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CLINICAL INVESTIGATION
Year : 2008  |  Volume : 52  |  Issue : 5  |  Page : 541 Table of Contents     

Role of Epidural Anaesthesia and Analgesia in Reducing Postoperative Morbidity and Mortality During Major Abdominal Surgery


1 Professor, Department Of Anaesthesia & Critical Care, S.N.Medical College, Agra, India
2 P.G.Student, Department Of Anaesthesia & Critical Care, S.N.Medical College, Agra, India
3 Associate Professor, Department Of Anaesthesia & Critical Care, S.N.Medical College, Agra, India
4 Lecturer, Department Of Anaesthesia & Critical Care, S.N.Medical College, Agra, India

Date of Acceptance07-Jul-2008
Date of Web Publication19-Mar-2010

Correspondence Address:
Uma Srivastava
15, Master Plan Road, New Lajpat Kunj, Agra-282002
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Three hundred sixty six adult patients scheduled for major abdominal surgery were randomized to receive either general anaesthesia with postoperative parenteral analgesia (Group GA, n=187) or combined general and epidural anaesthesia with postoperative epidural analgesia (Group CEGA, n=179). Aim of the study was to determine whether epidural anaesthesia and analgesia could reduce the incidence of death and major post-operative complications. Overall there was no significant difference in the incidence of mortality and major morbidity between the two groups except that the respiratory complications were significantly reduced in CEGA group (P<0.05). 11 (5.88%)& 7 (3.9%) patients died in the groups GA and CEGA respectively during hospital stay (P>0.05). Pain relief was signifi­cantly better in CEGA group with cumulative pain scores being less in CEGA group (P<0.001). Mean time of ileus was slightly shorter in CEGA group but time of first oral intake& bowel movement as well as length of hospital stay was same in two groups. It was concluded that although the incidence of mortality and all the major morbidities were not reduced by epidural anaesthesia& analgesia, the better pain control and significant reduction in respiratory complications justify the use of epidural analgesia in patients who are expected to have severe pain& may develop postoperative respiratory complications.

Keywords: Epidural anaesthesia and analgesia, Major abdominal surgery, Outcome, Mortality, Morbidity


How to cite this article:
Srivastava U, Rana SP, Kumar A, Saxena S, Chand T, Kannaujia A, Chandra P, Khan I. Role of Epidural Anaesthesia and Analgesia in Reducing Postoperative Morbidity and Mortality During Major Abdominal Surgery. Indian J Anaesth 2008;52:541

How to cite this URL:
Srivastava U, Rana SP, Kumar A, Saxena S, Chand T, Kannaujia A, Chandra P, Khan I. Role of Epidural Anaesthesia and Analgesia in Reducing Postoperative Morbidity and Mortality During Major Abdominal Surgery. Indian J Anaesth [serial online] 2008 [cited 2019 Dec 12];52:541. Available from: http://www.ijaweb.org/text.asp?2008/52/5/541/60671


   Introduction Top


Successful outcome is the most desirable end point of any surgical procedure. Therefore anaesthetic and analgesic technique should aim not only to provide op­timal conditions for surgery, but also to reduce postop­erative morbidity and mortality thus improves outcome [1] . The stress response to surgery results in disturbances in the body homeostasis [2],[3] . Some of these responses may be detrimental and can affect outcome [4],[5] . Many beneficial effects of epidural anaesthesia and analgesia (EAA) have been demonstrated during peri-operative period including attenuation of surgical stress response, effective pain relief, faster recovery of gut functions, reduction in postoperative thrombo-embolic and cardio-respiratory complications [4],[5],[6],[7],[8] . But whether these benefits ultimately make a difference in the outcome of surgical patients is a long running controversy [4],[9],[10],[11],[12] .The present study was designed to determine whether the use of intraoperative epidural anaesthesia combined with general anaesthesia and postoperative epidural analgesia affects the postoperative mortality and major morbidity in patients undergoing major abdominal surgery compared to conventional general ana­esthesia with parenteral postoperative analgesia.


   Methods Top


The present study was carried out over a period of 36 months after the approval by hospital Ethical Committee. We selected 400 patients of either sex aged 20 years or more who underwent major abdominal surgery. We excluded patients requiring laparoscopic surgery, receiving chemotherapy, requiring surgery within 24-48 hours of admission, or who had any contraindication to epidural catheterization. Informed con­sent was obtained from each patient.

