Вы находитесь на странице: 1из 4

Benefits, Risks and Complications of Perioperative Use of Epidural Anesthesia

DOI: 10.5455/medarh.2012.66.340-343
Med Arh. 2012 Oct; 66(5): 340-343
Received: May 18th 2012
Accepted: July 25th 2012


Benefits, Risks and Complications

of Perioperative Use of Epidural
Dragana Unic-Stojanovic1, Srdjan Babic2, Miomir Jovic1,3
Department of anesthesiology and intensive care, Dedinje Cardiovascular Institute, Belgrade, Serbia1
Department of vascular surgery, Dedinje Cardiovascular Institute, Belgrade, Serbia2
Faculty of Medicine, University of Belgrade, Serbia3

se of thoracic epidurals is widespread for intraoperative and postoperative

analgesia. Thoracic epidural anaesthesia (TEA) reduces sympathetic activity
and thereby influences perioperative function of vital organ systems. A results
of recent studies suggest that TEA decreases postoperative morbidity and mortality. There is better pain control with TEA in a wide range of surgical procedures.
Use of TEA is associated with the risk of harm, but also the other methods used to
control perioperative pain and stress response carry specific risks. Timely diagnosis
and treatment of spinal compression or infection are crucial to ensure patient safety
with TEA. The benefits of TEA outweigh the risks with respect to the perioperative
outcome and organ protection, if basic guidelines are followed. Key words: epidural
anesthesia, epidural analgesia, outcomes, complications.
Corespoding author: Dragana Unic-Stojanovic, MD. Cardiovascular Institute, Heroja Milana Tepica 1
street, 11000 Belgrade, Serbia, e-mail: dunic@yubc.net; Phone No: +381648431103


Epidural anesthesia/analgesia is commonly used as a analgesic technique for

major surgery. Most currently published
studies lack definitive answers to the
question, Does intraoperative use of epidural anesthesia improve outcome?, although more and more published papers
indicates a benefits of thoracic epidural
anesthesia and analgesia on the cardiac,
respiratory, and immune systems as well
as on the surgical stress response.
This review aims to outline benefits
and risks of epidural anesthesia with respect to the perioperative pathophysiology, outcome and organ protection, citing
the latest findings from published reports.


Cardiovascular causes account
for 63% of perioperative mortality in
a high-risk patient population and for
30% of perioperative mortality in lowrisk patients (1). Thoracic epidural anesthesia (TEA) with local anesthetics can
produce a selective segmental blockade
of the cardiac sympathetic innervations
(T1-T5)(2) and reduce the major determinants of myocardial oxygen demand,
such as blood pressure, heart rate, and
contractility (3). It improves the balance
between cardiac supply and demand (3).
By blocking sympathetically mediated
coronary constriction, endocardial to
epicardial blood flow ratio is improved,

Med Arh. 2012 Oct; 66(5): 340-343 review

thus optimizing the regional distribution of myocardial blood flow. Blood flow
to ischemic regions of myocardium, with
TEA, may increase (4, 5, 6). Compared
with TEA, lumbar epidural anesthesia
with local anesthetics does not provide
the same physiologic benefits (7, 8, 9).
The meta-analysis by Popping et al.
(10) in abdominal and thoracic procedures showed a significant reduction
in myocardial infarction (MI) with
primarily TEA. Similar, the VACS trial
(n=1021) shown that the abdominal aortic surgery subgroup (n=374) had significantly lower incidences of cardiovascular complications (9.8 vs 17.9%,
p=0.03) primarily due to reduction in
IM (2.7 vs 7.9%, p=0.05) (11). The beneficial effects of TEA on cardiac morbidity
in high risk patients (like aortic reconstructions) may require several days of
postoperative epidural analgesia (3, 12).
The maximum cardiac benefits are
seen with continuing postoperative thoracic epidural analgesia for 48-72 hours.
In addition, Beattie at al. (13) reported
a 4-fold reduction in the incidence of
postoperative congestive heart failure,
MI and death in patients treated with
24-h postoperative epidural analgesia
compared to systemic analgesia.

