title: Effects of High Thoracic Epidural Analgesia on Myocardial Blood Flow in Patients With Ischemic Heart Disease The Effects of Continuous Epidural Anesthesia and Analgesia on Stress Response and Immune Function in Patients Undergoing Radical Esophagectomy Randomized clinical trial of multimodal optimization of surgical care in patients undergoing major colonic resection Preoperative Cardiac Events in Elderly Patients with Hip Fracture Randomized to Epidural or Conventional Analgesia Lung Function under High Thoracic Segmental Epidural Anesthesia with Ropivacaine or Bupivacaine in Patients with Severe Obstructive Pulmonary Disease Undergoing Breast Surgery The Effects of Thoracic Epidural Analgesia with Bupivacaine 0.25% on Ventilatory Mechanics in Patients with Severe Chronic Obstructive Pulmonary Disease Epidural anaesthesia and analgesia and outcome of major surgery: a randomised trial Epidural analgesia and arterial reconstructive surgery to the leg: effects on fibrinolysis and platelet degranulation. Perioperative Intravenous Lidocaine Has Preventive Effects on Postoperative Pain and Morphine Consumption After Major Abdominal Surgery Functional Recovery After Open Versus Laparoscopic Colonic Resection: A Randomized, Blinded Study Effect of Postoperative Epidural Analgesia on Morbidity and Mortality Following Surgery in Medicare Patients Postoperative Wound Oxygen Tension with Epidural or Intravenous Analgesia: A Prospective, Randomized, Single-blind Clinical Trial Improvement of 'dynamic analgesia' does not decrease atelectasis after thoracotomy. The Effects of Postoperative Pain Management on Immune Response to Surgery Effect of Postoperative Epidural Analgesia on Morbidity and Mortality After Total Hip Replacement Surgery in Medicare Patients Perioperative epidural analgesia and outcome after major abdominal surgery in high-risk patients. Comparison of Morphine, Ketorolac, and Their Combination for Postoperative Pain: Results from a Large, Randomized, Double-blind Trial Perioperative myocardial ischemic injury in high-risk vascular surgery patients: incidence and clinical significance in a prospective clinical trial. Epidural Morphine Decreases Postoperative Hypertension by Attenuating Sympathetic Nervous System Hyperactivity Effect of Epidural Anesthesia and Analgesia on Perioperative Outcome: A Randomized, Controlled Veterans Affairs Cooperative Study Intravenous Lidocaine Speeds the Return of Bowel Function, Decreases Postoperative Pain, and Shortens Hospital Stay in Patients Undergoing Radical Retropubic Prostatectomy Cardiovascular effects of two different regional anaesthetic techniques for unilateral leg surgery Underpowering in randomized trials reporting a sample size calculation.
abstract: Background —In patients with ischemic heart disease , high thoracic epidural analgesia ( TEA ) has been proposed to improve abnormalities of coronary function by inhibiting cardiac sympathetic tone . We evaluated the effect of TEA on myocardial blood flow in patients with ischemic heart disease . Methods and Results —Twenty male patients with multivessel ischemic heart disease were studied . An epidural catheter was inserted between the second and third thoracic vertebral interspace ( Th2 to Th3 ) . Analgesia was induced by epidural injection of bupivacaine 0.5 % , and a sensory block from the sixth cervical ( C6 to C7 ) to Th10 ( Th8 to Th11 ) vertebral interspace was achieved . Myocardial blood flow was measured with dynamic 13N-ammonia PET with and without TEA at rest , during pharmacological vasodilation with dipyridamole , and during sympathetic stimulation with the cold pressor test . Myocardial blood flow during dipyridamole increased similarly , regardless of TEA , in all regions except in myocardium subtended by collateral arteries in which blood flow increased more with than without TEA ( P<0.05 ) . Without TEA , myocardial blood flow during the cold pressor test remained unchanged compared with myocardial blood flow at rest . In contrast , with TEA , myocardial blood flow increased in all vascular territories . Coronary vascular resistance increased during the cold pressor test without TEA , whereas with TEA , coronary resistance decreased in myocardium subtended by nonstenotic and stenotic coronary vessels and remained unchanged in myocardium subtended by occluded vessels . Conclusions —In patients with multivessel ischemic heart disease , TEA partly normalizes the myocardial blood flow response to sympathetic stimulation We investigated whether perioperative extensive epidural block ( C3-L ) affects postoperative immune response in patients undergoing radical esophagectomy . Patients undergoing radical esophagectomy were r and omly assigned to either general anesthesia with continuous epidural infusion via 2 epidural catheters that was continued for postoperative analgesia ( group E , n = 15 ) or intraoperative general anesthesia and postoperative IV morphine analgesia ( group G , n = 15 ) . Plasma levels of