{"id":3267,"date":"2021-05-19T23:12:19","date_gmt":"2021-05-19T20:12:19","guid":{"rendered":"https:\/\/www.esrahellas.gr\/?page_id=3267"},"modified":"2021-07-16T11:24:32","modified_gmt":"2021-07-16T08:24:32","slug":"systematic-reviews-in-regional-anaesthesia-regional-anaesthesia-and-outcome","status":"publish","type":"page","link":"https:\/\/www.esrahellas.gr\/en\/esra-highlights\/systematic-reviews-in-regional-anaesthesia-regional-anaesthesia-and-outcome\/","title":{"rendered":"SYSTEMATIC REVIEWS IN REGIONAL ANAESTHESIA:  REGIONAL ANAESTHESIA AND OUTCOME"},"content":{"rendered":"  <div id=\"page-header-1131279431\" class=\"page-header-wrapper\">\n  <div class=\"page-title dark featured-title\">\n\n    \n    <div class=\"page-title-inner container align-center flex-row medium-flex-wrap\" >\n              <div class=\"title-wrapper flex-col text-left medium-text-center\">\n          <h1 class=\"entry-title mb-0\">\n            SYSTEMATIC REVIEWS IN REGIONAL ANAESTHESIA:  REGIONAL ANAESTHESIA AND OUTCOME          <\/h1>\n        <\/div>\n                    <div class=\"title-content flex-col flex-right text-right medium-text-center\">\n        <div class=\"title-share pt-half pb-half\"><div class=\"social-icons share-icons share-row relative icon-style-fill\" ><a href=\"https:\/\/www.facebook.com\/sharer.php?u=https:\/\/www.esrahellas.gr\/en\/esra-highlights\/systematic-reviews-in-regional-anaesthesia-regional-anaesthesia-and-outcome\/\" data-label=\"Facebook\" onclick=\"window.open(this.href,this.title,'width=500,height=500,top=300px,left=300px'); return false;\" target=\"_blank\" class=\"icon primary button circle tooltip facebook\" title=\"Share on Facebook\" aria-label=\"Share on Facebook\" rel=\"noopener nofollow\"><i class=\"icon-facebook\" aria-hidden=\"true\"><\/i><\/a><a href=\"https:\/\/twitter.com\/share?url=https:\/\/www.esrahellas.gr\/en\/esra-highlights\/systematic-reviews-in-regional-anaesthesia-regional-anaesthesia-and-outcome\/\" onclick=\"window.open(this.href,this.title,'width=500,height=500,top=300px,left=300px'); return false;\" target=\"_blank\" class=\"icon primary button circle tooltip twitter\" title=\"Share on Twitter\" aria-label=\"Share on Twitter\" rel=\"noopener nofollow\"><i class=\"icon-twitter\" aria-hidden=\"true\"><\/i><\/a><a href=\"mailto:?subject=SYSTEMATIC%20REVIEWS%20IN%20REGIONAL%20ANAESTHESIA%3A%20%20REGIONAL%20ANAESTHESIA%20AND%20OUTCOME&body=Check%20this%20out%3A%20https%3A%2F%2Fwww.esrahellas.gr%2Fen%2Fesra-highlights%2Fsystematic-reviews-in-regional-anaesthesia-regional-anaesthesia-and-outcome%2F\" class=\"icon primary button circle tooltip email\" title=\"Email to a Friend\" aria-label=\"Email to a Friend\" rel=\"nofollow\"><i class=\"icon-envelop\" aria-hidden=\"true\"><\/i><\/a><a href=\"https:\/\/www.linkedin.com\/shareArticle?mini=true&url=https:\/\/www.esrahellas.gr\/en\/esra-highlights\/systematic-reviews-in-regional-anaesthesia-regional-anaesthesia-and-outcome\/&title=SYSTEMATIC%20REVIEWS%20IN%20REGIONAL%20ANAESTHESIA%3A%20%20REGIONAL%20ANAESTHESIA%20AND%20OUTCOME\" onclick=\"window.open(this.href,this.title,'width=500,height=500,top=300px,left=300px'); return false;\" target=\"_blank\" class=\"icon primary button circle tooltip linkedin\" title=\"Share on LinkedIn\" aria-label=\"Share on LinkedIn\" rel=\"noopener nofollow\"><i class=\"icon-linkedin\" aria-hidden=\"true\"><\/i><\/a><\/div><\/div>      <\/div>\n    <\/div>\n\n     \n<style>\n#page-header-1131279431 {\n  margin-bottom: 20px;\n}\n<\/style>\n  <\/div>\n    <\/div>\n  \n<div class=\"row align-middle\"  id=\"row-1803375721\">\n\n\t<div id=\"col-588388837\" class=\"col medium-3 small-12 large-3\"  >\n\t\t\t\t<div class=\"col-inner\"  >\n\t\t\t\n\t\t\t\n\t<div class=\"img has-hover x md-x lg-x y md-y lg-y\" id=\"image_1868853008\">\n\t\t\t\t\t\t\t\t<div class=\"img-inner dark\" >\n\t\t\t<img loading=\"lazy\" decoding=\"async\" width=\"709\" height=\"1030\" src=\"https:\/\/www.esrahellas.gr\/wp-content\/uploads\/2021\/05\/logo-malta.jpg\" class=\"attachment-large size-large\" alt=\"\" \/>\t\t\t\t\t\t\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\n<style>\n#image_1868853008 {\n  width: 100%;\n}\n<\/style>\n\t<\/div>\n\t\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\n\t\n\n\t<div id=\"col-1347112876\" class=\"col medium-9 small-12 large-9\"  >\n\t\t\t\t<div class=\"col-inner\"  >\n\t\t\t\n\t\t\t\n<h3>ESRA Highlights<\/h3>\n<p><strong>22nd Annual ESRA Congress<\/strong><\/p>\n<p><strong>September 10 &#8211; 13, 2003, Saint Julian, Malta<\/strong><\/p>\n<p><strong>Congress Highlights<\/strong><\/p>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\n\t\n<\/div>\n<div class=\"row\"  id=\"row-1970669860\">\n\n\t<div id=\"col-559762968\" class=\"col small-12 large-12\"  >\n\t\t\t\t<div class=\"col-inner text-left\"  >\n\t\t\t\n\t\t\t\n<p><strong>SYSTEMATIC REVIEWS IN REGIONAL ANAESTHESIA:<\/strong><\/p>\n<p><strong>REGIONAL ANAESTHESIA AND OUTCOME<\/strong><\/p>\n<p><strong>Andre Van Zundert<\/strong><\/p>\n<p>Catharina Hospital &#8211; Brabant Medical School<\/p>\n<p>Eindhoven &#8211; The Netherlands<\/p>\n<p>For full text in pdf form click <a href=\"https:\/\/www.esrahellas.gr\/wp-content\/uploads\/2021\/05\/SYSTEMATIC-REVIEWS-IN-REGIONAL-ANAESTHESIA.pdf\" target=\"_blank\">here<\/a>.