What the journals say

Cumulative meta-analyses of RCTs - Ballantyne 98

- reduced pulmonary complications, greater PaO2, insufficient power to show a difference.

Veteran Affairs study 2001

- RCT 1021 patients having abdominal surgery
- post op had epidural morphine prn or systemic opioid
Results
- Overall no difference
- aortic surgery subgroup had lower death or major morbidity (AMI, CVA, resp failure), extubation was 13h less, ICU stay
3.5H less.

MASTER study Lancet April 2002

Large multicentre RCT (many hospitals several countries) of Epidural anaesthesia/analgesia v GA + opioid analgesia (915
patients)
Results
- less pain with epidural over 72hrs
- no major adverse consequences from epidural use
- mortality same
- less respiratory failure in epidural group (NNT 15)

(Endpoints - death, 30 days, major morbidity

High risk criteria patients
- morbid obesity, diabetes, renal failure, respiratory insufficiency, liver disease, CCF, AMI, IHD, Age >75 (with other)
- open abdo/thorax surgery, >1hr duration (not cardiac or pulmonary surgery)
72h of epidural analgesia or systemic opioid (but details of management not specified)

Multiple RCTs from 1987 to 2002 summary:

Epidural better than or same as GA
- reduced morbidity and mortality
- improved graft function and coagulation status
- reduced cardiac and respiratory complications
- reduced cost of care.

Ballantyne ed Jan 2004

Conclusions
1. May not be possible with modern practice to show a benefit from epidurals for rare events eg death.
2. Better analgesia for thoracic and upper abdo surgery
3. Reduce minor morbidity (ileus, activity, atelectasis, quality of life)

Rigg JRA, Jamrozik K, Myles PS, et al and the MASTER Anaesthesia Trial Study Group. Epidural
anaesthesia and analgesia and outcome of major surgery: a randomized trial. Lancet 2002;
359:1276-1282.