stress hormones , cytokines , C-reactive protein ( CRP ) , leukocyte counts , and distribution of lymphocyte subsets were assessed before and after surgery and on postoperative days ( PODs ) 1 and 3 . In comparison with group E , significant increases in plasma epinephrine level at the end of surgery ( P < 0.05 ) and norepinephrine level at the end of surgery ( P < 0.01 ) and on POD1 ( P < 0.01 ) and POD3 ( P < 0.01 ) and significant decrease in cluster of differentiation ( CD4/CD8 ratio ) at the end of surgery ( P < 0.05 ) were observed in group G. However , there were no significant differences in other variables between groups . In both groups , plasma cortisol , adrenocorticotropic hormone , interleukin (IL)-1β , IL-6 , IL-10 , and CRP levels were increased after surgery ( each group P < 0.01 ) and IL-1β , IL-6 , IL-10 , and CRP were still increased on POD1 and POD3 ( each change , each group P < 0.01 ) . Leukocyte counts were increased on POD1 ( each group P < 0.05 ) and POD3 ( each group P < 0.01 ) . The proportion of lymphocytes decreased from the end of surgery to POD3 ( each group P < 0.01 ) . The proportion of B cells was increased on POD1 ( each group P < 0.01 ) ; that of natural killer cells was decreased at POD1 and POD3 ( each group P < 0.01 ) . We conclude that tissue damage and inflammation apparently overcome the effects of extensive epidural block on stress response and immune function in radical esophagectomy The aim of this trial was to compare  multimodal optimization  with  conventional perioperative management  in a consecutive series of patients undergoing a wide range of colorectal procedures Background Perioperative myocardial ischemia occurs in 35 % of unselected elderly patients undergoing hip fracture surgery .  Perioperative epidural analgesia may reduce the incidence of adverse cardiac events . Methods The effect of early administration of epidural analgesia during the stressful presurgical period , on preoperative cardiac events was evaluated in a prospect i ve r and omized study in 68 patients with hip fractures who either had known coronary artery disease or were at high risk for coronary artery disease . On admission to the emergency room , patients were assigned to receive a usual care analgesic regimen ( intramuscular meperidine , control group , n = 34 ) or continuous epidural infusion of local anesthetic and opioid ( epidural group , n = 34 ) . Monitoring in the preoperative period included a preoperative history and physical examination , daily assessment of cardiac adverse events , serial electrocardiograms , cardiac enzymes , and pain scores . Results Preoperative adverse cardiac events were significantly more prevalent in the control group compared with the epidural group ( 7 of 34 vs. 0 of 34;P = 0.01 ) . Adverse cardiac events included fatal myocardial infa rct ion in three , fatal congestive heart failure in one , nonfatal congestive heart failure in one , and new onset atrial fibrillation in two . The incidence of intraoperative and postoperative adverse cardiac events was similar for the two groups . The significant difference between groups in the incidence of preoperative cardiac events prompted interruption of the study after the planned interim analysis . Conclusions The authors ’ data indicate that compared with conventional analgesia , early administration of continuous epidural analgesia is associated with a lower incidence of preoperative adverse cardiac events in elderly patients with hip fracture who have or are at risk for coronary artery disease . Preoperative epidural analgesia may be advantageous for this surgical population Background Because general anesthesia with tracheal intubation can elicit life-threatening bronchospasm in patients with bronchial hyperreactivity , epidural anesthesia is often preferred . However , segmental high thoracic epidural anesthesia ( sTEA ) causes pulmonary sympathetic and respiratory motor blockade . Whether it can be safely used for chest wall surgery as a primary anesthetic technique in patients with chronic obstructive pulmonary disease or asthma is unclear . Furthermore , ropivacaine supposedly evokes less motor blockade than bupivacaine and might minimize side effects . To test the feasibility of the technique and the hypotheses that ( 1 ) sTEA with ropivacaine or bupivacaine does not change lung function and ( 2 ) there is no difference between sTEA with ropivacaine or bupivacaine , the authors studied 20 patients with severe chronic obstructive pulmonary disease ( forced expiratory volume in 1 s [ FEV1 ] = 52.1 ± 17.3 % of predicted [ mean ± SD ] ) or asthma who were undergoing breast surgery . Methods In a double-blind , r and omized fashion , sTEA was performed with 6.6 ± 0.5 ml of either ropivacaine , 0.75 % ( n = 10 ) , or bupivacaine , 0.75 % ( n = 10 ) . FEV1 , vital capacity , FEV1 over vital capacity , spread of analgesia ( pin prick ) , h and and foot skin temperatures , mean arterial pressure , heart rate , and local