Benefits, Risks and Complications of Perioperative Use of Epidural Anesthesia

The pathophysiology of postoperative pulmonary complications after
surgery is multifactorial and includes
disruption of normal respiratory muscle activity from either surgery or anesthesia, a reflex inhibition of phrenic
nerve activity with subsequent decrease
in diaphragmatic function, and uncontrolled postoperative pain (14). The improvements of pulmonary function related to epidural anesthesia/analgesia
(EAA) may be result of: (1) blocking of
reflexes inhibiting diaphragmatic function demonstrable after abdominal and
thoracic surgery, with a beneficial effect
on pulmonary mechanics (15); (2) effective pain relief allowing the patient to
take deep breaths, cough and cooperate
with physiotherapy (15, 16); (3) avoidance of high-dose systemic opioids that
reduces respiratory depression; and (4)
reduction of the stress response to surgery with reducing the level of postoperative immunosuppression, which may
contribute to decreasing in pulmonary
infection (17, 18).
Well-conducted studies have found
no significant correlation between postoperative pulmonary function tests
(PFTs) and the incidence of pulmonary
complications (19, 20). But, recent study
reported a benefit of postoperative PFTs
(FVC and FEV1) on postoperative days
1 and 4, in chronic obstructive pulmonary disease (COPD) patients operated
under combined general and epidural
anesthesia and postoperative epidural
analgesia compared with COPD patients with general anesthesia and intravenous analgesia 820). However, there is
not improved overall clinical outcome,
probably owing to the small number of
patients included in the study (20).
There is significant reduction in
the incidence of pulmonary infection
(7,10,21,22), respiratory failure (16), reintubation (11), prolonged ventilation
(23) and prolonged ICU stays (11) with
TEA in patients undergoing abdominal or thoracic surgery (7,10,21). The
strongest preventive effect was seen
in patients with the most severe type
of COPD (22). However, other studies
have failed to demonstrate a beneficial
effect of EA on postoperative pneumonia, probably of a small number of patient involved in analysis (24).

Although postoperative pain management is enhanced by the use of epidural anesthesia, the use of EA in patients with COPD has been controversial because of ongoing fears that it may
acutely reduce lung function. For example, the use of high thoracic epidurals has been associated with decreased
spirometric values by possibly blocking
intercostal muscle innervation (25, 22).
However, several studies have failed to
show any deleterious respiratory effects
from EA (25, 26).


A combination of indirect and direct mechanisms for regional anesthesia effects on blood coagulation are responsible for the antithrombotic effects
of regional block. Epidural analgesia attenuates the hypercoagulable response
to surgery and improves fibrinolytic
function by attenuating the stress response. Tuman et al. (27) reported a
significant reduction in vascular graft
occlusion with use of EA (p<0.007). In
addition, they found that general anesthesia patients are hypercoagulable,
whereas the epidural group maintain
normal coagulation. TEA has a less significant effect on lower extremity and
deep pelvis blood flow; analysis that included 5 randomized trials in patients
undergoing abdominal surgery, found
no significantly reduction of thromboembolic complications of 22.4% to
15.7% (28). TEA provides benefits on
coagulation by improved venous blood
flow, attenuation of the sympathetic
response to surgery, the anticoagulant
properties of local anesthetics, early
mobility, and lowering of mean arterial pressure MAP (3). Epidural anesthesia prevents perioperative venous
stasis (29). Cochrane meta-analysis
from Parker and al. (30) reported significantly reduced incidence of perioperative venous thrombosis with the use
of epidural anesthesia.
Animal studies demonstrate that
TEA can cause effective sympathetic
block with reductions in inflammation.
Liver perfusion and hepatic inflammatory response might be influenced by
TEA independently from cardiac output (31,32). Despite an attenuated inflammatory response in those cases

with epidural anesthesia, there is no improved outcome variables.

