The document attached has been archived with permission from the editor of the Medical Journal of Australia. An external link to the publisher’s copy is included.Paul S Myles, Ian Power and Konrad Jamrozi

Jamrozik, Konrad

Myles, Paul S.

Power, Ian

The Medical Journal of Australia

Adelaide Research &amp; Scholarship

 PUBLISHED VERSION    Myles, Paul S.; Power, Ian; Jamrozik, Konrad  Epidural block and outcome after major surgery Medical Journal of Australia, 2002; 177(10):536-537  This article is available from the Medical Journal of Australia at: https://www.mja.com.au/journal/2002/177/10/epidural-block-and-outcome-after-major-surgery                          http://hdl.handle.net/2440/47218   PERMISSIONS   This document has been archived with permission from the editor of the Medical Journal of Australia, 26 April 2007.    536 MJA Vol 177 18 November 2002EDITORIALSlook for the characteristic sign of optic disc cupping. EveryGP should view a patient’s optic disc with an ophthalmo-scope from time to time, especially if one or more riskfactors are present. Anyone with significant optic disccupping, or asymmetry between the optic discs of the twoeyes, should be referred for investigation.Ivan GoldbergOphthalmologistSydney Eye HospitalStuart L GrahamOphthalmologist, Sydney Eye Hospital, University of Sydney, andSave Sight Institute, Sydney, NSWPaul R HealeyDirector of Glaucoma Research, Department of OphthalmologyCentre for Vision Research, Millennium Institute, Westmead, NSW1. Mitchell P, Smith W, Attebo K, Healey PR. Prevalence of open-angle glaucoma inAustralia: the Blue Mountains Eye Study. Ophthalmology 1996; 103: 1661-1669.2. Rochtchina E, Mitchell P. Projected number of Australians with glaucoma in 2000and 2030. Clin Exp Ophthalmol 2000; 28: 146-148.3. Attebo K, Mitchell P, Smith W. Visual acuity and the causes of visual loss inAustralia: the Blue Mountains Eye Study. Ophthalmology 1996; 103: 357-364.4. Mitchell P, Cumming RG, Mackey D. Inhaled corticosteroids, family history andrisk of glaucoma. Ophthalmology 1999; 106: 2301-2306.5. Mitchell P, Smith W, Chey T. Open-angle glaucoma and diabetes: the BlueMountains Eye Study. Ophthalmology 1997; 104: 712-718.6. Foran S, Wang JJ, Mitchell P. Causes of incident visual impairment: the BlueMountains Eye Study. Arch Ophthalmol 2002; 120: 613-619.7. Kass MA, Heuer DK, Higginbotham EJ, et al. The Ocular Hypertension TreatmentStudy. Arch Ophthalmol 2002; 120: 701-713.8. The AGIS Investigators. The Advanced Glaucoma Intervention Study (AGIS), 7:the relationship between control of intraocular pressure and visual field deteriora-tion. Am J Ophthalmol 2000; 130: 429-440.9. Goldberg I, Graham SL, Klistorner AI. Multifocal objective perimetry (MOP) in thedetection of glaucomatous field loss. Am J Ophthalmol 2002; 133: 29-39. ❏Epidural block and outcome after major surgeryPatients at increased risk of postoperative respiratory complications may benefitPATIENTS UNDERGOING SURGERY need good advice notonly about whether a particular elective procedure is trulynecessary and likely to be of benefit, but also about thenature and chances of an adverse outcome from the surgeryitself. Those with heart failure, coronary artery disease,diabetes or emphysema are more likely to suffer seriouscomplications or death after major surgery. Epidural anaes-thesia and analgesia may be a preferable technique in suchpatients,1 as epidural block can attenuate the neurohumoralstress response to surgery,2 potentially improving postopera-tive cardiorespiratory function and reducing complications.Many small randomised controlled trials (RCTs) havesupported this conjecture, but, because most serious com-plications after anaesthesia and surgery are rare, none hashad sufficient power to demonstrate whether epidural blocksignificantly improves postoperative outcome. A solution tothis problem is to combine the results of all available trials ina meta-analysis. Applying this approach to data from 141RCTs involving 9559 patients, Rodgers et al showed thatthe use of epidural or spinal block (with or without generalanaesthesia) resulted in a significant 30% reduction inmortality after surgery.3 Outcomes causing major morbidity(major morbidity endpoints) such as thromboembolism andpneumonia were also reduced. Another recent systematicreview found that epidural block reduces postoperativemyocardial infarction.4 Although these findings are support-ive, they were based exclusively on small RCTs, and meta-analyses sometimes give conflicting results when comparedwith large RCTs.5In 1984, Yusuf et al explained how large, simple ran-domised trials can reliably detect moderate effects on impor-tant but uncommon outcomes such as death or majormorbidity after surgery.6 Two of us are part of an Australiangroup that has recently published the results of a largemulticentre RCT of epidural block in 888 high-risk patientsundergoing major abdominal surgery (the MASTER trial).7Patients were randomly allocated to receive general anaes-thesia with or without epidural block. The epidural blockwas established before the commencement of surgery (epi-dural anaesthesia) and epidural analgesia was continued forthree days after surgery. All other care was left to thediscretion of the anaesthetist and surgical team: mostpatients were managed in general surgical wards aftersurgery, although some required