ; 4 % were lost to follow up . The mean duration of acute plus convalescent hospital bed occupancy was 84.4 days . There was a significantly lower mortality in the subarachnoid anaesthetic group by 14 days after surgery . The majority of the deaths in the general anaesthetic group were clustered between 6 and 16 days . However , at the end of 2 months the mortality rates were similar in both groups . It is conceivable that the difference in the distribution of deaths between the groups was a result of thrombo-embolism Forty elderly patients ( mean age 78.9 years ) undergoing acute surgery for hip fracture were given at r and om either spinal analgesia with bupivacaine 0.75 % or general anaesthesia with diazepam , fentanly and N2O/O2 . Mental function was studied pre‐operatively with an abbreviated mental test and 1 week and 3 months postoperatively in both groups . Mortality and number of complications was similar in the two groups , but a shorter time of ambulation was seen in the spinal group compared to the general anaesthetic group . No persistent impairment in mental function was found after acute hip surgery under spinal or general anaesthesia and the only advantage of regional technique was a shorter time of ambulation We assessed the efficacy and side effects of postoperative analgesia with three different pain regimens in 90 patients undergoing major abdominal surgery . The patients were r and omly assigned to one of three groups : epidural morphine ( EM ) or sufentanil ( ES ) , both combined with bupivacaine , or IM morphine ( IM ) at fixed intervals . Before incision , patients in the epidural groups received sufentanil or morphine in bupivacaine via a thoracic catheter , followed by a continuous infusion 1 h later . General anesthesia consisted of N2 O/O2 and isoflurane for all groups . Patients in all groups received IV sufentanil as part of their anesthetic management . Patients in the IM group received IV sufentanil 1 [ micro sign]g/kg before incision , and patients in all groups received sufentanil 10 [ micro sign]g for inadequate analgesia . Postoperatively , the epidural or IM treatment was continued for > or = to5 days . Postoperative analgesia at rest and during coughing and movement was significantly better in the epidural groups than in the IM group during the 5 consecutive days . There were no significant differences between the epidural groups . The incidence of most side effects was similar in all groups . We conclude that epidural analgesia provided better pain relief than IM analgesia , even if the latter was optimized by fixed-dose administration at fixed intervals and included adjustments on dem and . Epidural sufentanil and morphine , both combined with bupivacaine , seemed to be equally effective with similar side effects . Implication s : Postoperative analgesia with epidural sufentanil or morphine and bupivacaine after major abdominal surgery seemed to be better than the conventional method of IM morphine treatment , despite optimal administration , i.e. , fixed doses at fixed intervals with regular adjustments . Analgesic efficacy and side effects of epidural sufentanil and morphine were similar . ( Anesth Analg 1998;87:1346 - 53 The choice between regional versus general anaesthesia for elderly patients undergoing hip surgery is debated . It is vitally important to see if the type of anaesthetic administered affects per- and postoperative morbidity and mortality .  Seventy women more than 75 yr old suitable for spinal anaesthesia were included in this study . They were r and omly divided into two groups : in one ( n = 35 ) , general anaesthesia was given with sodium thiopentone , fentanyl , enflurane and vecuronium ; in the other ( n = 35 ) , spinal anaesthesia was performed with 3 ml 0.5 % bupivacaine in isobaric solution . During the anaesthetic period , there were no statistically significant differences between both groups in systolic arterial pressure falls or in increases in the heart rate X systolic arterial pressure product . No serious cardiovascular collapse was encountered . Seven patients ( 20 % ) receiving general anaesthesia had mental changes against four only ( 14.2 % ) in the spinal group . In patients having general anaesthesia , 22.9 % developed bronchopneumonia as opposed to 8.6 % in the spinal anaesthesia group ( p less than 0.05 ) . The mortality rate at three months was rather similar in the two groups . It was concluded that , in order to reduce the incidence of postoperative central dysfunction and bronchopneumonia , spinal anaesthesia should be preferred in geriatric patients for lower limb surgery It has long been held that the acute-phase and neuroendocrine response to stress requires afferent neural input for its propagation . To further clarify the role of afferent neural impulses in this process and to determine the ability of epidural anesthesia to attenuate the normal perioperative stress response , 39 patients undergoing uncomplicated abdominal