Comparison of Intravenous or Epidural Patient-controlled Analgesia in the Elderly after Major Abdominal Surgery Effect of Epidural Anesthesia and Analgesia on Perioperative Outcome: A Randomized, Controlled Veterans Affairs Cooperative Study Epidural anaesthesia and analgesia and outcome of major surgery: a randomised trial [Patient-controlled analgesia versus epidural analgesia using bupivacaine or morphine following major abdominal surgery. No difference in postoperative morbidity]. Effects of two different anesthesia-analgesia methods on incidence of postoperative delirium in elderly patients undergoing major thoracic and abdominal surgery: study rationale and protocol for a multicenter randomized controlled trial [Postoperative analgesia: comparing continuous epidural catheter infusion of local anesthetic and opioid and continuous wound catheter infusion of local anesthetic]. Comparison of the modulatory effects of four different fast-track anesthetic techniques on the inflammatory response to cardiac surgery with cardiopulmonary bypass. A Randomized Study of Combined Spinal‐Epidural Analgesia versus Intravenous Meperidine during Labor: Impact on Cesarean Delivery Rate Prospective, randomized comparison of extrapleural versus epidural analgesia for postthoracotomy pain. A Direct Search Procedure to Optimize Combinations of Epidural Bupivacaine, Fentanyl, and Clonidine for Postoperative Analgesia Impact on postoperative pain of long‐lasting pre‐emptive epidural analgesia before total hip replacement: a prospective, randomised, double‐blind study What Concentration of Sufentanil Should be Combined with Ropivacaine 0.2% wt/vol for Postoperative Patient-Controlled Epidural Analgesia? Randomized Controlled Trial Comparing Traditional with Two “Mobile” Epidural Techniques: Anesthetic and Analgesic Efficacy Perioperative epidural analgesia and outcome after major abdominal surgery in high-risk patients. Epidural Anesthesia and Analgesia in High‐risk Surgical Patients Thoracic epidural analgesia or intravenous morphine analgesia after thoracoabdominal esophagectomy: a prospective follow-up of 201 patients. Thoracic Epidural versus Intravenous Patient-controlled Analgesia after Cardiac Surgery: A Randomized Controlled Trial on Length of Hospital Stay and Patient-perceived Quality of Recovery Labor pain relief using bupivacaine and sufentanil: patient controlled epidural analgesia versus intermittent injections. Postoperative analgesia for the surgical correction of congenital clubfoot: comparison between peripheral nerve block and caudal epidural block. Postoperative Analgesia with Intramuscular Morphine at Fixed Rate Versus Epidural Morphine or Sufentanil and Bupivacaine in Patients Undergoing Major Abdominal Surgery Programmed Intermittent Epidural Bolus Versus Continuous Epidural Infusion for Labor Analgesia: The Effects on Maternal Motor Function and Labor Outcome. A Randomized Double-Blind Study in Nulliparous Women Epidural versus Continuous Transversus Abdominis Plane Catheter Technique for Postoperative Analgesia after Abdominal Surgery General Anesthesia versus Epidural and General Anesthesia in Radical Cystectomy
Background Patient-controlled analgesia ( PCA ) with intravenous morphine and patient-controlled epidural analgesia ( PCEA ) , using an opioid either alone or in combination with a local anesthetic , are two major advances in the management of pain after major surgery . However , these techniques have been evaluated poorly in elderly people . This prospect i ve , r and omized study compared the effectiveness on postoperative pain and safety of PCEA and PCA after major abdominal surgery in the elderly patient . Methods Seventy patients older than 70 yr of age and undergoing major abdominal surgery were assigned r and omly to receive either combined epidural analgesia and general anesthesia followed by postoperative PCEA , using a mixture of 0.125 % bupivacaine and sufentanil ( PCEA group ) , or general anesthesia followed by PCA with intravenous morphine ( PCA group ) .  Pain intensity was tested three times daily using a visual analog scale . Postoperative evaluation included mental status , cardiorespiratory and gastrointestinal functions , and patient satisfaction scores . Results Pain relief was better at rest ( P = 0.001 ) and after coughing ( P = 0.002 ) in the PCEA group during the 5 postoperative days . Satisfaction scores were better in the PCEA group . Although incidence of delirium was comparable in the PCA and PCEA groups ( 24%vs . 