Postoperative ileus is very common
after abdominal surgery (>90% in many
series) and may increase resource utilization by prolonging hospital stay (33).
TEA causes sympatholysis, depression of postoperative reflex inhibition
of gastrointestinal motility, reduced
the inflammatory response and opioid
consumption and superior pain therapy,
that contribute to reduced duration of
postoperative ileus (23) and improved
microcirculation with subsequent improved bowel function (34, 35, 36). Recovery of postoperative ileus occurs
earlier when epidural local anesthetic
is used alone compared with the use of
a combination of epidural opioid and
local anesthetic.
TEA exerts beneficial effects on intestinal perfusion as long as its hemodynamic consequences are adequately
controlled (37). However, TEA may deteriorate intestinal perfusion in case of
substantial deterioration in systemic
hemodynamics (38, 39). The use of
small doses of norepinephrine to maintain systemic perfusion pressure has
been shown not to compromise intestinal perfusion in experimental abdominal surgery (40).

TEA attenuates postoperative nitrogen excretion, amino acid oxidation,
and decreased muscle protein synthesis while minimizing whole body protein catabolism. Muscle mass may be
spared (41).


The intraoperative use of epidural

local anesthetics for abdominal aortic
surgery have several advantages: (1) a
reduced need for intraoperative inhalational and intravenous (opioid) anesthetics, which allows early extubation
of the trachea; (2) reduced requirements
for vasodilating agents before and during cross-clamping of the aorta; and (3)
excellent postoperative analgesia, which
allows for earlier recovery of pulmonary

Received: May 18th 2012 review


Benefits, Risks and Complications of Perioperative Use of Epidural Anesthesia

Potential/Probable Benefits of Epidural

Reduced myocardial infarction
Reduced congestive heart failure
Reduced blood loss
Reduction in transfusion requirements
Reduced deep venous thrombosis
Reduced pulmonary infection
Lower incidence of respiratory failure
Reduced pulmonary embolism
Reduced respiratory depression
Reduced hypoxemia
Reduced intubation time
Reduced ileus
Surgical outcomes
Reduced length of stay
Reduced 30-day mortality

Table 1. Potential/Probable Benefits of Epidural


and gastrointestinal functions (42). Disadvantages include the close attention to

intravascular volume status that is necessary during unclamping of the aorta (42).

Some analyses showed the superior analgesic effects of TEA that may
lead to increased patient satisfaction
(77), reduced intensive care unit stay,
and better health-related quality of life
(78,50,62). Epidural analgesia provides
superior analgesia at rest and with activity compared with opioid-based analgesia (including intravenous patientcontrolled analgesia [IV PCA]), for all
types of surgery through postoperative
day 4 (16, 23, 42-46). Greater improvements were noted when the regimen included local anesthetics and when level
of epidural catheter matched site of surgery (e.g., catheter for thoracic surgery).


There is modest evidence for reduction of mortality with epidural analgesia. Analysis of clinical registries indicate modest association between epidural
analgesia and reduced mortality (45). It
is needed to known, although these registry have huge number of patients, that
data from registry suffer from methodological issues such the as accuracy of
defining complications and retrospective
nature. There is a data about no significantly lower mortality in patients who
received postoperative epidural analgesia during lower-risk procedures (e.g.,
total knee replacement, hysterectomy)

or in patients with lower comorbidity

indices (15). Procedure specific metaanalyses and individual RCTs have not
noted an effect from epidural analgesia but lack sufficient sample size due
to the relatively low incidence of mortality (0,2-5%) (11, 13, 16). The biggest
prospective trial of the outcome effects, the Multicentre Australian Study
of Epidural Anesthesia (MASTER) trial
(16) randomized 915 high risk patients
to combined general/epidural anesthesia followed by 72 hours of postoperative epidural analgesia (low thoracic or
high lumbar placement) with local anesthetic and opioids vs general anesthesia followed by systemic opioid treatment and undergoing mixed abdominal
surgical procedures) showed that overall mortality rates were similar between
groups (5.1 vs 4.3%). However, the trial
was underpowered to shown the moderate outcome effect of TEA, and interpretation of the results maybe compromised (46).