aortic replacement were r and omized to receive either general anesthesia with postoperative patient-controlled intravenous morphine ( n = 19 ) or combined regional/general anesthesia with intraoperative epidural catheter anesthesia using Bupivacaine to the T4 dermatome level followed by postoperative epidural morphine ( n = 20 ) . The stress response was quantitated by blinded measurement of baseline and postoperative ( 0 , 12 , 24 , 48 , and 72 hours ) serum cortisol , epinephrine norepinephrine , total catecholamines , interleukin (IL)-1beta , IL-6 , tumor necrosis factor (TNF)-alpha , and C-reactive protein ( CRP ) . Total operative time ( 4.2 + /- 0.3 vs 4.3 + /- 0.4 hours ) , 72-hour fluid requirement ( 7.0 + /- 0.6 vs 6.8 + /- 0.71 mL ) , and length of hospitalization ( 7.8 + /- 1.4 vs 8.1 + /- 1.2 days ) were not different between groups . All patients showed a significant increase in cortisol , epinephrine , norepinephrine , total catecholamines , CRP , and IL-6 in the postoperative period ( P < 0.05 ) . IL-1beta and TNF-alpha were less predictable and undetectable in most patients . There was no difference in any of the stress response indices between those patients receiving patient-controlled or epidural catheter anesthesia . In fact , the only parameter that was predictive of increased activation of the stress response was the length of operation , irrespective of anesthetic method . Those patients with operative times greater than 5 hours ( n = 10 ) developed significantly higher CRP , IL-1beta , IL-6 , and TNF-alpha levels ( P < 0.05 ) at 12 and 24 hours postoperatively than those with total operative times less than 4 hours ( n = 16 ) . The neuroendocrine response to major surgical stress is propagated normally despite epidural blockade and is intensified with prolonged operative times . The inflammatory cytokines appear to play a major role in this process Background There are no r and omized studies on neonatal outcome after spinal versus general anesthesia for cesarean delivery in preeclamptic patients with a nonreassuring fetal heart trace . This study examined both markers of neonatal hypoxia and maternal hemodynamics . Methods Seventy patients were r and omized to general ( n = 35 ) or spinal anesthesia ( n = 35 ) . The general anesthesia group received thiopentone , magnesium sulfate , and suxamethonium intravenously before intubation , followed by 50 % nitrous oxide in oxygen , 0.75–1.5 % isoflurane , and morphine after delivery . The target end-tidal partial pressure of carbon dioxide ( Pco2 ) was 30–34 mmHg . The spinal anesthesia group received 1.8 ml hyperbaric bupivacaine plus 10 & mgr;g fentanyl at the L3–L4 interspace . Heart rate and blood pressure were measured at specific time points . Hypotension was treated with ephedrine .  Maternal arterial and neonatal umbilical arterial blood gas sample s were taken at delivery . Resuscitation requirements were recorded . Results In both groups , hemodynamic measures remained within acceptable limits . Spinal anesthesia patients required more ephedrine ( 13.7 vs. 2.7 mg ) . Maternal Paco2 was lower in the spinal group ( 28.9 vs. 32.4 mmHg ) . One-minute Apgar scores were lower after general anesthesia . Base deficit was greater ( 7.13 vs. 4.68 mEq/l ) and neonatal umbilical arterial pH was lower ( 7.20 vs. 7.23 ) after spinal anesthesia . Post hoc analysis showed that if maternal diastolic blood pressure on admission was greater than 110 mmHg , neonatal umbilical arterial base deficit was greater after spinal anesthesia . There was no difference in the number of patients with Apgar scores less than 7 at 1 or 5 min or umbilical arterial pH less than 7.2 or in the requirements for resuscitation . Conclusions In preeclamptic patients with a nonreassuring fetal heart trace , spinal anesthesia for cesarean delivery was associated with a greater mean neonatal umbilical arterial base deficit and a lower median umbilical arterial pH. The clinical significance remains to be established . Maternal hemodynamics were similar and acceptable with either anesthetic technique In 1987 , Yeager et al. reported that intraoperative epidural anesthesia with local anesthetics and postoperative epidural analgesia with opiates diminished postoperative morbidity . In our first clinical trial on this topic , the better postoperative analgesia with epidural bupivacaine-fentanyl failed to improve the outcome after major abdominal operations over that obtained with parenteral piritramide . This r and omized controlled investigation was design ed to assess whether intraoperative epidural anesthesia with bupivacaine plus light general anesthesia and postoperative epidural analgesia with morphine would diminish the overall rate of postoperative complications after major abdominal operations compared with general anesthesia ( without epidural ) followed by patient controlled analgesia with morphine , and with intraoperative epidural anesthesia with bupivacaine and