anesthetic plasma concentrations were measured with patients in the sitting and supine positions before and during sTEA . Results Segmental high thoracic epidural anesthesia ( segmental spread C4–T8 [ bupivacaine ] and C5–T9 [ ropivacaine ] ) significantly decreased FEV1 from 1.22 ± 0.54 l ( supine ) to 1.09 ± 0.56 l ( ropivacaine ) and from 1.23 ± 0.49 l to 1.12 ± 0.46 l ( bupivacaine ) . In contrast , FEV1 over vital capacity increased from 64.6 ± 13.5 to 68.2 ± 14.5 % ( ropivacaine ) and from 62.8 ± 12.4 to 66.5 ± 13.6 % ( bupivacaine ) . There was no difference between ropivacaine and bupivacaine . Skin temperatures increased significantly , whereas arterial pressure and heart rate significantly decreased indicating widespread sympathetic blockade . All 20 patients tolerated surgery well . Conclusions Despite sympathetic blockade , sTEA does not increase airway obstruction and evokes only a small decrease in FEV1 as a sign of mild respiratory motor blockade with no difference between ropivacaine and bupivacaine . Therefore , sTEA can be used in patients with severe chronic obstructive pulmonary disease and asthma undergoing chest wall surgery  as an alternative technique to general anesthesia Optimal analgesia is important after thoracotomy in pulmonary-limited patients to avoid pain-related pulmonary complications . Thoracic epidural anesthesia ( TEA ) can provide excellent pain relief . However , potential paralysis of respiratory muscles and changes in bronchial tone might be unfavorable in patients with end-stage chronic obstructive pulmonary disease ( COPD ) . Therefore , we evaluated the effect of TEA on maximal inspiratory pressure , pattern of breathing , ventilatory mechanics , and gas exchange in 12 end-stage COPD patients .  Pulmonary resistance , work of breathing , dynamic intrinsic positive end-expiratory pressure , and peak inspiratory and expiratory flow rates were evaluated by assessing esophageal pressure and airflow . An increase in minute ventilation ( 7.50 ± 2.60 vs 8.70 ± 2.10 L/min;P = 0.04 ) by means of increased tidal volume ( 0.46 ± 0.16 vs 0.53 ± 0.14 L/breath;P = 0.003 ) was detected after TEA . These changes were accompanied by an increase in peak inspiratory flow rate ( 0.48 ± 0.17 vs 0.55 ± 0.14 L/s;P = 0.02 ) and a decrease in pulmonary resistance ( 20.7 ± 9.9 vs 16.6 ± 8.1 cm H2O · L−1 · s−1;P = 0.02 ) . Peak expiratory flow rate , dynamic intrinsic positive end-expiratory pressure , work of breathing , Pao2 , and maximal inspiratory pressure were unchanged ( all P > 0.50 ) . We conclude that TEA with bupivacaine 0.25 % can be used safely in end-stage COPD patients BACKGROUND Epidural block is widely used to manage major abdominal surgery and postoperative analgesia , but its risks and benefits are uncertain . We compared adverse outcomes in high-risk patients managed for major surgery with epidural block or alternative analgesic regimens with general anaesthesia  in a multicentre r and omised trial . METHODS 915 patients undergoing major abdominal surgery with one of nine defined comorbid states to identify high-risk status were r and omly assigned intraoperative epidural anaesthesia and postoperative epidural analgesia for 72 h with general anaesthesia ( site of epidural selected to provide optimum block ) or control . The primary endpoint was death at 30 days or major postsurgical morbidity . Analysis by intention to treat involved 447 patients assigned epidural and 441 control . FINDINGS 255 patients ( 57.1 % ) in the epidural group and 268 ( 60.7 % ) in the control group had at least one morbidity endpoint or died ( p=0.29 ) . Mortality at 30 days was low in both groups ( epidural 23 [ 5.1 % ] , control 19 [ 4.3 % ] , p=0.67 ) . Only one of eight categories of morbid endpoints in individual systems ( respiratory failure ) occurred less frequently in patients managed with epidural techniques ( 23 % vs 30 % , p=0.02 ) . Postoperative epidural analgesia was associated with lower pain scores during the first 3 postoperative days . There were no major adverse consequences of epidural-catheter insertion . INTERPRETATION Most adverse morbid outcomes in high-risk patients undergoing major abdominal surgery are not reduced by use of combined epidural and general anaesthesia and postoperative epidural analgesia . However , the improvement in analgesia , reduction in respiratory failure , and the low risk of serious adverse consequences suggest that many high-risk patients undergoing major intra-abdominal surgery will receive substantial benefit from combined general and epidural anaesthesia intraoperatively with continuing postoperative epidural analgesia It has been suggested that the incidence of early graft occlusion after arterial reconstructive surgery to the leg may be decreased by epidural analgesia . This effect may be mediated by the suppression of the usual cortisol response to surgery , which results in increased circulating plasminogen activator inhibitor-1 with consequent adverse