<\/p>\n<p>\u00a0<\/p>\n<p>Central neuraxial and peripheral blockades are widely used to manage surgery and postoperative analgesia, but its risks and benefits are uncertain.<\/p>\n<p>Several perioperative modalities have been said to reduce morbidity after major surgery, including the use of regional anesthesia rather than general anesthesia, perioperative invasive hemodynamics, and perioperative epidural analgesia.<\/p>\n<p>Whether epidural anesthesia and analgesia improve the outcome of major abdominal surgery is a long-running controversy. Many beneficial aspects of epidural anesthesia have been reported, including more stable cardiovascular hemodynamics, better peripheral vascular circulation, better suppression of surgical stress, positive effect on postoperative nitrogen balance, and better postoperative pain control. Perhaps the explanation can be found in the fact that general anesthesia leads to an intense afferent activity in CNS triggers. This neuro-endocrine action is called the &#8220;stress response&#8221;, which leads to hypercoagulability.<\/p>\n<p>Postoperative cardiac morbidity and mortality continue to pose considerable risks to surgical patients, as myocardial infarction is a leading cause of postoperative morbidity. Epidural analgesia is considered to have beneficial effects on cardiac outcomes. However, the use in high-risk cardiac patients remains controversial. Beattie (2001) demonstrated in a meta-analysis study of 1.173 patients that postoperative thoracic epidural analgesia showed a significant reduction in post-myocardial infarction.<\/p>\n<p>\u0391 meta-analysis of randomized controlled trials (Rodgers, 2000) found that, compared with other analgesic techniques, neuraxial block was associated with significantly decreased perioperative morbidity and mortality. Venous thromboembolism (50% reduction), myocardial infarction (33% reduction), pneumonia (39% reduction), postoperative respiratory depression (59% reduction) was found in the studied population, with a 50% lower chance on bleeding complications.<\/p>\n<p>\u0391 review article on the prevention of perioperative myocardial ischemia following surgery, recommends inhibition of sympathetic nervous system activity (WarltieI, 2000). Furthermore, there is growing evidence that for major non-cardiac surgery, outcome is improved when regional anaesthesia, which provides sympathetic blockade, is employed (Buggy, 1999).<\/p>\n<p>High thoracic epidural analgesia (\u03a41 to \u03a45) results in a reduction of the heart rate, improves ischemia-induced left ventricular dysfunction, reduces signs of coronary insufficiency, decreases the incidence of arrhythmias and improves the myocardial oxygen supply-demand balance. Lower thoracic and lumbar epidural anesthesia results in a peripheral sympathetic blockade together with a block of the splanchnic fibers, producing vasodilation in the blocked areas and compensatory vasoconstriction in the remaining unblocked areas. Scott (2001) demonstrated beneficial effects of thoracic epidural anesthesia in patients undergoing coronary bypass grafting: earlier extubation, better postoperative pulmonary function, fewer lower respiratory tract infections, less arrhythmias and a lower incidence of stroke and renal failure.<\/p>\n<p>Pulmonary effects of epidural anesthesia are a result of the blockade of sympathetic and intercostal nerves and the interruption of an inhibitory reflex of the phrenic motor nerve drive. \u0391 substantial reduction in deep vein thrombosis and pulmonary embolism, arrhythmias and myocardial infarction was demonstrated in the meta-analysis studies of Rodgers (2000) and Beattie (2001). An increased alveolar \u03a1\u039f2 and a decreased incidence of pulmonary infections and overall pulmonary complications could be demonstrated by Ballantyne (1998).