light general anesthesia followed by postoperative bupivacaine-morphine analgesia . METHODS . A total of 292 patients undergoing infrarenal aortic bypass operation , gastric resection , gastrectomy , duodenum-preserving pancreatic resection , Whipple 's operation or cystectomy and neobladder formation were r and omly divided into three groups : 1 . PCA group ( patient controlled analgesia , n = 107 ) : patients were operated on under general anesthesia ( midazolam , fentanyl , N2O/O2 , if necessary with addition of halothane , enflurane or isoflurane ; muscle relaxation with pancuronium bromide ) . Postoperative management consisted in patient-controlled analgesia with morphine ( Prominject ) , bolus 2 mg , lock-out 5 min ( recovery room , intensive care unit ) or 15 min ( surgical ward ) . 2 . EBM group ( epidural bupivacaine+morphine , n = 95 ) : operation under light general anesthesia ( midazolam , low-dose fentanyl , N2O/O2 , pancuronium bromide ) . In addition , a mixture of bupivacaine ( 0.25 % ) and morphine ( 60 micrograms/ml ) was infused ( approximately 0.1 ml/kg.h ) via an epidural catheter during and after the operation ( approximately 72 h ) . 3 . EM group ( epidural morphine , n = 90 ) : operation under the same kind of general-epidural anesthesia as in the EBM group . Postoperatively , epidural injection of morphine ( 0.05 mg/kg in 10 ml of saline ) on request up to the 3rd postoperative day . Quality of analgesia ( at rest and when patients coughed vigorously ) , strength of cough , and rate-pressure product were recorded at 8:00 h , 12:00 noon , 16:00 h and 20:00 h on the 1st , 2nd and 3rd postoperative days . Incidence and intensity of all postoperative complications ( cardiovascular , pulmonary , renal and other organ failure , reoperations , major infection , sepsis , thromboembolism , metabolic and mental disturbances ) were assessed from the day of operation until discharge or death ( n = 10 ) , respectively . RESULTS AND DISCUSSION . In the PCA and EM groups analgesia was equal but of slightly inferior quality compared with the EBM group . The ability to cough was best in the EBM group and significantly worse in the PCA and EM groups , with no difference between the last two . ( ABSTRACT TRUNCATED AT 400 WORDS The mortality following surgical correction of upper femoral fractures was investigated in 578 patients , over the age of 50 yr , r and omly allocated to receive spinal ( bupivacaine ) or general ( enflurane or neurolept ) anaesthesia .  Thirty days after surgery the mortality was 6 % after spinal and 8 % after general anaesthesia ( ns ) . Six months to 2 years after surgery the mortality was identical in the two groups . There were no differences with respect to ambulation and discharge . The estimated blood loss was smaller ( P less than 0.05 ) in patients receiving spinal anaesthesia .  Regardless of the anaesthetic technique , a high short-term mortality was related to age , male sex , and trochanteric fracture , whereas excess long-term mortality was related to male sex and high ASA scores 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 UNLABELLED The aim of our study was to compare epidural anesthesia and analgesia ( EDA ) with ropivacaine versus general anesthesia followed by IV patient-controlled analgesia with morphine ( GA/PCA )  after hip replacement regarding pain , side effects , and discharge from the postanesthesia care unit . After ethics committee approval , r and omization , and informed consent , 90 patients were enrolled . In Group EDA , epidural anesthesia ( ropivacaine 10 mg/mL , 15 - 25 mL ) was followed by an epidural infusion ( 2 mg/mL , 4 - 6 mL/h for 24 h , plus top-up doses of 6 - 10 mL for 48 h ) . GA/PCA patients received general anesthesia ( isoflurane/N2O/fentanyl ) followed by IV patient-controlled analgesia with morphine postoperatively .  Pain was assessed by using visual analog scales ( 0 - 100 mm ) at rest and during physiotherapy . Pain at rest was less in the EDA ( n = 43 ) group than in the GA/PCA ( n = 45 ) group ( at 10 h : 11.8+/-12.9 vs. 28.4+/-17.1 [ P < 0.001 ] ; at 24 h : 14.3+/-11.7 vs. 24.0+/-17 [ P<0.01 ] ; in 48 h : 14.3+/-9.3 vs. 21.1+/-17.4 [ P = 0.1 ] ) . Whereas EDA patients were deemed ready for discharge from the postanesthesia care unit earlier than GA/PCA patients ( 5.6+/-8.9 vs. 39.7+/-41.5 min ) , the actual discharge time was comparable . The median time for first passage of flatus was shorter in the EDA group than in the GA/PCA group ( 26 vs. 47 h ) . Nausea and vomiting were more common in the GA/PCA group than in the EDA group ( 16 % vs. 28 % and 11 % vs. 22 % , respectively ) , whereas hypotension ( 11 % vs. 4 % ) and bradycardia ( 14 % vs. 2 % ) were less frequent . Under the conditions of the present study , EDA with ropivacaine provided pain control after hip replacement superior to that provided by IV patient-controlled analgesia with morphine , particularly during the first 24 h. Both approaches to pain