effects on fibrinolysis . To investigate this and other potential mechanisms , 30 patients undergoing arterial reconstructive surgery to the leg were r and omized to receive either general anaesthesia or general anaesthesia plus epidural analgesia . Post-operative analgesia was provided by morphine infusion or epidural analgesia , respectively . Blood sample s were collected at 0 , 2 , 4 , 6 , 12 and 24 h , and 2 , 3 and 5 days and analysed for cortisol , plasminogen activator inhibitor-1 antigen , interleukin-6 and beta thromboglobulin . The incidence of graft-related and systemic complications was recorded for 30 days . Only one patient developed early graft occlusion that required embolectomy and eventually amputation . There were no significant changes from control values in either group of patients in circulating cortisol , plasminogen activator inhibitor-1 and beta thrombogobulin ( a marker for platelet degranulation ) . Interleukin-6 values increased significantly in both groups after 4 h and remained elevated until day 3 . There were no significant differences between the groups in any variable measured . We conclude that any effect of epidural analgesia on early graft patency is unlikely to be mediated by fibrinolysis or platetlet degranulation Sodium channel blockers are approved for IV administration in the treatment of neuropathic pain states . Pre clinical studies have suggested antihyperalgesic effects on the peripheral and central nervous system . Our objective in this study was to determine the time course of the analgesic and antihyperalgesic mechanisms of perioperative lidocaine administration . Forty patients undergoing major abdominal surgery participated in this r and omized and double-blinded study . Twenty patients received lidocaine 2 % ( bolus injection of 1.5 mg/kg in 10 min followed by an IV infusion of 1.5 mg · kg−1 · h−1 ) , and 20 patients received saline placebo . The infusion started 30 min before skin incision and was stopped 1 h after the end of surgery . Lidocaine blood concentrations were measured . Postoperative pain ratings ( numeric rating scale of 0–10 ) and morphine consumption ( patient-controlled analgesia ) were assessed up to 72 h after surgery . Mean lidocaine levels during surgery were 1.9 ± 0.7 & mgr;g/mL. Patient-controlled analgesia with morphine produced good postoperative analgesia ( numeric rating scale at rest , ≤3 ; 90%–95 % ; no group differences ) . Patients who received lidocaine  reported less pain during movement and needed less morphine during the first 72 h after surgery ( 103.1 ± 72.0 mg versus 159.0 ± 73.3 mg ; Student ’s t-test ; P < 0.05 ) . Because this opioid-sparing effect was most pronounced on the third postoperative day , IV lidocaine may have a true preventive analgesic activity , most likely by preventing the induction of central hyperalgesia in a clinical ly relevant manner Background : Laparoscopic colonic surgery has been cl aim ed to hasten recovery and reduce hospital stay compared with open operation . Recently , enforced multimodal rehabilitation ( fast-track surgery ) has improved recovery and reduced hospital stay in both laparoscopic and open colonic surgery . Since no comparative data between laparoscopic and open colonic resection with multimodal rehabilitation are available , the value of laparoscopy per se is unknown . Methods : In a r and omized , observer- and -patient , blinded trial , 60 patients ( median age 75 years ) underwent elective laparoscopic or open colonic resection with fast-track rehabilitation and planned discharge after 48 hours .  Functional recovery was assessed in detail during the first postoperative month . Results : Median postoperative hospital stay was 2 days in both groups , with early and similar recovery to normal activities as assessed by hours of mobilization per day , computerized monitoring of motor activity assessed , pulmonary function , cardiovascular response to treadmill exercise , pain , sleep quality , fatigue , and return to normal gastrointestinal function . There were no significant differences in postoperative morbidity , mortality , or readmissions , although 3 patients died in the open versus nil in the laparoscopic group . Conclusion : Functional recovery after colonic resection is rapid with a multimodal rehabilitation regimen and without differences between open and laparoscopic operation . Further large-scale studies are required on potential differences in serious morbidity and mortality Background Because of the uncertainty and limitations in available r and omized controlled trials , we performed an analysis of the Medicare cl aims data base to determine whether an association exists between postoperative epidural analgesia and mortality . Methods A 5 % nationally r and om sample of Medicare beneficiaries from 1997 to 2001 was analyzed to identify patients undergoing segmental excision of the lung ( International Statistical Classification of Diseases , Ninth Revision , Clinical Modification