The patients were divided in two groups of 200 patients each using a random number table. Patients in GA Group received balanced general anaesthesia with endotracheal intubation. Before general anaesthesia the patients of Group CEGA received epidural anaesthe­sia through a catheter placed at lumbar inter-space with 20-25 ml of 0.25% bupivacaine after 3 ml of test dose. General anaesthetic technique was similar in both the groups. Monitoring included heart rate, NIBP, ECG, EtCO 2 and pulse oximetry. Intraoperatively, all patients were managed depending upon the patient's pre-op­erative status& type of surgery. IV fluids& blood trans­fusion was given according to the haemodynamic moni­toring and estimation of blood loss under the guidance of anaesthesia consultant. At the end of surgery, neuro­muscular blockade was antagonized and tracheal ex­tubation was done provided the patients were con­scious, haemodynamically stable and maintained ad­equate ventilation in both groups. After surgery epidu­ral catheter was left in place for as long as required. In Group GA postoperative analgesia was provided by 50-100 mg of tramadol& if pain relief was inadequate butorphanol (1mg) IV was given. In CEGA group an­algesia was provided by 10-15 ml of 0.125% bupivacaine with 50mg of tramadol. In both the groups, analgesia was repeated on demand.

In all the patients if respiration was inadequate or if cardiovascular status was unstable at the end of op­eration, the patient was shifted to ICU and respiration was assisted or controlled using mechanical ventilator. The patients remained in the ICU until the anaesthesiologist caring for them felt they could be trans­ferred to surgical ward. Each patient's postoperative course was followed until the discharge from the hos­pital or death during hospital stay. Post-operative pain was assessed using 10 point VAS in the morning& evening for first 3 post-operative days.

Major clinical outcome variables studied were mortality and major morbidities as follows­

  1. Cardiac complications such as myocardial inf arction, angina, CHF etc.
  2. Respiratory complications: - Pneumonia, acute respiratory failure requiring mechanical venti lation >24 hrs in the post-operative period.
  3. Severe hypotension&/ cardiac arrest
  4. Renal failure
  5. Gastrointestinal bleeding
  6. Septicaemia
  7. Surgical complications


Apart from these, post-operative ileus (time from surgery to return of peristalsis/ passing of flatus), time of first bowel movement, oral intake and total hospital stay were also recorded.


   Statistical analysis Top


We presumed that if the use of EAA could re­duce the incidence of major complications and mortal­ity rate from 30 to 15%, this would be a clinically sig­nificant result. A sample size of minimum 175 patients per group was calculated with 80% chances of detect­ing the difference (a=0.05, two sided test). We recruited 200 patients in each group considering 10-15% loss to follow up after randomization. Patient's characteristics, pre-operative risk factors& pain scores were com­pared using X 2 or t test& post-operative morbidity and mortality were compared using Fischer Extract test with P<0.05 as significant.


   Results Top


Initially 200 patients were recruited in each group but 13 patients were excluded from GA group due to cancellation or placement of epidural catheter in the post-operative period and 21 from the CEGA group due to accidental removal or failure of placement of epidural catheter leaving 187&179 patients in groups GA& CEGA respectively.

Demographic data, duration of surgery& hospi­tal stay of the two groups was similar [Table 1]. The patients underwent surgical procedure under six cat­egories: biliary surgery in 98 patients, gastrointestinal in 109 patients, major surgery for ovarian or uterine ma­lignancy in 29 patients, urological surgery in 72 patients, abdomino-perineal surgery in 34 patients and explor­atory laparotomy in 24 patients. The surgical proce­dures were evenly distributed between the two groups. Among the preoperative risk factors, more patients in CEGA group had respiratory diseases (P=0.038). About 19% patients in GA and 22% in CEGA group had more than one preoperative risk factors [Table 2]. Postoperative pain relief was better in CEGA group, cumulative pain score for first three days being signifi­cantly lower in CEGA group (P<0.001) [Table 3]. The mean time of ileus was slightly less in CEGA group (2.98±1.4 days in GA and 2.56±1 days in CEGA group) but the difference was not statistically signifi­cant. There was no difference in two groups regarding time of oral intake or first bowel movement. Median duration of hospital stay was also similar in each group [Table 1].

