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 .
Perioperative myocardial ischemic injury in high-risk vascular surgery patients: incidence and clinical significance in a prospective clinical trial.
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
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 .