management were equally safe . IMPLICATION S Compared with general anesthesia and postoperative IV patient-controlled analgesia with morphine , epidural anesthesia and analgesia with the new local anesthetic ropivacaine enables patients to be discharged sooner from a postanesthesia care unit and provides superior pain relief during the first 24 h after hip replacement Cardiovascular and hormonal responses to reconstructive abdominal aortic surgery were studied in 20 patients anaesthetized either with moderate-dose fentanyl ( 20 micrograms kg-1 ) combined with isoflurane , nitrous oxide and oxygen ( n = 10 ) , or with thoracolumbar epidural bupivacaine combined with isoflurane , nitrous oxide and oxygen ( n = 10 ) . After the start of operation , hypotension occurred in four patients in the epidural group . In both groups , the aortic cross-clamping caused slight increases both in mean arterial pressure and in calculated systemic vascular resistance , and a significant decrease in cardiac index . At the same time , a marked increase in plasma vasopressin was seen in the fentanyl group . Plasma catecholamines were low in both groups . After aortic declamping , the cardiac index improved in both groups , although two patients in the fentanyl group and four patients in the epidural group were hypotensive . Post-operatively , eight patients in the fentanyl group were hypertensive , versus none in the epidural group , in which bupivacaine-fentanyl was administered epidurally . At the same time , plasma vasopressin and adrenaline increased significantly in both groups , whereas plasma noradrenaline did so only in the fentanyl group . The results suggest that thoracolumbar epidural bupivacaine combined with low-dose isoflurane in nitrous-oxide-oxygen prevents intra-operative hypertension and tachycardia , but it may cause hypotension . Post-operative hypertension and tachycardia as well as the increase in plasma noradrenaline are prevented by epidural administration of bupivacaine-fentanyl 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 Background Choice of perioperative analgesia may affect the rate of recovery of gastrointestinal function and thus duration and cost of hospitalization after colonic surgery Objective To evaluate the maternal and fetal effects of three anesthetic methods used r and omly in women with severe preeclampsia who required cesarean delivery . Methods Eighty women with severe preeclampsia , who were to be delivered by cesarean , were r and omized to general ( 26 women ) , epidural ( 27 ) , or combined spinalepidural ( 27 ) anesthesia .  The mean preoperative blood pressure ( BP ) was approximately 170/110 mmHg , and all women had proteinuria . Anesthetic and obstetric management included antihypertensive drug therapy and limited intravenous ( IV ) fluid and drug therapy . Results The mean  gestational age  at delivery was 34.8 weeks . All infants were born in good condition  as assessed by Apgar scores and umbilical arterial blood gas determinations . Maternal hypotension result ing from regional anesthesia was managed without excessive IV fluid administration . Similarly , maternal BP was managed without severe hypertensive effects in women undergoing general anesthesia . There were no serious maternal or fetal complications attributable to any of the three anesthetic methods . Conclusion General as well as regional anesthetic methods are equally acceptable for cesarean delivery in pregnancies complicated by severe preeclampsia if steps are taken to ensure a careful approach to either method Purpose The goal of this r and omized study was to determine whether combined general and epidural anaesthesia with postoperative epidural analgesia , compared with general anaesthesia and postoperative intravenous analgesia , reduced the incidence of perioperative myocardial ischaemia in patients undergoing elective aortic surgery . Method Patients were r and omly assigned to one of two groups . One group ( EPI , n = 48 ) received combined general and epidural anaesthesia and postoperative epidural analgesia for 48 hrs . The other group ( GA , n = 51 ) received general anaesthesia followed by postoperative intravenous analgesia . Anaesthetic goals were to maintain haemodynamic stability ( ± 20 % of preoperative values ) , and a stroke volume > 1 ml · kg−1 . A Holter monitor was attached to each patient the day before surgery . Leads 11 , V2 , and V5 were monitored . Myocardial ischaemia was defined as ST segment depression > 1 mm measured at 80 millisec beyond the J point or an elevation of 2 mm 60 millisec beyond the J point which lasted > 60 sec. An event that lasted > 60 sec but returned to the baseline for > 60 sec and then recurred , was counted as two separate events . The Holter tapes were review ed by a cardiologist blind to the patient ’s group . Results There were no demographic differences between the two groups . Myocardial ischaemia was common ; it occurred in 55 % of patients . In