26 % , respectively ) , mental status was improved on the fourth and fifth postoperative days in the PCEA group . The PCEA group recovered bowel function more quickly than did the PCA group . Cardiopulmonary complications were similar in the two groups . Conclusion After major abdominal surgery in the elderly patient , patient-controlled analgesia , regardless of the route ( epidural or parenteral ) , is effective . The epidural route using local anesthetics and an opioid provides better pain relief and improves mental status and bowel activity 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 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 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 Background Delirium is a common complication in elderly patients after surgery and associated with increased morbidity and mortality . Studies suggest that deep anesthesia and intense pain are important precipitating factors of postoperative delirium . Neuraxial block is frequently used in combination with general anesthesia for patients undergoing major thoracic and abdominal surgery . Compared with general anesthesia alone and postoperative intravenous analgesia , combined epidural-general anesthesia and postoperative epidural analgesia decreases the requirement of general anesthetics during surgery and provided better pain relief after surgery . However , whether combined epidural-general anesthesia plus epidural analgesia is superior to general anesthesia plus intravenous analgesia in decreasing the incidence of postoperative delirium remains unknown . Methods / design This is a multicenter , open-label , r and omized , parallel-controlled clinical trial . One thous and eight hundred elderly patients ( age range 60–90 years ) who are scheduled to undergo major thoracic or abdominal surgery are r and omized to receive either general anesthesia plus postoperative intravenous analgesia or combined epidural-general anesthesia plus postoperative epidural analgesia . The primary outcome is the 7-day incidence of postoperative delirium . Secondary outcomes include the duration of postoperative delirium , the intensity of pain during the first three days after surgery , the 30-day incidences of postoperative non-delirium complications , the length of stay in hospital after surgery and 30-day all-cause mortality . Discussion Results of the present study will provide information to guide clinical practice in choosing appropriate anesthesia-analgesia method for elderly patients undergoing major thoracic and abdominal surgery . Trial registration The study is registered on Clinical Trials.gov NCT01661907 and Chinese Clinical Trial Registry ChiCTR-TRC-12002371 BACKGROUND AND OBJECTIVES Continuous wound infusion has been investigated as a method of postoperative pain control and its efficacy has been demonstrated when compared to saline infusion . The objective of this study was to compare the quality of postoperative analgesia , the use of opioids as rescue analgesia , patient satisfaction , and the incidence of complications between epidural catheter infusion of local anesthetic and opioids and continuous wound infusion of local anesthetic . METHODS Thirty-eight patients undergoing elective laparotomy under general anesthesia , r and omly divided into two groups , participated in this study . Group I ( GI ) received postoperative patient-controlled epidural analgesia ( PCEA ) with continuous infusion of ropivacaine and fentanyl , while Group II ( GII ) receive postoperative patient-controlled continuous wound catheter infusion of ropivacaine . In the postoperative period , the following parameters were assessed : quality of analgesia through the Visual Analogue Scale ; use of rescue opioids ; and adverse effects driving patient satisfaction . RESULTS Decreased pain at rest and with movements ( p < 0.05 ) and lower consumption of rescue opioids ( p < 0.05 ) were observed in GI in all intervals evaluated , as well as greater patient satisfaction in the post anesthesia care unit ( PACU ) . The incidence of complications was similar in both groups except for pruritus which prevailed in GI between 6 ( p < 0.05 ) and 24 ( p < 0.001 ) postoperative hours . CONCLUSIONS Postoperative analgesia with opioids and local anesthetics via PCEA was superior to the patient-controlled local anesthetic infusion into surgical wound . The incidence of side effects was similar in both groups OBJECTIVES To test the hypothesis that the choice of anesthesia technique for coronary artery surgery influences the degree and magnitude of the subsequent inflammatory response and its consequences . DESIGN Prospect i ve , r and omized , comparative study . SETTING Major university teaching hospital . PARTICIPANTS Sixty patients undergoing elective surgery . INTERVENTIONS Patients were r and omized into an alfentanil group , a high-dose remifentanil group , a low-dose remifentanil group , or a thoracic epidural group , in combination with a propofol target-controlled infusion . The study was blinded for the opioid , except in the epidural group . Tight control of perioperative hemodynamic parameters was maintained , and the postoperative management was strictly st and ardized . Bactericidal permeability-increasing protein as an indicator of the polymorphonuclear neutrophil response , interleukin-6 