Potential complications of EAA may
decrease the acceptance and enthusiasm for these techniques. Complications may be directly related to the performance of the technique or may result
from poor management of the block.
Neurovascular injury during catheter
placement and local anesthetic/analgesic reactions are uncommon. Sympatholysis leads to hypotension and bradycardia, as important 2 potential hemodynamic events of EAA. A prospective
multicenter randomized trial shown
that the incidence of hypotension is
41% after epidural combined with general anesthesia, and 23% after use of
general anesthesia alone (p=0.049) (21).
There are no significant differences in
heart rate or episodes of bradycardia
(21). In order to maintain stable hemodynamics, EAA is associated with excessive fluid administration. However,
the incidence of complications associated with excess fluid administration,
cardiac, pulmonary, and/or hemodilution are actually reduced with EAA (21).
Adverse effects related to medications
used in TEA include nausea, vomiting,
pruritus, hypotension, urinary retention, sedation, and respiratory depression. Reports of dysesthesia, paresthe-

Received: May 18th 2012 review

sias, weakness, and local anesthetic toxicity are rare (47). Systemic absorption
of local anesthetics at high doses can
produce seizures, loss of airway protective reflexes, respiratory depression,
coma and cardiac arrhythmias with hemodynamic instability (48,49). Catheter
complications result from inadvertent
penetration of the dural space, damage
to neurovascular structures, or infection. Accidental dural puncture during
needle insertion occurred 0.161.3%
and subsequent postdural headaches
developed in 1686% of these patients
(50). Meningitis and epidural abscess
are rare complications (3 cases of meningitis and no epidural abscess in a series that included 65000 epidural cases
(51, 47). Factors likely influencing infection may include perioperative antibiotic use and duration of TEA use. The
risk of infection appears to increase after the second day of epidural catheterization, and a longer duration of use has
an incidence of local infection that approaches that of intravascular devices
(47). Paraplegia, the most feared complication of epidural anesthesia, is usually the result of an epidural hematoma
during catheter placement or removal
(52). Rarely, a spinal abscess or anterior spinal artery syndrome will cause


The incidence of epidural hematoma formation was estimated to be
less than 1 in 150 000 in one study and
found to be none in a second series of
100 000 (14,53). Injury to the spinal vasculature during catheter placement occurs in approximately 312% of cases,
yet this rarely results in symptomatic
epidural hematomas. Symptomatic
epidural hematomas are usually associated with anticoagulation, catheter
placement/removal during anticoagulation, and/or trauma during catheter placement. There are a number of
case reports of spontaneous spinal hematomas during dual antiplatelet therapy without any anesthetic manipulation (54, 55, 56). Additionally, spontaneous spinal hematomas have been described both with clopidogrel and acetylsalicylic acid alone (57). A review of
61 cases of symptomatic epidural hematomas found that 41 (68%) patients