hospital , preoperative ischaemia was uncommon ( CA = 3 , EP1 = 8) . Intraoperative ischaemia was common ( GA = 18 , EP1 = 25 ) . Mesenteric traction produced the largest number of ischaemic ( GA = 11 , EP1 = 11 ) events . Postoperative ischaemia was most common on the day of surgery . Termination of epidural analgesia produced a burst of ischaemia ( 60 events in 9 patients ) Conclusion Combined general and epidural anaesthesia and postoperative epidural analgesia do not reduce the incidence of myocardial ischaemia or morbidity compared with general anaesthesia and postoperative intravenous analgesia . RésuméObjectifDéterminer avec une élude r and omisée si l’anesthésie générale et épidurale combinée suivie d’une analgésie épidurale postopératoire comparée à l’anesthésie générale suivie d’une analgésie intraveineuse postopératoire diminuait l’incidence de l’ischémie myocardique périopératoire chez des patients soumis à une chirurgie aortique non urgente . MéthodeLes patients étaient répartis au hasard en deux groupes . Un groupe ( IEP1 , n = 48 ) recevait une anesthésie générale et épidurale combinée et une analgésie épidurale postopératoire pendant 48 h. L’autre groupe ( AG , n = 51 ) recevait une anesthésie générale suivie d’une analgésie intraveineuse postopératoire . Les objectifs anesthésiques étaient de maintenir la stabilité hémodynamique ( ± 20 % des valeurs préopératoires ) , et un volume d’éjection > 1 ml · kg−1 . Un jour avant l’intervention , un moniteur de Holter avec les dérivations 11 , V2 et V5 était relié au patient . Une depression du segment ST plus gr and e que 1 mm mesurée 80 millisec après le point J ou une élévation de 2 mm mesurée 60 millisec après le point J était considérée comme une ischémie myocardique si elle durait plus de 60 sec. Un épisode de plus de 60 sec avec un retour à la ligne de base pendant 60 sec et plus avec récurrence , était considéré comme 2 épisodes séparés . Les bobines du Holter était révisée par un cardiologue neutre . RésultatsLes données démographiques étaient entre les groupes . L’ischémie myocardique était fréquente , survenant chez 55 % des patients . A l’hôpital , l’ischémie préopératoire était rare ( AG = 3 , EP1 = 8) . L’ischémie peropératoire était fréquente ( AG = 18 , EP1 = 25 ) . La traction mésentérique provoquait le plus gr and nombre d’épisodes d’ischémie ( AG = 11 , EP1 = 11 ) . L’ischémie postopératoire survenait le plus fréquemment le jour même de la chirurgie . L’arrêt de l’analgésie épidurale provoquait des poussées ischémiques ( 60 épisodes chez 9 patients ) . Conclusion L’anesthésie générale et épidurale combinée à l’analgésie épidurale ne réduit pas l’incidence de l’ischémie myocardique et de la morbidité comparativement à l’anesthésie générale suivie d’une l’analgésie intraveineuese Background Despite evidence that regional anesthesia may be associated with fewer perioperative complications than general anesthesia , most studies that have compared cardiac outcome after general or regional anesthesia alone have not shown major differences . This study examines the impact of anesthetic choice on cardiac outcome in patients undergoing peripheral vascular surgery who have a high likelihood of associated coronary artery disease . Methods Four hundred twenty‐three patients , between 1988 and 1991 , were r and omly assigned to receive general ( n = 138 ) , epidural ( n = 149 ) , or spinal anesthesia ( n = 136 ) for femoral to distal artery bypass surgery . All patients were monitored with radial artery and pulmonary artery catheters . Postoperatively , patients were in a monitored setting for 48–72 h and had daily electrocardiograms for 4–5 days and creatine phosphokinase/isoenzymes every 8 h x 3 , then daily for 4 days . Cardiac outcomes recorded were myocardial infa rct ion , angina , and congestive heart failure . Results Baseline clinical characteristics were not different between anesthetic groups . Overall , the patient population included 86 % who were diabetic , 69 % with hypertension , 36 % with a history of a prior myocardial infa rct ion , and 41 % with a history of smoking . Cardiovascular morbidity and overall mortality were not significantly different between groups when analyzed by either intention to treat or type of anesthesia received . In the intention to treat analysis , incidences of cardiac event or death for general , spinal , and epidural groups were 16.7 % , 21.3 % , and 15.4 % , respectively . The absolute risk difference observed between general and all regional anesthesia groups for cardiac event or death was ‐1.6 % ( 95 % confidence interval ‐9.2 % , 6.1 % ) This reflected a nonsignificant trend for lower risk of postoperative events with general anesthesia . Conclusions The choice of anesthesia , when delivered as described , does not significantly influence cardiac morbidity and overall mortality in patients undergoing peripheral vascular surgery In a prospect i ve study , patients undergoing cholecystectomy were r