as an inducer of the acute-phase response , and lipopolysaccharide-binding protein and C-reactive protein as parameters of the acute phase response were determined at regular intervals . Ventilator dependency and analgesia were evaluated as clinical outcome measures . MEASUREMENTS AND MAIN RESULTS Interleukin-6 levels increased in all groups . Plasma levels in the epidural group were significantly higher at all time points than in the other groups . The increase in the plasma levels of bactericidal permeability-increasing protein , lipopolysaccharide-binding protein , and C-reactive protein showed the same pattern in all groups , and no significant differences among the 4 groups were observed . CONCLUSIONS Supplementation of a fast-track anesthetic technique with epidural analgesia preserves hemodynamic stability and is associated with faster extubation times ( p = 0.003 ) and less postoperative pain ( p = 0.045 ) . Thoracic epidural analgesia was associated with significantly higher levels of IL-6 throughout the study period as compared with the total intravenous anesthesia groups . The exact clinical relevance of this finding remains unclear Background Combined spinal‐epidural ( CSE ) analgesia produces rapid‐onset pain relief and allows ambulation in early labor . Epidural local anesthetics may contribute to an increase in operative deliveries by decreasing perineal sensation and causing motor weakness . Operative delivery rates might be reduced with CSE , by avoiding or delaying administration of local anesthetics . This study compares the operative delivery rates associated with a CSE technique and those associated with intravenous meperidine for labor analgesia . Methods Healthy parturients at full term were assigned r and omly to receive CSE or intravenous meperidine analgesia . The CSE group received 10 [ micro sign]g intrathecal sufentanil , followed by epidural bupivacaine and fentanyl at their next request for analgesia . Parturients receiving intravenous meperidine had 50 mg on dem and ( maximum , 200 mg in 4 h ) . Labor and delivery outcomes in both groups were recorded and compared . Results An intent‐to‐treat analysis of 1,223 women indicated that CSE does not increase the rate of cesarean delivery for dystocia in nulliparous and parous women ( CSE , 3.5 % vs. intravenous meperidine , 4 ; P = not significant ) or in nulliparous women alone ( CSE , 7 % vs. intravenous meperidine , 8 % ; P = not significant ) . Profound fetal bradycardia that necessitated emergency cesarean delivery within 1 h of the time the mother received sufentanil occurred in 8 of 400 parturients ( compared with 0 of 352 who received meperidine ; P < 0.01 ) . However , the method of fetal monitoring differed between the two groups . Despite this , neonatal outcomes were similar overall . Conclusions Combined spinal‐epidural analgesia during labor does not increase the cesarean delivery rate for dystocia in healthy parturient patients at full term , regardless of parity . However , an unexpected increase in the number of cesarean deliveries for profound fetal bradycardia after intrathecal sufentanil was observed . Further investigation is warranted BACKGROUND Thoracic epidural analgesia is considered the method of choice for postthoracotomy analgesia , but it is not suitable for every patient and is associated with some risks and side effects . We therefore evaluated the effects of an extrapleural intercostal analgesia as an alternative to thoracic epidural analgesia . METHODS In a prospect i ve , r and omized study , pain control , recovery of ventilatory function , and pulmonary complications were analyzed in patients undergoing elective lobectomy or bilobectomy . Two groups of 15 patients each were compared : one received a continuous extrapleural intercostal nerve blockade ( T3 through T6 ) with bupivacaine through an indwelling catheter , the other was administered a combination of local anesthetics ( bupivacaine ) and opioid analgesics ( fentanyl ) through a thoracic epidural catheter . RESULTS Both techniques were safe and highly effective in terms of pain relief and recovery of postoperative pulmonary function . However , minor differences were observed that , together with practical benefits , would favor extrapleural intercostal analgesia . CONCLUSIONS These results led us to suggest that extrapleural intercostal analgesia might be a valuable alternative to thoracic epidural analgesia for pain control after thoracotomy and should particularly be considered in patients who do not qualify for thoracic epidural analgesia Background The authors applied an optimization model ( direct search ) to find the optimal combination of bupivacaine dose , fentanyl dose , clonidine dose , and infusion rate for continuous postoperative epidural analgesia . Methods One hundred ninety patients undergoing 48-h thoracic epidural analgesia after major abdominal surgery were studied . Combinations of the variables of bupivacaine dose , fentanyl dose , clonidine dose , and infusion rate were investigated to optimize the analgesic effect ( monitored by verbal descriptor pain score ) under restrictions dictated by the incidence and severity of side effects . Six combinations were empirically chosen and investigated . Then a stepwise optimization model was applied to determine subsequent combinations until no decrease in the pain score after three consecutive steps was obtained . Results Twenty combinations were analyzed . The optimization procedure led to a reduction in the incidence of side effects and in the mean pain scores . The three best combinations of bupivacaine dose ( mg/h ) , fentanyl dose ( & mgr;g/h ) , clonidine dose ( & mgr;g/h ) , and infusion rate ( ml/h ) were : 9 - 21 - 5 - 7 , 8 - 30 - 0 - 9 , and 13 - 25 - 0 - 9 , respectively . Conclusions Given the variables investigated , the aforementioned combinations may be the optimal ones to provide postoperative analgesia after major abdominal surgery . Using the direct search method , the enormous number of possible combinations of a therapeutic strategy can be reduced to a small number of potentially useful ones . This is accomplished using a scientific rather than an arbitrary procedure Clinical studies on pre‐emptive analgesia have produced inconsistent results . We conducted a clinical study investigating the effect of long‐lasting pre‐emptive epidural analgesia on consumption of analgesics and acute pain .  Forty‐two patients scheduled for elective hip replacement for osteo‐arthritis were r and omly assigned to receive , on the day before operation , either 5 ml.h−1 ropivacaine 0.2 % ( study group , n = 21 ) or 5 ml.h−1 saline ( control group , n = 21 ) . Postoperative analgesia was achieved in both groups by patient‐controlled epidural analgesia ( PCEA ) with ropivacaine 0.2 % . The main outcome measure was consumption of local anaesthetics . Additional parameters included visual analogue pain scale ( VAS ) scores , consumption of rescue analgesics , requests for PCEA boluses , and side‐effects . The pre‐operative parameters and pain scores were similar in the two groups . Epidural blocks provided sufficient operative analgesia in all patients . Pre‐emptive analgesia was continued for 11–20 h and led to significantly decreased pain scores before surgery . The consumption of local anaesthetics was decreased postoperatively in the study group ( 194 mg vs. 284 mg in the postoperative period ) . Furthermore , bolus requests occurred more frequently in the control group . VAS scores did not differ significantly between groups . Long‐lasting ‘ pre‐emptive ’ epidural analgesia decreases postoperative pain with improved pain control In this r and omized double-blinded study , we sought to determine an optimal dose-combination of sufentanil with ropivacaine 0.2 % wt/vol as postoperative epidural analgesics . One hundred twenty patients undergoing major abdominal surgery under general and thoracic epidural anesthesia ( T9 - 11 ) were assigned to groups receiving  patient-controlled epidural analgesia with ropivacaine 0.2 % wt/vol ( R ) , ropivacaine 0.2 % wt/vol + sufentanil 0.5 & mgr;g/mL ( R+S0.5 ) , 0.75 & mgr;g/mL ( R+S0.75 ) , 1.0 & mgr;g/mL ( R+S1 ) . A visual analog score of less than 40 was considered effective , and all side effects were recorded . In r and omized subgroups ( 10 patients per group ) , plasma pharmacokinetic data were obtained for both epidural drugs . Four patients in Group R and two in Group R+S0.5 were excluded because of inadequate analgesia . The drug infusion rates ( range of means : 5.4–5.9 mL/h ) were similar in all patients . Analgesia was superior for sufentanil 0.75 & mgr;g/mL with no further enhancement by the larger sufentanil concentration of 1 & mgr;g/mL.  Sufentanil plasma levels were within the range of the minimal effective concentrations ( highest in R+S1 ) , and there was no covariation between plasma levels and pain relief . Free ropivacaine plasma concentrations remained stable for 96 h. No severe side effects were detected , although pruritus correlated with an increasing dose of sufentanil . We conclude that the combination of ropivacaine 0.2 % wt/vol and 0.75 & mgr;g/mL sufentanil provided the best analgesia with the fewest side effects of the three combinations tested . Implication s : Sufentanil is added to epidural infusions of ropivacaine 0.2 % wt/vol to improve the effectiveness of postoperative pain management . Regarding the risk of side effects , however , it is still unclear what concentration of sufentanil should be added to the local anesthetic . For postoperative thoracic epidural analgesia after major abdominal surgery , the combination of ropivacaine 0.2 % wt/vol and 0.75 & mgr;g/mL sufentanil result ed in an appropriate cost : benefit ratio between good analgesia and side effects Background The authors recently