The incidence of respiratory complications was significantly higher in GA group than in CEGA group whereas the incidence of other complications was similar. [Table 4] The incidence of both respiratory fail­ure and pneumonia was significantly reduced in CEGA group than the other group (P=0.042) [Table 4]. Proportion of patients who had one or more complications was approximately 22%& 18% in GA& CEGA groups respectively showing reduction in complications by 4% only. The difference was statistically insignificant (P=0.333). In GA group 11 (5.88%) patients died in the hospital compared to 7 (3.9%) in CEGA group (P=0.383).


   Discussion Top


Overall results of our study demonstrated that there was not much difference in the incidence of seri­ous postoperative morbidities and mortality between patients receiving general anaesthesia with standard postoperative parenteral analgesia or receiving com­bined epidural and general anaesthesia with postop­erative epidural analgesia. Two major benefits observed in CEGA group were lower incidence of postoperative respiratory complications in terms of reduced incidence of pneumonia and respiratory failure and superior post­operative analgesia. The cumulative pain scores ob­served for the first 3 days were consistently lower in CEGA group than in the GA group. Most of the pub­lished reports have unanimously agreed to better pain management with epidural regimen. [3],[5],[7],[9],[10],[13],[14] . The incidence of respiratory complication was significantly less in CEGA group as also reported previously [10],[14],[15],[16],[17],[18] . Res­piratory complications after abdominal surgery result from the pattern of restriction as well as ventilation ab­normalities [4] . It has been speculated that adequate pain relief allows patients to cough, sigh and change posi­tion more easily thus lesser chances of chest infections, pneumonia, atelectasis and need of postoperative ven­tilatory support [16],[18] .

It was interesting to note that despite more number of patients having pre-existing respira­tory disease in CEGA group, the incidence of postop­erative respiratory complications did not increase in this group. This finding supports further that epidural anal­gesia confers some benefit in preventing respiratory complications. The incidence of other serious compli­cations such as cardiac, renal and surgical etc was more or less similar in both the groups, a finding in agreement with other studies. [9],[10],[15]

Another benefit offered by EA was shorter time of postoperative ileus, although the time of oral intake and first bowel movement were similar in both groups. Improvement in gastrointestinal functions has been documented [4],[5],[6] . But this benefit was not of much clinical importance as the time of oral intake& bowel movement remain unaltered. Regarding the incidence of mortality our results did not show any influence of the epidural analgesic technique on postoperative mor­tality. Many studies concur with our findings [9],[10],[13],[15] .

The role of epidural anaesthesia& analgesia in determining surgical outcome is a matter of debate till date [4],[11],[12],[18],[19] as the available literature shows contra­dictory reports. Some have favorable opinion, [8],[16],[20] while others deny this. [9],[10],[13],[15] . There could be several possible causes of this. Firstly, anaesthesia and surgery have increasingly become safe even in high risk pa­tients [10],[21] and the incidence of mortality and serious non­fatal morbidity is so low [19],[22] that a very large sample size is required to demonstrate any significant differ­ence between techniques [19],[21] . Secondly many factors influence the outcome of surgical patients including age, ASA status, severity& duration of surgical procedure as well as anaesthetist's& surgeon's skill and experi­ence etc [1],[9],[10],[11],[22] . Therefore to show the benefits of anaesthetic or analgesic technique in isolation is diffi­cult. [11],[18] . Finally, some benefits of epidural analgesia such as quality of postoperative analgesia are easy to demonstrate but to show benefits in terms of reduced morbidity and mortality is much more difficult. It is widely believed that large, multicenter, randomized controlled trials are required to provide valid data on this sub­ject [4],[10],[17],[21] .

To conclude, we were unable to demon­strate overall beneficial effects of EAA in reducing post­operative mortality and morbidity after major abdomi­nal surgery, but its use certainly resulted in better pain management& reduction in respiratory complications. In view of these beneficial effects, epidural analgesia can be considered in high-risk patients[7] undergoing major abdominal surgeries who are expected to have severe pain[9] and are prone for respiratory complica­tions postoperatively.