and omly allocated to receive ( a ) intermittent intramuscular morphine ( n = 25 ) , ( b ) continuous intravenous morphine infusion ( n = 25 ) or ( c ) epidural bupivacaine ( n = 25 ) for postoperative pain relief . Morphine by intravenous infusion provided comparable pain relief to intermittent intramuscular morphine ; there was no significant difference in the incidence of postoperative pulmonary complications . Patients receiving epidural bupivacaine for 12 h had better analgesia than patients receiving morphine ( P < 0.001 ) . Arterial oxygen tensions were also significantly higher in the epidural group for the first three postoperative days ( P < 0.05 ) . Epidural analgesia was associated with a significant reduction in the incidence of pulmonary complications ( P < 0.01 ) and chest infection ( P < 0.05 ) Sixty patients scheduled for colonic surgery were r and omly allocated to four groups according to postoperative pain medication : I. Control group , the patients received oxycodone intramuscularly ( 0.15 mg kg1 ) on request . II . Epidural bupivacaine ( 0.25 % ) continuously administered by infusion pump , 66 ml h‐1 , for 48 h. III . Epidural morphine , 2–6 mg , at the end of operation and repeated on the first and second postoperative mornings . IV . Epidural morphine , 2–6 mg per die , administered for 48 h continuously by infusion pump . All patients received a balanced anaesthesia with enflurane , fentanyl and vecuronium . Postoperatively , intramuscular oxycodone was given on request . There were no significant differences between the groups in changes in peak flow , spirometry and blood‐gas analyses postoperatively . Pain intensity ( visual analogue scale ) was lower in Groups II and III at 3 h and in Group IV at 24 h compared to the control Group I. All the epidurally treated groups needed less additional analgesics than the control Group I. Postoperatively bowel movements occurred on the second day in Group II ( bupivacaine ) as compared to the fourth day in all other groups ( P < 0.05 ) 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 : Perioperative morbidity may be modifiable in high risk patients by the anesthesiologist 's choice of either regional or general anesthesia . This clinical trial compared outcomes between epidural ( EA ) and general ( GA ) anesthesia/analgesia regimens In a group of patients at high risk for cardiac and other morbidity who were undergoing similarly stressful surgical procedures . Methods : One hundred patients scheduled for elective vascular reconstruction of the lower extremities were r and omized to receive either EA for surgery followed by epidural analgesia , or GA for surgery followed by intravenous patient-controlled analgesia .  Hemodynamic monitoring , blood pressure , and heart rate limits were determined prior to r and omization . Management of anesthesia in the immediate postoperative period was st and ardized . The data collected included continuous electrocardiographic monitoring from the day before surgery through the third postoperative day , serial electrocardiograms , and cardiac enzymes . Cardiac ischemia , myocardial infa rct ion , unstable angina , and cardiac death were identified by a cardiologist blinded to the type of anesthesia received . Other major morbidity was determined at the time of hospital discharge and at 1 and 6 months after surgery . Results : Eleven patients who received GA required regrafting or an embolectomy during their hospital stay , compared with two patients who received EA . This association of GA with reoperation remained significant after adjustment for baseline differences . Cardiac outcomes were similar in the two groups with respect to perioperative death ( 1 EA and 1 GA ) , death within 6 months ( 4 EA and 3 GA ) , nonfatal myocardial infa rct ion within 7 days ( 2 EA and 2 GA ) , unstable angina ( 0 EA and 2 GA ) , and myocardial ischemia following r and omization ( 17 EA and 23 GA ) . Rates of major infections in the two groups ( 1 EA and 2 GA ) , renal failure ( 3 EA and 3 GA ) , and pulmonary complications ( 3 EA and 7 GA ) also were similar . Conclusions : Carefully conducted epidural and general anesthesia appear to be associated with comparable rates of cardiac and most other morbidity in patients undergoing lower extremity vascular surgery . However , compared with general anesthesia , epidural anesthesia is associated with a lower incidence of reoperatlon for inadequate tissue perfusion and , therefore , may be advantageous for this surgical population Sixty patients with fractured neck of femur and scheduled for surgical correction were r and omly allocated to receive one of three anaesthetic techniques : general anaesthesia ; spinal analgesia ; psoas compartment block . The patients in the local anaesthetic groups also received a light general anaesthetic . There was little difference in the pre‐ , intra‐ and postoperative events , and no difference in postoperative mortality In a prospect i ve r and omized multi-centre study , the mortality following internal fixation surgery for fracture of the upper femur was investigated in 538 elderly patients allocated to receive subarachnoid blockade or general ( narcotic-relaxant ) anaesthesia .  