Benefits, Risks and Complications of Perioperative Use of Epidural Anesthesia

had coagulation defects (58). This association has led to one of the most controversial issues surrounding EAA: the
use of anticoagulation and risk of epidural hematoma formation (3) TEA in
patients receiving an anticoagulant,
antiplatelet, or fibrinolytic drug needs
to be performed with caution. In 2010,
the European guidelines on the use of
neuraxial blockade in anticoagulated
patients were updated and now cover
most recently introduced antiplatelet
and anticoagulant drugs (59). In patients with organ dysfunction, for example, renal insufficiency, adapted risk
evaluation and careful patient selection
are warranted (37, 59). Prophylactic anticoagulation can be started the evening
after surgery in aim to ensure the maximal safety of TEA (59,60). The withdrawal of antiplatelet drugs leads to rebound effects with an increased rate of
thromboembolic events (61, 62). Consequently, a consensus has been reached
to continue antiplatelet medication in
almost all surgical cases other than in
emergency intracranial, spinal, and intraocular surgery, where bleeding is potentially catastrophic and bridging with
tirofiban and heparin is recommended
(63). In patients taking acetylsalicylic
acid, guidelines allow neuraxial blockade without restrictions on the timing
and dosage (59). In all guidelines, the
additional risk of the concomitant use
of acetylsalicylic acid and other anticoagulant drug is emphasized. While acetylsalicylic acid is regarded as safe antiplatelet therapy, thienopyridine derivates such as clopidogrel are not recommended 5-7 days before TEA (59).
The beneficial effects of epidurals
can be seen if epidurals work. It shown
that mortality and cardiac morbidity may be worsened by inadequate or
failed regional anesthesia (64), suggesting that epidural efficacy or expertise
with the technique may contribute to
postsurgical outcome (65). The report
of 600 sequential epidurals used for
postoperative analgesia, McLeod and
colleagues demonstrated failure to provide good analgesia for the intended duration of the block in one-third of patients (66).

operative pain control. Whether regional

anesthesia influences outcome after surgery is a controversial topic. TEA provides optimal pain therapy in a wide
range of surgical procedures and may
contribute reduction of perioperative
morbidity and mortality after major abdominal and thoracic surgery. Several
meta-analyses have investigated this important topic with controversial results.
Improvement in outcome can probably
be achieved when the skills of individual
practitioners are improved and regional
anesthesia is used wisely and appropriately leading to reduced failure rates.
Good operating procedures and a
high level of awareness can largely improve the safety of TEA in patients receiving antiplatelet and anticoagulant
drugs. There is a high level of safety
when TEA is used as established in

Epidural anesthesia/analgesia are

used widely for intraoperative and post-

















Bangalore S, Wetterslev J, Pranesh S, Sawhney S, Gluud C, Messerli FH.