showed that “ mobile ” epidural analgesia , using low-dose local anesthetic-opioid mixtures , reduces the impact of epidural analgesia on instrumental vaginal delivery , relative to a traditional technique . The main prespecified assessment of pain relief efficacy , women 's postpartum estimates of labor pain after epidural insertion , did not differ . The detailed analgesic efficacy and the anesthetic characteristics of the techniques are reported here . Methods A total of 1,054 nulliparous women were r and omized , in labor , to receive boluses of 10 ml 0.25 % bupivacaine ( traditional ) , combined spinal-epidural ( CSE ) analgesia , or low-dose infusion ( LDI ) , the latter groups utilizing 0.1 % bupivacaine with 2 & mgr;g/ml fentanyl .  Visual analog scale pain assessment s were collected throughout labor and delivery and 24 h later . Details of the conduct of epidural analgesia , drug utilization , and requirement for anesthesiologist reattendance were recorded . Results A total of 353 women were r and omized to receive traditional epidural analgesia , 351 received CSE , and 350 received LDI . CSE was associated with a more rapid onset of analgesia , lower median visual analog scale pain scores than traditional in the first hour after epidural insertion , and a significant reduction in bupivacaine dose given during labor . Pain scores reported by women receiving LDI were similar to those in the traditional group throughout labor and delivery . Anesthesiologist reattendance was low but greater with each mobile technique . Conclusions Relative to traditional epidural analgesia , LDI is at least as effective and CSE provided better pain relief in the early stages after insertion . The proven efficacy of mobile epidurals and their beneficial impact on delivery mode make them the preferred techniques for epidural pain relief in labor 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 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 OBJECTIVE Thoracoabdominal esophagectomy is a major surgical procedure that carries significant postoperative morbidity and mortality . Because the choice of analgesic technique may influence outcome , the impact of thoracic epidural or intravenous analgesia was investigated after esophagectomy . DESIGN Prospect i ve observational study during January 1996 until January 2002 . SETTING University hospital . PARTICIPANTS All patients undergoing thoracoabdominal esophagectomy during the 6-year period . INTERVENTIONS Patients were prospect ively monitored during a 6-year period . Duration of surgery , intraoperative blood loss , fluid administration , postoperative intubation time , intensive care unit ( ICU ) stay , pain relief and related side effects , postoperative complications , hospital stay , and in-hospital and long-term mortality were compared in relation with the analgesic technique . MEASUREMENTS AND MAIN RESULT Thoracic epidural analgesia with bupivacaine/morphine was used in 166 patients , and intravenous morphine analgesia was used in 35 patients .  Postoperative intubation time and ICU stay were similar in both groups . Patients with epidural analgesia experienced less pain . Sedation , respiratory depression , hallucinations , and confusion were more common in the intravenous morphine group . Postoperative weight did not differ between the groups , despite fluid replacement that was higher in the epidural group during the first 24 hours . The in-hospital mortality rate was 0.5 % . CONCLUSIONS No differences in morbidity/mortality rates depending on analgesic treatment were observed in patients undergoing thoracoabdominal esophagectomy . Thoracic epidural analgesia provided better pain relief with fewer opioid-related side effects than intravenous morphine analgesia . However , postoperative epidural analgesia was associated with more technical difficulties Background : Perioperative thoracic epidural analgesia reduces stress response and pain scores and may improve outcome after cardiac surgery . This prospect i ve , r and omized trial was design ed to compare the effectiveness of patient-controlled thoracic epidural analgesia with patient-controlled analgesia with intravenous morphine on postoperative hospital length of stay and patients ’ perception of their quality of recovery after cardiac surgery . Methods : One hundred thirteen patients undergoing elective cardiac surgery were r and omly assigned to receive either combined thoracic epidural analgesia and general anesthesia followed by patient-controlled thoracic epidural analgesia or general anesthesia followed by to patient-controlled analgesia with intravenous morphine .  