The 28-day mortality was 6.6 % with subarachnoid , and 5.9 % with general , anaesthesia . The difference was not significant ( 95 % confidence limits : -3.5 to + 4.8 ) . At 1 year following surgery , the mortality was 20.4 % . Increasing age , ischaemic heart disease , cardiac failure , preoperative arrhythmias and poor ASA status were all associated with increases in early and long term mortality . A delay to surgery of more than 24 h from admission was also associated with an increased 28-day mortality . Senile dementia and admission other than from the patient 's own home , were factors associated with a poorer long term outcome . From the point of view of mortality , subarachnoid anaesthesia did not appear to confer any advantages over general anaesthesia in non-prosthetic surgery for hip fracture in the elderly To assess the role of postoperative analgesia on  myocardial ischemia after aortic surgery , we compared intravenous patient-controlled analgesia ( PCA ) with thoracic epidural analgesia ( TEA ) .  One hundred twenty-four patients were prospect ively r and omized to the PCA or TEA group . In the TEA group , a T6 - 7 or T7 - 8 epidural catheter was inserted before the induction of general anesthesia . Within 1 h of the end of surgery , analgesia and 24-h two-channel Holter monitoring were begun . Myocardial ischemia was defined as ST segment depression > or = to1 mm , 0.06 s after the J point , and lasting for more than 1 min . In the PCA group , a bolus of morphine , 0.05 mg/kg , was given , followed by 0.02 mg/kg of morphine on dem and every 10 min . Bupivacaine 0.125 % and fentanyl 10 micro g/mL was used in the TEA group . Analgesics were titrated to maintain a visual analog scale score < or = to3 . The overall incidence of myocardial ischemia was 18.4%-18.2 % for TEA and 18.6 % for PCA ( P = not significant ) . There were no differences between the groups in the total duration of ischemia per patient ( 22.2 + /- 119.8 min for TEA and 20.5 + /- 99 min for PCA ) and the number of episodes per patient ( 0.69 + /- 2.1 for TEA and 1.2 + /- 4.9 for PCA ) . Twenty-three patients had an adverse cardiac outcome , although there were no differences between the groups . The postoperative pain control was superior with TEA . In these patients undergoing elective aortic surgery , the use of postoperative TEA did not result in a lower incidence of early myocardial ischemia compared with intravenous PCA with morphine , despite better analgesia with TEA . Implication s : Postoperative myocardial ischemia is associated with adverse cardiac outcome . Using Holter monitoring after aortic surgery , this study shows that the use of thoracic epidural analgesia with bupivacaine and fentanyl did not result in a lower incidence of myocardial ischemia compared with intravenous patient-controlled analgesia with morphine . ( Anesth Analg 1997;85:1233 - 9 Fifty-seven patients , all over the age of 64 , with femoral neck fracture were r and omized to receive epidural or halothane anesthesia  to see if the anesthetic technique influenced the incidence of postoperative confusion . All patients were lucid on admission . Using the American Psychiatric Association 's Diagnostic and Statistical Manual of Mental Disorders ( DSM-III ) as criteria for confusion , we found that 44 % of the patients developed confusion that correlated closely to a history of mental depression ( P < 0.01 ) and to the use of drugs with anticholinergic effect ( P < 0.005 ) . There was no difference in the incidence of confusion between the two anesthetic groups . In patients given halothane , however , early postoperative hypoxemia was associated with confusion ( P < 0.05 ) . Patients with confusion had significantly more postoperative complications and almost four times longer hospitalization times . It is concluded that anticholinergic medication and a history of mental depression are predominant risk factors for development of postoperative confusion and in this respect are more important than the anesthetic technique 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 Quantitative assessment of myocardial ischaemia during incremental spinal , single-dose spinal and general anaesthesia may provide guidelines for the choice of anaesthetic technique for osteo synthesis of hip fractures in the elderly atherosclerotic individual . Forty-three patients with coronary artery disease were allocated to receive either incremental spinal anaesthesia ( bupivacaine 0.5 % plain ) ( A ) , single-dose spinal anaesthesia ( 2.5 mL of bupivacaine 0.5 % plain ) ( B ) or general anaesthesia ( fentanyl , thiopentone , atracurium , enflurane , N2O/O2 ) ( C ) for hip surgery .  