Perioperative beta blockers in patients having non-cardiac surgery: a
meta-analysis. Lancet. 2008; 372: 1962-1976.
Liu S, Carpenter RL, Neal JM. Epidural anesthesia and analgesia. Anesthesiology. 1995; 82: 1474-1506.
Moraca RJ, Sheldon DG, Thirlby RC. The Role of Epidural Anesthesia
and Analgesia in Surgical Practice. Ann Surg. 2003; 238(5): 663-673.
Blomberg S, Emanuelsson H, Kvist H, et al. Effects of thoracic epidural
anesthesia on coronary arteries and arterioles in patients with coronary artery disease. Anesthesiology. 1990; 73: 840-847.
Nygard E, Kofoed KF, Freiberg J, et al. Effects of high thoracic epidural
analgesia on myocardial blood flow in patients with ischemic heart disease. Circulation.2005; 111: 2165-2170.
Schmidt C, Hinder F, Van Aken H, et al. The effect of high thoracic
epidural anesthesia on systolic and diastolic left ventricular function in patients with coronary artery disease. Anesth Analg. 2005;
100: 1561-1569.
Rodgers A, Walker N, Schug S, McKee A, Kehlet H, van Zundert A,
Sage D, Futter M, Saville G, Clark T, MacMahon S: Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials. BMJ. 2000; 321: 1493.
Taniguchi M, Kasaba T, Takasaki M: Epidural anesthesia enhances sympathetic nerve activity in the unanesthetized segments in cats. Anesth
Analg. 1997; 84: 391-397.
Meissner A, Rolf N, Van Aken H: Thoracic epidural anesthesia and the
patient with heart disease: benefits, risks, and controversies. Anesth
Analg. 1997; 85: 517-528.
Popping DM, Elia N, Marret E, Remy C, Tramer MR: Protective effects
of epidural analgesia on pulmonary complications after abdominal
and thoracic surgery: a meta-analysis. Arch Surg. 2008; 143: 990-999.
Park WY, Thompson JS, Lee KK: Effect of epidural anesthesia and analgesia on perioperative outcome: a randomized, controlled Veterans
Affairs cooperative study. AnnSurg. 2001; 234: 560-569.
Baron JF, Bertrand M, Barre E, et al. Combined epidural and general
anesthesia versus general anesthesia for abdominal aortic surgery. Anesthesiology. 1991; 75: 611-618.
Beattie WS, Badner NH, Choi P: Epidural analgesia reduces postoperative myocardial infarction: a meta-analysis. Anesth Analg 2001;
Warner DO: Preventing postoperative pulmonary complications:
the role of the anesthesiologist. Anesthesiology 2000; 92:1467-1472.
Wu CL, Hurley RW, Anderson GF, Herbert R, Rowlingson AJ, Fleisher
LA: Effect of postoperative epidural analgesia on morbidity and mortality following surgery in medicare patients. Reg Anesth Pain Med
2004; 29:525-533.
Rigg JR, Jamrozik K, Myles PS, Silbert BS, Peyton PJ, Parsons RW, Collins KS: Epidural anaesthesia and analgesia and outcome of major surgery: a randomised trial. Lancet 2002; 359:1276-1282.
Smetana GW: A 68-year-old man with COPD contemplating colon cancer surgery. JAMA. 2007; 297: 2121-2123.
Lawrence VA, Cornell JE, Smetana GW, American College of Physicians:
Strategies to reduce postoperative pulmonary complications after noncardiothoracic surgery: Systematic review for the American College of
Physicians. Ann Intern Med. 2006; 144: 596-608.
Ballantyne JC, Carr DB, deFerranti S, et al. The comparative effects
of postoperative analgesic therapies on pulmonary outcome: cumulative meta-analyses of randomized, controlled trials. Anesth Analg.
1998; 86: 598-612.
Panaretou V, Toufektzian L, Siafaka I, Kouroukli I, Sigala F, Vlachopoulos C, Katsaragakis S, Zografos G, Filis K. Postoperative pulmonary function after open abdominal aortic aneurysm repair in patients
with chronic obstructive pulmonary disease: epidural versus intravenous analgesia. Annals of Vascular Surgery. 2012; 26(2): 149-155.
Borghi B, Casati A, Iuorio S, et al. Frequency of hypotension and bradycardia during general anesthesia, epidural anesthesia, or integrated
epidural-general anesthesia for total hip replacement. J Clin Anesth.
2002; 14: 102-106.
Lier F. Epidural Analgesia Is Associated with Improved Health Outcomes of Surgical Patients with Chronic Obstructive Pulmonary Disease. Anesthesiology. 2011; 115: 315-321.
Nishimori M, Ballantyne JC, Low JH. Epidural pain relief versus systemic opioid-based pain relief for abdominal aortic surgery. Cochrane
Database Syst Rev. 2006;3: CD005059.