high-dependency or inten-sive care. Thus, our trial was a test of effectiveness in routinepractice and its results can be generalised.There was no significant difference in mortality at 30 daysor in overall morbidity — 57% of epidural and 61% ofcontrol group patients had at least one morbidity endpoint(sepsis, respiratory failure, myocardial infarction, heart fail-ure, renal failure, gastrointestinal [bleeding or need forparenteral nutrition], hepatitis, or haematological [anaemia,leukopenia, or thrombocytopenia]) or died (P = 0.30).Mortality at 30 days was low in both groups (epidural,5.1%; control, 4.3%). Of the eight morbidity endpointsstudied, only one, respiratory failure, occurred less fre-quently in patients managed with epidural block (epidural,23%; control, 30%; P = 0.03). Another large RCT pub-lished recently showed similar results.8 Thus, there is noevidence that epidural block improves outcome in mostpatients undergoing major abdominal surgery with generalanaesthesia, other than for respiratory complications.Nevertheless, in the MASTER trial, pain scores over thefirst three days after surgery were significantly lower in theepidural group. This difference occurred despite most par-ticipants in the control group receiving multimodal analge-sia.1 This demonstrates some benefit from epidural block: areduction in pain may assist deep breathing and coughingMJA Vol 177 18 November 2002 537EDITORIALSafter surgery, and this may help prevent atelectasis andpneumonia. The MASTER trial, and other recent data,3,8provide some evidence to support this conjecture.What are the risks of epidural block? One should take intoaccount the risk of an epidural haematoma when an epiduralor spinal needle is placed, particularly in a patient receivinganticoagulation therapy (eg, perioperative thromboprophy-laxis). The risk of epidural haematoma or abscess is verylow, with estimates varying widely from about 1 : 1700 to1 : 200 000.9,10 Concern regarding damage to the spinalcord (leading to paraplegia) or nerves must be weighed upagainst the benefits of improved postoperative analgesia.Evidence-based practice is dependent on good qualityresearch, and the best evidence comes from large trials.6The MASTER trial provides reliable information for doc-tors and their patients on which to base their decisionsregarding the best methods of anaesthesia and analgesiaafter surgery. Epidural block seems to provide additionalbenefit for patients at increased risk of postoperative respira-tory complications. When considering use of epidural block,doctors and patients also need to weigh up the benefits ofimproved pain relief against the (rare) risk of paraplegia andother nerve injury. Our experience has been that somepatients will choose postoperative epidural analgesia afterbeing given this information.Paul S MylesHead of Research, and Associate Professor, Department of AnaesthesiaAlfred Hospital, and Monash University, Melbourne, VICIan PowerProfessor, Department of Anaesthesia, Critical Care and Pain MedicineThe University of Edinburgh, ScotlandKonrad JamrozikProfessor of Primary Care EpidemiologyImperial College Faculty of Medicine, London, UK, and Visiting ProfessorDepartment of Public Health, University of Western Australiap.myles@alfred.org.au1. National Health and Medical Research Council. Acute pain management:scientific evidence. Canberra: NHMRC, 1998.2. Liu S, Carpenter RL, Neal JM. Epidural anesthesia and analgesia. Their role inpostoperative outcome. Anesthesiology 1995; 82: 1474-1506.3. Rodgers A, Walker N, Schug S, et al. Reduction of post-operative mortality andmorbidity with epidural or spinal anaesthesia: results from overview of ran-domised trials. BMJ 2000; 321: 1493-1497.4. Beattie WS, Badner NH, Choi P. Epidural analgesia reduces postoperativemyocardial infarction: a meta-analysis. Anesth Analg 2001; 93: 853-858.5. LeLoerier J, Gregoire G, Benhaddad A, et al. Discrepancies between meta-analyses and subsequent large randomized, controlled trials. N Engl J Med1997; 337: 536-542.6. Yusuf S, Collins R, Peto R. Why do we need some large, simple randomizedtrials? Stat Med 1984; 3: 409-420.7. Rigg JRA, Jamrozik K, Myles PS, et al and the MASTER Anaesthesia Trial StudyGroup. Epidural anaesthesia and analgesia and outcome of major surgery: arandomised trial. Lancet 2002; 359: 1276-1282.8. Park WY, Thompson J, Lee KK. Effect of epidural anesthesia and analgesia onperioperative outcome. A randomised controlled Veterans’ Administration study.Ann Surg 2001; 234: 560-571.9. Wang LP, Hauerberg J, Schmidt JF. Incidence of spinal epidural abscess afterepidural analgesia: a national 1-year survey. Anesthesiology 1999; 91: 1928-1936.10. Horlocker TT. Complications of spinal and epidural anesthesia. Anesthesiol ClinNorth Am 2000; 18: 461-485. ❏

Epidural block and outcome after major surgery

Myles, PS

Power, I

Jamrozik, K

University of Queensland eSpace

https://digital.library.adelaide.edu.au/dspace/bitstream/2440/47218/1/hdl_47218.pdf

Epidural block and outcome after major surgery

Abstract

Similar works

Full text

Available Versions

Adelaide Research & Scholarship

University of Queensland eSpace

Epidural block and outcome after major surgery

Abstract

Similar works

Full text

Available Versions

Adelaide Research &amp; Scholarship

University of Queensland eSpace

Adelaide Research & Scholarship