codes 32.3 and 32.4 ) , complete pneumonectomy ( code 32.5 ) , partial excision of large intestine ( codes 45.73 and 45.76 ) , anastomosis of the esophagus ( codes 42.5 and 42.6 ) , total knee replacement/revision ( codes 81.54 and 81.55 ) , total/radical abdominal hysterectomy ( codes 68.4 and 68.6 ) , partial/radical pancreaticoduodenectomy ( codes 52.5 and 52.7 ) , partial/complete nephrectomy ( codes 55.4 and 55.5 ) , partial/complete cystectomy ( codes 57.6 and 57.7 ) , hepatotomy/lobectomy of the liver ( codes 50.0 and 50.3 ) , partial/total gastrectomy ( codes 43.5 to 43.9 ) , and radical retropubic prostatectomy ( codes 60.4 and 60.5 ) . Patients were divided into 2 groups , depending on the presence or absence of postoperative epidural analgesia . The rate of major morbidity and death at 7 and 30 days after surgery were compared . Multivariate regression analyses incorporating race , gender , age , comorbidities , hospital size , hospital teaching status , and hospital technology status were performed . Results The presence of epidural analgesia was associated with a significantly lower odds of death at 7 days ( odds ratio [ OR ] , 0.52 ; 95 % confidence interval [ CI ] , 0.38 to 0.73 ; P = .0001 ) and 30 days ( OR , 0.74 ; 95 % CI , 0.63 to 0.89 ; P = .0005 ) after surgery ; however , no difference was seen between the groups with regard to overall major morbidity , with the exception of an increase in pneumonia at 30 days for the epidural group ( OR , 1.91;[95 % CI , 1.09 to 3.34 ; P = .02 ) . Conclusions Postoperative epidural analgesia may contribute to lower odds of death after surgery Background Adequate tissue oxygen tension is an essential requirement for surgical-wound healing . The authors tested the hypothesis that epidural anesthesia and analgesia increases wound tissue oxygen tension compared with intravenous morphine analgesia . Methods In a prospect i ve , r and omized , blind clinical study , the authors allocated patients having major abdominal surgery ( n = 32 ) to receive combined general and epidural anesthesia with postoperative patient-controlled epidural analgesia ( epidural group , n = 16 ) , or general anesthesia alone with postoperative patient-controlled intravenous analgesia ( intravenous group , n = 16 ) . An oxygen sensor and a temperature sensor were placed subcutaneously in the wound before closure . Wound oxygen tension ( Pwo2 ) and temperature were measured continuously for 24 h. Other variables affecting wound tissue oxygenation and visual analogue scale ( VAS ) pain scores were also documented . Results Despite epidural patients having lower body temperatures at the end of surgery ( 35.7 ± 0.3 ) versus 36.3 ± 0.5 ° C , P = 0.004 ) , they had significantly higher mean Pwo2 over the 24 h period , compared with the intravenous group ( 64.4 ± 14 vs. 50.7 ± 15 ) mmHg , mean ( SD ) , 95 % CI difference , −22 to −5 , P = 0.002 ) . Area under the Pwo2 −24 h time curve was also significantly higher in the epidural group ( 930 ± 278 vs. 749 ± 257 ) mmHg × h , 95 % CI difference −344 to −18 , P = 0.03 ) . VAS pain scores at rest and moving were significantly lower in the epidural group at all times . Conclusion Epidural anesthesia and postoperative analgesia for major abdominal surgery increases wound tissue oxygen tension compared with general anesthesia and intravenous morphine analgesia There is still controversy concerning the beneficial aspects of ' dynamic analgesia ' ( i.e. pain while coughing or moving ) on the reduction of postoperative atelectasis . In this study , we tested the hypothesis that thoracic epidural analgesia ( TEA ) prevents these abnormalities as opposed to multimodal analgesia with i.v . patient controlled analgesia ( i.v . PCA ) after thoracotomy . Fifty-four patients undergoing thoracotomy ( lung cancer ) were r and omly assigned to one of the two groups . Clinical respiratory characteristics , arterial blood gas , and pulmonary function tests ( forced vital capacity and forced expiratory volume in 1 s ) were obtained before surgery and on the next 3 postoperative days . Atelectasis was compared between the two groups by performing computed tomography ( CT ) scan of the chest at day 3 . Postoperative respiratory function and arterial blood gas values were reduced compared with preoperative values ( mean ( SD ) FEV1 day 0 : 1.1 ( 0.3 ) litre ; 1.3 ( 0.4 ) litre ) but there was no significant difference between groups at any time . PCA and TEA provided a good level of analgesia at rest ( VAS day 0 : 21 ( 15/100 ) ; 8 ( 9/100 ) ) , but TEA was more effective for analgesia during mobilization ( VAS day 0 : 52 ( 3/100 ) ; 25 ( 17/100 ) ) . CT scans revealed comparable amounts of atelectasis ( expressed as a percentage of total lung volume ) in the TEA ( 7.1 (2.8)% ) and in the i.v . PCA group ( 6.71 (3.2)% ) . There was no statistical difference in the number of patients presenting with at least one atelectasis of various types ( lamellar , plate , segmental , lobar ) Surgery is associated with immune alterations , which are the combined result of tissue damage , anesthesia , postoperative pain , and psychological stress . In the present study , we compared the effects of several postoperative pain management techniques on postoperative immune function .  