Peyton PJ, Myles PS, Silbert BS, Rigg JA, Jamrozik K, Parsons R: Perioperative epidural analgesia and outcome after major abdominal surgery
in high-risk patients. Anesth Analg. 2003; 96: 548-554.
Takasaki M, Takahashi T. Respiratory function during cervical and
thoracic extradural analgesia in patients with normal lungs. Br J Anaesth. 1980; 52: 1271-1276.
Sundberg A, Wattwil M, Arvill A. Respiratory effects of high thoracic
epidural anaesthesia. Acta Anaesthesiol Scand. 1986; 30: 215-217.
Tuman KJ, McCarthy RJ, March RJ, et al. Effects of epidural anesthesia
and analgesia on coagulation and outcome after major vascular surgery. Anesth Analg. 1991; 73: 696-704.
Kehlet H, Holte K. Effect of postoperative analgesia on surgical outcome. Br J Anaesth. 2001; 87: 62-72.
Delis KT, Knaggs AL, Mason P, Macleod KG. Effects of epidural-andgeneral anesthesia combined versus general anesthesia alone on the venous hemodynamics of the lower limb. A randomized study. Thromb
Haemost. 2004; 92: 1003-1011.
Parker MJ, Handoll HH, Griffiths R. Anaesthesia for hip fracture surgery
in adults. Cochrane Database Syst Rev. 2004: CD000521.
Freise H, Daudel F, Grosserichter C, et al. Thoracic epidural anesthesia
reverses sepsis-induced hepatic hyperperfusion and reduces leukocyte
adhesion in septic rats. Crit Care. 2009; 13: R116.
Freise H, Lauer S, Konietzny E, et al. Hepatic effects of thoracic epidural analgesia in experimental severe acute pancreatitis. Anesthesiology. 2009; 111: 1249-1256.
Mythen MG: Postoperative gastrointestinal tract dysfunction. Anesth
Analg. 2005; 100: 196-204.
Taqi A, Hong X, Mistraletti G, Stein B, Charlebois P, Carli F. Thoracic
epidural analgesia facilitates the restoration of bowel function and dietary intake in patients undergoing laparoscopic colon resection using a traditional, nonaccelerated, perioperative care program. Surg
Endosc. 2007; 21: 247-252.
Freise H, Fischer LG. Intestinal effects of thoracic epidural anesthesia.
Curr Opin Anaesthesiol. 2009; 22: 644-648.
Baig MK, Wexner SD. Postoperative ileus: a review. Dis Colon Rectum. 2004; 47: 516-526.
Freise H, Van Aken HK. Risks and benefits of thoracic epidural anaesthesia. Br. J. Anaesth. 2011; 107(6): 859-868.
Schwarte LA, Picker O, Hohne C, Fournell A, Scheeren TW. Effects of
thoracic epidural anaesthesia on microvascular gastric mucosal oxygenation in physiological and compromised circulatory conditions in
dogs. Br J Anaesth. 2004; 93: 552-559.
Adolphs J, Schmidt DK, Korsukewitz I, et al. Effects of thoracic epidural
anaesthesia on intestinal microvascular perfusion in a rodent model of
normotensive endotoxaemia. Intensive Care Med. 2004; 30: 2094-2101.
Fotiadis RJ, Badvie S, Weston MD, Allen-Mersh TG: Epidural analgesia
in gastrointestinal surgery. Br J Surg. 2004; 91: 828-841.
Lattermann R, Wykes L, Eberhart L, Carli F, Meterissian S, Schricker
T: A randomized controlled trial of the anticatabolic effect of epidural analgesia and hypocaloric glucose. Reg Anesth Pain Med.
2007; 32: 227-232.
Wu CL, Cohen SR, Richman JM, Rowlingson AJ, Courpas GE, Cheung
K, Lin EE, Liu SS: Efficacy of postoperative patient-controlled and
continuous infusion epidural analgesia versus intravenous patientcontrolled analgesia with opioids: a meta-analysis. Anesthesiology.
2005; 103: 1079-1088.
Carli F, Trudel JL, Belliveau P: The effect of intraoperative thoracic epidural anesthesia and postoperative analgesia on bowel function after
colorectal surgery: A prospective, randomized trial. Dis Colon Rectum 2001; 44:1083-1089.
Werawatganon T, Charuluxanun S. Patient controlled intravenous opioid analgesia versus continuous epidural analgesia for pain after intra-abdominal surgery. Cochrane Database Syst Rev 2005; CD004088