ST segment monitoring was performed from the induction of anaesthesia and for the following 48 h , and perioperative hypotension , blood loss and fluid therapy were recorded . ST depression developed in two out of 14 ( A ) , seven out of 15 ( B ) and six out of 14 ( C ) patients ( P = 0.14 ) . In ( A ) , a total of seven ST depressions occurred in the observation period as opposed to 125 in ( B ) and 16 in ( C ) ( P < 0.05 ) . Intra-operative ST depression only occurred in ( B ) . Three ( A ) , 33 ( B ) and 40 ( C ) hypotensive events were recorded ( P < 0.002 ) . Altogether , 56 % of hypotensive patients developed ST depression compared with 10 % of normotensive patients ( P < 0.003 ) . In ( A ) , 1.6 mL of 0.5 % bupivacaine were used as opposed to the fixed 2.5 mL dose in ( B ) ( P < 0.001 ) . In the first post-operative week , mortality was higher in ( B ) ( P < 0.05 ) but , after 1 month , there was no significant difference in mortality between the three groups . The incidence of hypotension and myocardial ischaemia was lowest in the group receiving incremental spinal anaesthesia Fifty patients undergoing elective abdominal aortic surgery were r and omised to receive either combined epidural and general anaesthesia and postoperative epidural analgesia ( CEGA ) or general anaesthesia and postoperative intravenous morphine infusion ( GA ) . Prospect i ve data was collected in order to compare the two groups . This included intraoperative cardiovascular changes and postoperative complications . The use of intraoperative vasopressors was significantly higher in the CEGA group ( P < 0.01 ) but the use of intravenous glyceryl trinitrate was significantly lower ( P < 0.01 ) . There was no significant difference between groups in regard to blood loss , volume replacement or in the number of patients requiring postoperative ventilation . Two patients in the CEGA group died postoperatively compared to one in the GA group ( not significant ) . There was no significant difference between groups in the total number or type of postoperative complications . Combining epidural anaesthesia with general anaesthesia altered intraoperative cardiovascular management but did not affect postoperative outcome In a prospect i ve r and omized trial the effects of continuous peridural analgesia on gastrointestinal motility and the postoperative course was studied in 48 consecutive patients with elective colorectal resections . 24 patients had peridural analgesia ( PDA ) with bupivacaine while 24 patients received intravenous analgesia ( IVA ) with pentazocine . With PDA the first passage of flatus and faeces was significantly accelerated . PDA was not associated with an increased rate of anastomotic breakdown and there were no respiratory complications in the PDA group Background The efficacy and effects of epidural analgesia compared with patient-controlled analgesia ( PCA ) have not been reported in patients undergoing major vascular surgery . We compared the effects of epidural bupivacaine-morphine with those of intravenous PCA morphine  after elective infrarenal aortic surgery . Methods Forty patients classified as American Society of Anesthesiologists physical status 2 or 3 received  general anesthesia plus postoperative PCA using morphine sulfate ( group PCA ; n = 21 ) or general anesthesia plus perioperative epidural morphine - bupivacaine ( group EPI ; n = 19 ) during a period of 48 h. During operation , EPI patients received 0.05 mg/kg epidural morphine and 5 ml 0.25 % bupivacaine followed by an infusion of 0.125 % bupivacaine with 0.1 % morphine ( 0.1 mg/ml ) ; group PCA received 0.1 mg/kg intravenous morphine sulfate .  Continuous electrocardiographic monitoring ( V4 and V5 leads ) was performed from the night before surgery until 48 h afterward . Respiratory inductive plethysmographic data were recorded after tracheal extubation . Visual analog pain scores at rest and after movement were performed every 4 h after extubation . Results Nurse-administered intravenous morphine  and time to tracheal extubation were less in group EPI , as were visual analog pain scores at rest and after movement from 20 to 48 h. Complications and the duration of intensive care unit and hospital stay were comparable . There was a similar , low incidence of postoperative apneas , slow respiratory rates , desaturation , and S-T segment depression . Conclusions Epidural morphine-bupivacaine is associated with reduced early postoperative intravenous opioid requirements , more rapid tracheal extubation , and superior analgesia after abdominal aortic surgery , with comparable respiratory effects
target: : Compared with general anesthesia , neuraxial anesthesia may reduce the 0-to-30-day mortality for patients undergoing a surgery with an intermediate-to-high cardiac risk ( level of evidence moderate ) .
background: BACKGROUND : This analysis summarized Cochrane review s that assess the effects of neuraxial anesthesia on perioperative rates of death , chest infections , and myocardial infa rct ion .