Patients hospitalized for abdominal surgery were r and omly assigned to one of three postoperative pain management techniques : opiates on dem and ( intermittent opiate regimen [ IOR ] ) , patient-controlled analgesia ( PCA ) , and patient-controlled epidural analgesia ( PCEA ) .  Postoperative pain was assessed . Blood sample s were collected before and 24 , 48 , and 72 h after surgery . Production of interleukin (IL)-1&bgr ; , IL-2 , and IL-6 , natural killer cell cytotoxicity , and lymphocyte mitogenic responses were assessed . Patients of the PCEA group exhibited lower pain scores in the first 24 h after surgery compared with patients of the IOR and PCA groups . Mitogenic responses were suppressed in all groups in the first 24 h , returned to preoperative values by 72 h in the PCEA group , but remained suppressed in the PCA group . Production of IL-1&bgr ; and IL-6 increased in the IOR and PCA groups , whereas it remained almost unchanged in the PCEA group . Patients receiving an epidural mixture of opiate and local anesthetics ( PCEA group ) exhibited reduced suppression of lymphocyte proliferation and attenuated proinflammatory cytokine response in the postoperative period Background and Objectives : The effect of postoperative epidural analgesia ( vs. systemic analgesia ) on patient outcomes is unclear . Available r and omized controlled trials ( RCTs ) have focused on the intraoperative period and not properly examined the effect of postoperative epidural analgesia ( EA ) on outcomes . Methods : A 5 % nationally r and om sample of Medicare beneficiaries from 1994 to 1999 was analyzed to identify patients undergoing total hip arthroplasty ( Common Procedural Terminology [ CPT ] code 27130 , 27132 , 27134 , 27137 , 27138 ) . Patients were divided into 2 groups depending on the presence or absence of postoperative EA based on the CPT coding ( 01996 ) . The rate of major morbidity ( acute myocardial infa rct ion , deep venous thrombosis , pulmonary embolism , angina , respiratory failure , heart failure , cardiac dysrhythmias , pneumonia , pulmonary edema , sepsis , acute renal failure , paralytic ileus , acute cerebrovascular event ) and death at 7 and 30 days after the procedure were compared . Multivariate regression analysis was performed to determine if the presence of postoperative ( EA ) had an independent effect on mortality or major morbidity . Data were reported as an odds ratio with 95 % confidence intervals ( CI ) when appropriate . Results : The unadjusted 7‐ and 30‐day death rate was significantly lower for EA versus no EA ( 1.9/1000 [ 95 % CI : 0.2‐3.6 ] vs. 3.9/1000 [ 95 % CI : 3.0‐6.2 ] at 7 days [ P = .04 ] and 5.8/1000 [ 95 % CI : 2.9‐8.7 ] vs. 9.9/1000 [ 95 % CI : 8.6‐11.3 ] at 30 days [ P = 0.01 ] ) . However , multivariate regression analysis revealed that there was no difference between the groups with regard to mortality or major morbidity with the exception of an increase in deep venous thrombosis in patients who received EA . Conclusions : The use of postoperative EA was not associated a lower incidence of mortality and major morbidity in Medicare patients undergoing total hip arthroplasty . However , the results should be interpreted with caution because of limitations in using the Medicare cl aims data for analysis . Further trials using other properly conducted and design ed studies ( e.g. , RCTs ) would be ideal to vali date these results 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 : Meta-analyses report similar numbers needed to treat for nonsteroidal antiinflammatory drugs ( NSAIDs ) and opioids . Differences in baseline pain intensity among the studies from which these numbers needed to treat were derived may have confounded the results . NSAIDs have an opioid-sparing effect , but the importance of this effect is unclear . Therefore , the authors sought to compare the proportions of subjects who obtain pain relief with ketorolac versus morphine after surgery and to determine whether the opioid-sparing effect of an NSAID reduces the magnitude of opioid side effects . Methods : The study was a double-blind , r and omized controlled trial . The authors r and omly assigned 1,003 adult patients to receive 30 mg  ketorolac  or 0.1 mg/kg morphine intravenously . They calculated the proportion of subjects who achieved at least 50 % reduction in pain intensity 30 min after analgesic administration . Further , so long as pain intensity 30 min after analgesic administration was 5 or more out of 10 , patients received 2.5 mg morphine every 10 min until pain intensity was 4 or less out of 10 . The authors assessed the presence of opioid-related side effects . Results : Five hundred patients received morphine and 503 received ketorolac .  