Postoperative length of stay , time to eligibility for hospital discharge , pain and sedation scores , degree of ambulation , lung volumes , and organ morbidities were evaluated . A vali date d quality of recovery score was used to measure postoperative health status . Results : Length of stay and time to eligibility for hospital discharge were similar between the groups . Study groups differed neither in postoperative global quality of recovery score nor in five dimensions of quality of recovery score . Time to extubation was shorter ( P < 0.001 ) and consumption of anesthetics was lower in the patient-controlled thoracic epidural analgesia group . Pain relief , degree of sedation , ambulation , and lung volumes were similar between the study groups . There was a trend for lower incidences of pneumonia ( P = 0.085 ) and confusion ( P = 0.10 ) in the patient-controlled thoracic epidural analgesia group , whereas cardiac , renal , and neurologic outcomes were similar between the groups . Conclusions : In elective cardiac surgery , thoracic epidural analgesia combined with general anesthesia followed by patient-controlled thoracic epidural analgesia offers no major advantage with respect to hospital length of stay , quality of recovery , or morbidity when compared with general anesthesia alone followed by to patient-controlled analgesia with intravenous morphine OBJECTIVES To determine whether the use of patient-controlled epidural analgesia ( PCEA ) versus intermittent injections ( CIT ) result ed in local anesthetic dose reduction . STUDY DESIGN PCEA and CIT using a mixture of 0.125 % bupivacaine with sufentanil 1 or 0.75 microgram/ml were compared in 60 and 195 parturients , respectively . Assessment s included pain scores , local anesthetic consumption , degree of motor blockade , type of delivery and neonatal outcome . Statistical analysis was done using Student 's t test and Chi-squares . RESULTS PCEA and CIT provided effective analgesia during labor and delivery . A higher dose of opioid significantly reduced the use of local anesthetic solution in PCEA- patients . There was no difference in motor blockade , type of delivery and neonatal outcome . CONCLUSION Patient-controlled epidural analgesia is an effective , safe and acceptable alternative to conventional intermittent epidural injections for pain relief during labor and delivery BACKGROUND AND OBJECTIVES Correction of congenital clubfoot ( CCF ) is associated with severe postoperative pain .  Caudal epidural block associated with general anesthesia is the anesthetic technique used more often in children , but it is limited by the short duration of the postoperative analgesia . Peripheral nerve blocks are associated with a low incidence of complications and prolonged analgesia . The objective of this study was to compare the duration of analgesia in peripheral nerve blocks and caudal block , as well as morphine consumption in the first 24 hours after correction of CCF in children . METHODS This is a r and omized , double-blind study with children undergoing surgeries for posteromedial release of CCF , who were divided in four groups according to the anesthetic technique : caudal ( ACa ) , sciatic and femoral block ( IF ) , sciatic and saphenous block ( IS ) , and sciatic block and local anesthesia ( IL ) , associated with general anesthesia . In the first 24 hours , patients received oral dypirone and acetaminophen , and they were evaluated by anesthesiologists who were unaware of the technique used . Oral morphine ( 0.19 mg x kg(1 ) per day ) was administered according to the scores of the CHIPPS ( Children 's and infants ' postoperative pain scale ) scale . RESULTS One hundred and eighteen children separated into four groups : ACa ( 30 ) , IF ( 32 ) , IS ( 28 ) , and IL ( 28 ) participated in this study . The mean time between the blockade and the first dose of morphine  was 6.16 hours in group ACa , 7.05 hours in group IF , 7.58 in IS , and 8.18 hours in IL .  Morphine consumption was 0.3 mg.kg-1 per day in all four groups . Significant differences were not observed among the groups . CONCLUSIONS peripheral nerve blocks did not promote longer lasting analgesia or a decrease in morphine consumption in the first 24 hours in children undergoing CCF correction when compared to caudal epidural block 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 BACKGROUND : Programmed intermittent epidural anesthetic bolus ( PIEB ) technique may result in reduced total local anesthetic consumption , fewer manual boluses , and greater patient satisfaction compared with continuous epidural infusion ( CEI ) . In this r and omized , double-blind study , we compared the incidence of motor block and labor outcome in women who received PIEB or CEI for maintenance of labor analgesia . The primary outcome variable was maternal motor function and the secondary outcome was mode of delivery . METHODS : Nulliparous , term women with spontaneous labor and cervical dilation < 4 cm were eligible to participate in the study . Epidural analgesia was initiated and maintained with a solution of levobupivacaine 0.0625 % with sufentanil 0.5 & mgr;g/mL. After an initial epidural loading dose of 20 mL , patients were r and omly assigned to receive PIEB ( 10 mL every hour beginning 60 minutes after the initial dose ) or CEI ( 10 mL/h , beginning immediately after the initial dose ) for the maintenance of analgesia . Patient-controlled epidural analgesia ( PCEA ) using a second infusion pump with levobupivacaine 0.125 % was used to treat breakthrough pain . The degree of motor block was assessed in both lower extremities using the modified Bromage score at regular intervals throughout labor ; the end point was any motor block in either limb . We also evaluated PCEA bolus doses and total analgesic solution consumption . RESULTS : We studied 145 subjects ( PIEB = 75 ; CEI = 70 ) .  