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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
CONFLICT OF INTEREST: NONE DECLARED

REVIEW

Benefits, Risks and Complications


of Perioperative Use of Epidural
Anesthesia
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

1. INTRODUCTION

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.

340

2. CARDIOVASCULAR
SYSTEM
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

3. PULMONARY SYSTEM
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).

4. COAGULATION AND ANTIINFLAMMATORY EFFECTS


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.

5. GASTROINTESTINAL
FUNCTION
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).

6. DECREASED
POSTOPERATIVE
CATABOLISM
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).

7. TEA INTRAOPERATIVE USE

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

341

Benefits, Risks and Complications of Perioperative Use of Epidural Anesthesia

Potential/Probable Benefits of Epidural


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

Table 1. Potential/Probable Benefits of Epidural


Anesthesia/Analgesia

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


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

8. ANALGESIA
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).

9. OVERALL MORTALITY

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)
342

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).

10. COMPLICATIONS
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
paraplegia.

11. EPIDURAL HEMATOMA


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
guidelines.

Epidural anesthesia/analgesia are


used widely for intraoperative and post-

23.

12. CONCLUSION

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Received: May 18th 2012 review

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