Wijeysundera DN, Beattie WS, Austin PC, Hux JE, Laupacis A: Epidural
anaesthesia and survival after intermediate-to-high risk non-cardiac
surgery: a population-based cohort study. Lancet 2008; 372:562-569.
McGregor WE, Koler AJ, Labat GC, et al. Awake aortic aneurysm repair in patients with severe pulmonary disease. Am J Surg. 1999;
Grewal S, Hocking G, Wildsmith JA: Epidural abscesses. Br J Anaesth
2006; 96:292302
Auroy Y, Narchi P, Messiah A, et al. Serious complications related to
regional anesthesia. Anesthesiology. 1997; 87:479-486.
Horlocker TT. Regional anesthesia: complications of spinal and epidural anesthesia. Anesthesiol Clin North America. 2000; 18:461-485.
Tanaka K, Watanabe R, Harada T, et al. Extenzive applications of epidural anesthesia and analgesia in a university hospital; incidence
of complications related to tehnique: Reg Anesth. 1993; 1048-1056.
Kane RE. Neurologic deficits following epidural or spinal anesthesia.
Anesth Analg. 1981; 60: 150-161.
Schmidt A, Nolte H. Subdural and epidural hematoma following epidural anesthesia: a literature review. Anaesthesist. 1992; 41: 276-284.
Tyrba M. Epidural regional anesthesia and low molecular heparin: Pro (German). Anasth Intensivmed Notfallmed Schmerzther.
1993; 28: 179-181.
Lim SH, Hong BY, Cho YR, et al. Relapsed spontaneous spinal epidural hematoma associated with aspirin and clopidogrel. Neurol Sci
2011; 32: 687-689.
Moon HJ, Kim JH, Kwon TH, Chung HS, Park YK. Spontaneous spinal
epidural hematoma: an urgent complication of adding clopidogrel to
aspirin therapy. J Neurol Sci. 2009; 285: 254-256.
Omori N, Takada E, Narai H, Tanaka T, Abe K, Manabe Y. Spontaneous cervical epidural hematoma treated by the combination of surgical
evacuation and steroid pulse therapy. Intern Med. 2008; 47: 437-440.
Breivik H, Bang U, Jalonen J, Vigfusson G, Alahuhta S, Lagerkranser M.
Nordic guidelines for neuraxial blocks in disturbed haemostasis from
the Scandinavian Society of Anaesthesiology and Intensive Care Medicine. Acta Anaesthesiol Scand. 2010; 54: 16-41.
Vandermeulen Ep, Van aken H. Vermylen J. Anticoagulants and spinalepidural anesthesia. Anesth Analg. 1994; 79: 1165-1177.
Gogarten W, Vandermeulen E, Van Aken H, Kozek S, Llau JV, Samama
CM. Regional anaesthesia and antithrombotic agents: recommendations of the European Society of Anaesthesiology. Eur J Anaesthesiol. 2010; 27: 999-1015.
Geerts WH, Bergqvist D, Pineo GF, et al. Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based
Clinical Practice Guidelines (8th Edition). Chest. 2008; 133: 381S-453S.
Oscarsson A, Gupta A, Fredrikson M, et al. To continue or discontinue
aspirin in the perioperative period: a randomized, controlled clinical
trial. Br J Anaesth. 2010; 104: 305-312.
Grines CL, Boniw RO, Casez DE, et al, Prevention of premature discontiunation of dual antiplatelet therapz in patients with coronarz arterz
stents. Circulation. 2007; 115: 813-818.
Chassot PG, Delabays A, Spahn DR. Perioperative antiplatelet therapy:
the case for continuing therapy in patients at risk of myocardial infarction. Br J Anaesth. 2007; 99: 316-328.
Kettner SC, Willschke H, Marhofer P. Does regional anaesthesia really
improve outcome? Br. J. Anaesth. 2011; 107(1): i90-i95.
Bode RH Jr, Lewis KP, Zarich SW, et al. Cardiac outcome after peripheral vascular surgery: comparison of general and regional anesthesia.
Anesthesiology. 1996; 84: 3-13.
McLeod GA at al. Postoperative pain relief using thoracic epidural analgesia: outstanding success and disappointing failures. Anaesthesia. 2001; 56: 75-81.

Received: May 18th 2012 review

All in-text references underlined in blue are linked to publications on ResearchGate, letting you access and read them immediately.