Fifty percent of patients in the morphine group achieved pain relief , compared with 31 % in the ketorolac group ( difference , 19 % ; 95 % confidence interval , 13–25 % ) . The ketorolac – morphine group required less morphine ( difference , 6.5 mg ; 95 % confidence interval , −5.8 to −7.2 ) and had a lower incidence of side effects ( difference , 11 % ; 95 % confidence interval , 5–16 % ) than the morphine group . Conclusions : Opioids are more efficacious analgesics than NSAIDs , although historic data for these two drugs yield similar numbers needed to treat . Adding NSAIDs to the opioid treatment reduces morphine requirements and opioid-related side effects in the early postoperative period OBJECTIVE The purpose of this study was to assess prospect ively the incidence , health care re source utilization , and economic burden associated with perioperative myocardial ischemic injury ( PMII ) in high-risk patients undergoing noncardiac vascular surgery . METHODS Two hundred thirty-six patients consented to participate in a pharmacoeconomic sub study as part of a r and omized , multicenter clinical trial . Patients were assessed for  myocardial ischemic injury  by using clinical , biochemical , and electrocardiographic criteria . PMII was defined as fatal or nonfatal myocardial infa rct ion , new or worsened congestive heart failure , or new arrhythmias . Re source utilization parameters were compared for patients with and without PMII . Patients underwent the following index procedures : open abdominal aortic aneurysm repair ( n = 44 ) ,  bypass for aortoiliac disease ( n = 29 ) , bypass for femoropopliteal disease ( n = 62 ) , bypass for femorotibial disease ( n = 71 ) , extra-anatomic bypass ( n = 23 ) , and miscellaneous ( n = 7 ) . Patients undergoing carotid endarterectomy or only endovascular interventions were excluded . The incremental cost of PMII was estimated by applying the average costs ( adjusted to 2004 US dollars ) of the hospital ward ( dollar 700.00/d ) or intensive care unit ( dollar 2500.00/d ) to the length of stay differences for patients with and without PMII . RESULTS The overall mortality was 3.4 % ( 8/236 ) , and 7 of 8 deaths were related to PMII . PMII occurred in 42 ( 17.8 % ) of 236 patients : 22 myocardial infa rct ions , 11 congestive heart failures , and 12 new arrhythmias ( 3 patients had 2 PMII events ) . There was no evidence of differences in the incidence of PMII among the various index procedures . PMII was associated with a dramatic increase in re source utilization . The mean length of stay was 16.8 and 10.0 days for patients with and without PMII , respectively ( P < .001 ) . Intensive care unit care was required by 35 ( 83.3 % ) of 42 patients with and 121 ( 62.4 % ) of 194 patients without PMII ( P < .009 ) . The mean intensive care unit length of stay was 6.6 and 3.7 days for patients with and without PMII , respectively ( P < .009 ) . Ten ( 23.8 % ) of 42 patients with and 20 ( 10.3 % ) of 194 patients without PMII returned to the emergency department for care after discharge ( P < .02 ) . CONCLUSIONS In modern vascular surgery practice , PMII remains common despite the availability of beta-blockers and other preventative strategies . PMII is associated with dramatic increases in re source utilization and cost . The increase in re source utilization associated with PMII result ed in an estimated incremental cost per patient of dollar 9980.00 . If 250,000 high-risk open vascular operations are performed annually in the United States , the economic burden of PMII in these procedures alone approximates dollar 444 million . Strategies to decrease PMII incidence and severity should be evaluated in large-scale prospect i ve trials Twenty-four adults who were undergoing operations on the abdominal aorta were enrolled in a r and omized , double-blind , placebo-controlled study in which epidural morphine sulfate ( 6 mg ) was employed to attenuate the sympathoadrenal response to surgery to evaluate the possible contribution of sympathetic nervous system hyperactivity to postoperative hypertension . Patients who received epidural morphine required less parenteral morphine in the 24 hours following surgery , had lower analogue pain scores , and had markedly lower plasma norepinephrine levels when compared with patients in the control group who received an identical volume of saline in the epidural space . Epidural morphine had no effect on plasma epinephrine or arginine vasopressin levels . Fewer patients in the morphine group ( 4 of 12 vs 9 of 12 patients in the saline group ) required treatment for hypertension ( mean arterial blood pressure , greater than or equal to 110 mm Hg ) in the 24 hours following surgery . In addition , patients in the morphine group had lower blood pressures in the 24 hours following surgery . These data suggest that sympathetic nervous system activity and not adrenal epinephrine or pituitary secretion of arginine vasopressin