|Year : 2008 | Volume
| Issue : 5 | Page : 541
Role of Epidural Anaesthesia and Analgesia in Reducing Postoperative Morbidity and Mortality During Major Abdominal Surgery
Uma Srivastava1, Shiv Pratap Singh Rana2, Aditya Kumar1, Surekha Saxena1, Trilok Chand3, Ashish Kannaujia4, Parul Chandra2, Imran Khan2
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 Acceptance||07-Jul-2008|
|Date of Web Publication||19-Mar-2010|
15, Master Plan Road, New Lajpat Kunj, Agra-282002
Source of Support: None, Conflict of Interest: None
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 2020 Nov 28];52:541. Available from: https://www.ijaweb.org/text.asp?2008/52/5/541/60671
| Introduction|| |
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  . The stress response to surgery results in disturbances in the body homeostasis , . Some of these responses may be detrimental and can affect outcome , . 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 ,,,, . But whether these benefits ultimately make a difference in the outcome of surgical patients is a long running controversy ,,,, .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|| |
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
- Cardiac complications such as myocardial inf arction, angina, CHF etc.
- Respiratory complications: - Pneumonia, acute respiratory failure requiring mechanical venti lation >24 hrs in the post-operative period.
- Severe hypotension&/ cardiac arrest
- Renal failure
- Gastrointestinal bleeding
- 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|| |
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|| |
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|| |
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. ,,,,,, . The incidence of respiratory complication was significantly less in CEGA group as also reported previously ,,,,, . Respiratory complications after abdominal surgery result from the pattern of restriction as well as ventilation abnormalities  . 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 , .
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. ,,
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 ,, . 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 ,,, .
The role of epidural anaesthesia& analgesia in determining surgical outcome is a matter of debate till date ,,,, as the available literature shows contradictory reports. Some have favorable opinion, ,, while others deny this. ,,, . There could be several possible causes of this. Firstly, anaesthesia and surgery have increasingly become safe even in high risk patients , and the incidence of mortality and serious nonfatal morbidity is so low , that a very large sample size is required to demonstrate any significant difference between techniques , . 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 ,,,, . Therefore to show the benefits of anaesthetic or analgesic technique in isolation is difficult. , . 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 ,,, .
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 undergoing major abdominal surgeries who are expected to have severe pain and are prone for respiratory complications postoperatively.
| References|| |
|1.||Bonnet F, Marret E. Influence of anaesthetic and analgesic techniques on outcome after surgery. Brit J Anaesth 2005; 95: 52-58. [PUBMED] [FULLTEXT] |
|2.||Kehlet H, Willmore DW. Multimodal strategies to improve surgical outcome. Am J Surg 2002; 183: 630-44. |
|3.||Kehlet H, Dahl JB. Anaesthesia, surgery and challenges in postoperative recovery. Lancet 2003; 362:1921-8. [PUBMED] [FULLTEXT] |
|4.||Liu S, Carpenter RL, Neal JM. Epidural anaesthesia and analgesia: Their role in postoperative outcome. Anesthesiology 1995; 82: 1474-1506. |
|5.||Kehlet H. Multimodal approach to control postoperative pathophysiology and rehabilitation. Brit J Anaesth 1997; 78:606-617. [PUBMED] [FULLTEXT] |
|6.||Basse L, Jacobson DH, Billesbolle P. A clinical pathway to accelerate recovery after colonic resection. Ann Surg 2000; 232:51-7. |
|7.||Myles PS, Power I, Jamozik K. Epidural block and outcome after major surgery. MJA 2002; 177: 536-537. |
|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). |
|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. [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. |
|11.||Ballantyne JC. Does epidural analgesia improve surgical outcome? Editorial II, BMJ 2004; 92: 4-6. |
|12.||Bajaj P. Regional anaesthesia versus general anaesthesia: Is there an impact on outcome after major surgery? Ind J Anaesth 2007; 51: 153-154. |
|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. [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. [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. |
|16.||Yeager MP, Glass DD, Neff RK, et al. Epidural anesthesia and analgesia in high risk surgical patients. Anesthesiology 1987; 66: 729-736. |
|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. [PUBMED] [FULLTEXT] |
|18.||Buggy DJ, Smith G. Epidural anaesthesia and analgesia: Better outcome after major surgery? BMJ 1999; 319: 530-531. [PUBMED] [FULLTEXT] |
|19.||Liu SS, Wu CL. Effect of postoperative analgesia on major postoperative complications. Anesth Analg 2007; 104: 689-702. [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. [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. |
|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. |
[Table 1], [Table 2], [Table 3], [Table 4]