 
   References Top

1.Bonnet F, Marret E. Influence of anaesthetic and anal­gesic techniques on outcome after surgery. Brit J Anaesth 2005; 95: 52-58.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]  
2.Kehlet H, Willmore DW. Multimodal strategies to im­prove surgical outcome. Am J Surg 2002; 183: 630-44.  Back to cited text no. 2      
3.Kehlet H, Dahl JB. Anaesthesia, surgery and challenges in postoperative recovery. Lancet 2003; 362:1921-8.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]  
4.Liu S, Carpenter RL, Neal JM. Epidural anaesthesia and analgesia: Their role in postoperative outcome. Anes­thesiology 1995; 82: 1474-1506.  Back to cited text no. 4      
5.Kehlet H. Multimodal approach to control postopera­tive pathophysiology and rehabilitation. Brit J Anaesth 1997; 78:606-617.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]  
6.Basse L, Jacobson DH, Billesbolle P. A clinical pathway to accelerate recovery after colonic resection. Ann Surg 2000; 232:51-7.  Back to cited text no. 6      
7.Myles PS, Power I, Jamozik K. Epidural block and out­come after major surgery. MJA 2002; 177: 536-537.  Back to cited text no. 7      
8.Celleno D, Scarfini C, Muratori F et al. Combined epidu­ral /general anaesthesia: safety and outcome. Anestit: Esia-Italia Gennaio (12/2) 2002 (ESRA- Italian Chapter 2002-Relazioni).  Back to cited text no. 8      
9.Park WY, Thompson JS, Lee KK. Effect of epidural ana­esthesia and analgesia on perioperative outcome. A ran­domized controlled veterans Affairs Co-operative study. Ann Surg 2001; 234: 560-571.  Back to cited text no. 9  [PUBMED]  [FULLTEXT]  
10.Rigg JRA, Jamrozik K, Myles PS, et al. Epidural anaes­thesia and analgesia and outcome of major surgery. A randomized trial. The Lancet 2002; 359; 1276-1282.  Back to cited text no. 10      
11.Ballantyne JC. Does epidural analgesia improve surgi­cal outcome? Editorial II, BMJ 2004; 92: 4-6.  Back to cited text no. 11      
12.Bajaj P. Regional anaesthesia versus general anaesthe­sia: Is there an impact on outcome after major surgery? Ind J Anaesth 2007; 51: 153-154.  Back to cited text no. 12      
13.Peyton PJ, Myles PS, Silbert BS, et al. Peri-operative epidural analgesia and outcome after major abdominal surgery in high risk patients. Anesth Analg 2003; 96: 548-54.  Back to cited text no. 13  [PUBMED]  [FULLTEXT]  
14.Ozyuvaci E, Altan A, Karadeniz T, et al. General anaes­thesia versus epidural and general anaesthesia in radi­cal cystectomy. Urol Int 2005; 74: 62-67.  Back to cited text no. 14  [PUBMED]  [FULLTEXT]  
15.Hjortso NC, Neumann P, Frosig A, et al. A controlled study on the effect of epidural analgesia with local anaesthetics and morphine on morbidity after abdomi­nal surgery. Acta Anaesthesiol Scand 1985; 29: 790­796.  Back to cited text no. 15      
16.Yeager MP, Glass DD, Neff RK, et al. Epidural anesthe­sia and analgesia in high risk surgical patients. Anes­thesiology 1987; 66: 729-736.  Back to cited text no. 16      
17.Ballantyne JC, Carr DB, Deferranti S, et al. The compara­tive effect of postoperative analgesic therapies on pul­monary outcome: Cumulative meta-analyses of random­ized, controlled trials. Anesth Analg 1998; 86:598-612.  Back to cited text no. 17  [PUBMED]  [FULLTEXT]  
18.Buggy DJ, Smith G. Epidural anaesthesia and analgesia: Better outcome after major surgery? BMJ 1999; 319: 530­-531.  Back to cited text no. 18  [PUBMED]  [FULLTEXT]  
19.Liu SS, Wu CL. Effect of postoperative analgesia on major postoperative complications. Anesth Analg 2007; 104: 689-702.  Back to cited text no. 19  [PUBMED]  [FULLTEXT]  
20.Rodgers A, Walker N, Schug S, et al. Reduction of post­operative mortality and morbidity with epidural or spi­nal anaesthesia. BMJ 2000; 321: 1493-97.  Back to cited text no. 20  [PUBMED]  [FULLTEXT]  
21.Rigg JRA, Jamrozik K, Myles PS, et al. Design of the multicenter Australian study of epidural anesthesia and analgesia in major surgery: The MASTER trial. Con­trolled Clinical Trials 2000; 21: 244-256.  Back to cited text no. 21      
22.Birkmeyer JD, Stukel TA, Siewers AE, et al. Surgeon volume and operative mortality in the United States. N Engl J Med 2003; 249: 2117-27.  Back to cited text no. 22      



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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