Motor block was reported in 37 % in the CEI group and in 2.7 % in the PIEB group ( P < 0.001 ; odds ratio = 21.2 ; 95 % CI : 4.9–129.3 ) ; it occurred earlier ( P = 0.008 ) ( hazard ratio = 7.8 ; 95 % CI : 1.9–30.8 ; P = 0.003 ) and was more frequent at full cervical dilation in the CEI group ( P < 0.001 ) . The incidence of instrumental delivery was 20 % for the CEI group and 7 % for the PIEB group ( P = 0.03 ) . Total levobupivacaine consumption , number of patients requiring additional PCEA boluses , and mean number of PCEA boluses per patient were lower in the PIEB group ( P < 0.001 ) . No differences in pain scores and duration of labor analgesia were observed . CONCLUSIONS : Maintenance of epidural analgesia with PIEB compared with CEI result ed in a lower incidence of maternal motor block and instrumental vaginal delivery Transversus abdominis plane block is an effective postoperative analgesic technique after abdominal surgery , but no study has compared continuous transversus abdominis plane block with continuous epidural analgesia . We design ed a r and omised controlled trial comparing these techniques for major abdominal surgery . Patients in the epidural group received a bolus of 8 to 15 ml of ropivacaine 0.2 % and an infusion of 5 to 15 ml/hour and the transversus abdominis plane block group a bolus dose of 20 ml of ropivacaine 0.375 % bilaterally and an infusion of 0.2 % ropivacaine 8 ml/hour bilaterally , for three days . Both groups received paracetamol and patient controlled analgesia with fentanyl for three days . Primary outcomes were numerical rating scores for pain ( rest and dynamic over 72 hours ) and total fentanyl use ; complications and satisfaction scores were also noted . The study was terminated early after 42 patients had been r and omised ( epidural n=19 ; transversus abdominis plane block n=22 ; one excluded ) . No differences were found in regards to point pain scores or scores over time , either immediately postoperatively or in surgical wards ; total fentanyl requirement and Likert satisfaction scores were also similar in both groups . In this underpowered study we found comparable results between continuous transversus abdominis plane technique and epidural analgesia in regard to pain , analgesic use and satisfaction after abdominal surgery . To confirm this finding , r and omised trials with larger numbers of participants are needed Introduction : The aim of this study is to compare two different anesthetic techniques in radical cystectomy with regard to blood loss , transfusional requirements , intraoperative complications and the quality of analgesia . Material s and Methods : 50 patients scheduled for radical cystectomy were r and omized to two groups : group GA – general anesthesia , n = 25 and group CEGA – combined epidural and general anesthesia . The patients were monitored and hemodynamic changes , intraoperative bleeding , transfusional requirements , quality of analgesia and postoperative complications were evaluated . Results : There were no significant differences between the demographic characteristics of the two groups . Intraoperative bleeding which was 874.8 ± 190.7 ml in the CEGA group and 1,248.3 ± 343.4 ml in the GA group was statistically different ( p < 0.05 ) . Significantly more intraoperative blood transfusions in terms of units were required in the GA group . Analgesia was better in the CEGA group , with VAS values at 0 , 1 , 2 , 4 , 6 , 12 and 24 h significantly ( p < 0.05 ) lower than those observed in the GA group . No significant differences in intraoperative hemodynamic parameters or postoperative complications were noted between the two groups . Conclusions : Statistically significant differences in intraoperative bleeding were observed between the two groups : CEGA provides lower intraoperative bleeding and a better postoperative analgesia . Major operations such as radical cystectomy , which also is associated with considerable blood loss , a combination of general and epidural anesthesia may allow for less blood loss , with a better postoperative analgesia and without any increase in complications
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 : 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 .