is responsible for the development of hypertension following aortic surgery . Furthermore , epidural narcotics appear to provide a means of attenuating this response 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 Postoperative ileus is a concern among surgical patients .Epidural anesthesia and analgesia with local anesthetics can decrease the duration of ileus . Significant systemic absorption of local anesthesia occurs during epidural use . In this study , we examined whether many of the beneficial effects on bowel function seen with epidural lidocaine are also present when the drug is given parenterally . Forty patients undergoing radical retropubic prostatectomy were studied with one half of the patients receiving a lidocaine bolus ( 1.5 mg/kg ) and infusion ( 3 mg/min , unless weight < 70 kg , then 2 mg/min ) ; the other half received a saline infusion . A blind observer recorded the patient 's daily pain score , the time the patient first experienced flatulence and had the first bowel movement , and the total use of analgesics .  Lidocaine-treated patients first experienced flatulence in a significantly shorter time ( P < 0.01 ) than control patients . Lidocaine patients ' hospital stay was also significantly shorter ( P < 0.05 ) ; on average , they spent 1.1 fewer days in the hospital . IV lidocaine initiated before anesthesia and continued 1 h postoperatively significantly sped up the return of bowel function .  Lidocaine patients were also more comfortable postoperatively . Many of the bowel function benefits attributed to epidural lidocaine are also present when the drug is administered parenterally . Additionally , the length of hospital stay was reduced in lidocaine-treated patients . Implication s : This study prospect ively examined whether IV lidocaine could affect the return of bowel function after radical prostate surgery .  Lidocaine-treated patients had shorter hospital stays , less pain , and faster return of bowel function . In this population , lidocaine infusion can be a useful adjunct in anesthetic management . ( Anesth Analg 1998;86:235 - 9 Background : Cardiovascular function was assessed in 20 ASA I‐II patients , scheduled for elective orthopaedic surgery with tourniquet  in order to compare the haemodynamic changes induced by unilateral spinal anaesthesia and combined sciaticofemoral nerve block OBJECTIVE The objective of this study was to determine whether st and ard deviations ( SDs ) used in sample size calculations are smaller than those found in the result ing study sample , thereby leading to underpowered studies . METHOD The predicted SD used in the sample size calculation and the actual SD of the study sample were recorded for r and omized trials recently published in one of four major journals . RESULTS Sample SD was greater than predicted SD for 80 % of endpoints . About one quarter of trials required five times as many patients as specified in the sample size calculation . CONCLUSION Trials reporting sample size calculations for continuous endpoints published in the most reputable medical journals are often underpowered . There seems to be insufficient underst and ing that the SD of a sample of patients is a r and om variable , associated with imprecision , that can not easily be extrapolated from one population to another
target: The majority of evidence favors an ability of epidural analgesia to reduce postoperative cardiovascular and pulmonary complications only after major vascular surgery or in high-risk patients .
  This finding may become irrelevant because of rapid conversion of major surgery to minimally invasive techniques ( e.g. , endoluminal abdominal aortic repair ) that carry less risk of complications .
  There is also consistent evidence that epidural analgesia with local anesthetics is associated with faster resolution of postoperative ileus after major abdominal surgery .
  Again , this finding may also become irrelevant with the adoption of laparoscopic techniques and multimodal fast-track programs for abdominal surgery .
  There is no current evidence that perineural analgesia , continuous wound catheters using local anesthetics , IV patient-controlled analgesia with opioids , or addition of multimodal systemic analgesics have any clinical ly significant beneficial effect on postoperative complications .
  CONCLUSIONS : Overall , there is insufficient evidence to confirm or deny the ability of postoperative analgesic techniques to affect major postoperative mortality or morbidity .
  This is primarily due to typically insufficient subject numbers to detect differences in currently low incidences of postoperative complications
background: BACKGROUND : Few individual clinical trials have had sufficient subject numbers to definitively determine the effects of postoperative analgesia on major outcomes .
  Epidural analgesia with local anesthetics has the greatest theoretical potential to affect major outcomes and has been the most thoroughly investigated technique .