<\/p>\n<p>Park (2001) found in over 1000 patients undergoing abdominal aortic operations, that adequate epidural analgesia results in a shortened intensive care stay. It is important to know the target of the epidural: up to \u03a44, or \u03a46 level, and that the epidural is kept in place for 48 hours or even longer. Patients may ambulate earlier and oral feedings can be initiated at an earlier stage. Rigg (2002) found in a similar group (915 patients) that most adverse morbid outcomes are not reduced by the use of the combined spinal epidural anesthesia intraoperatively and the epidural catheter postoperatively. However they found improvement in analgesia, reduction in failure rate and a low risk of serious adverse consequences if the patients are treated with an adequate epidural technique, applying continuing postoperative epidural analgesia (MASTER study). Peyton (2003) however, could not find evidence that perioperative analgesia significantly influences major morbidity and mortality after major abdominal surgery, apart from respiratory failure. This study group comprised of 915 high risk patients.<\/p>\n<p>Especially in orthopedic surgery the combined use of central neuraxial blocks and peripheral blocks resulted in a faster rehabilitation (Singelyn, 1998 &#8211; Capdevilla, 1999). \u0391 recent study of Neal and co-workers (2003) found that a suprascapular nerve block with bupivacaine, as an adjunct to an interscalene block combined with general anesthesia, does not improve outcome measures after ambulatory surgery of the shoulder.<\/p>\n<p>There are many study problems when interpreting meta-analysis studies: sample size too small, poor or no randomization, too many types of surgery, lack of power to demonstrate differences, too many variables, too many confounding variables such as technique, type and quantity of local anesthetics, addition of opioids, the level of epidural placement, postoperative management may differ (ambulation, feeding, physiotherapy), &#8230;<\/p>\n<p>But what is relevant? Is regional anesthesia advantageous over general anesthesia in young healthy patients undergoing surgery on one of the limbs? Is reduced mortality really a good reason for this patient category? Even in a 50 or 60-year-old healthy patient undergoing peripheral orthopedic surgery accompanied by minimal blood loss, will it be difficult to prove that regional anesthesia has advantages over general anesthesia. Many of the outcome studies have focused on big outcomes such as: death, blood loss and transfusion requirements, and cardiovascular and pulmonary complications.<\/p>\n<p>From the patients point of view the positive points are absence of postoperative sedation, a rapid recovery, less PONV, excellent pain control, and the ability to ambulate (and feed) earlier. Some patients value regional anesthesia as they do not lose control of themselves, an unavoidable aspect of general anesthesia.<\/p>\n<p><strong>Are we, Anesthesiologists, doing the job right?<\/strong><\/p>\n<p>We have to insert a thoracic epidural catheter, give a good quality block blocking the nociceptive impulses during the surgical intervention and in the postoperative phase (up to three days). If a patient is pain free in the postoperative phase he is more in for physiotherapy, earlier ambulation and earlier feeding, as the patient feels more comfortable. \u0391 reduced morbidity and an accelerated convalescence can be obtained if a multimodal approach is applied in which the patient is adequately informed and prepared, where an appropriate epidural catheter technique is used, not only to provide intraoperative pain relief, but also to relief pain in the postoperative period. As such perioperative stress is attenuated, while the patient may recover earlier, due to earlier active exercises and an earlier start of enteral nutrition.<\/p>\n<p>It is hard to believe that regional anesthesia is beneficial in every patient and in every surgical intervention. However, common sense makes us to believe that some surgery (cataract, hip surgery, prostate surgery, Cesarean section, several extremity operations, &#8230;) are best performed under regional anesthesia. This means that a wide variety of patient populations undergoing surgery, is satisfied and often chooses the same regional anesthesia if they have to come a second time for an operation. Surgical outcome however is not only determined by anesthesia alone. Postoperative care (pain relief, early recovery, faster return of gastrointestinaI function and feeding, ability to return to work or to their former lifestyle) is dependent on many other factors. Early thromboprophylaxis and perioperative \u03b2-blockade also proved their value.<\/p>\n<p>Epidural anesthesia is not a cure for pre-existing morbidity that may contribute to postoperative complications. One cannot reduce death from severe coronary artery disease with a short-term intervention.<\/p>\n<p>Although it may be difficult to prove that regional anesthesia has major advantages on all aspects over general anesthesia, there is no study where general anesthesia has proven meaningful outcome improvements over regional anesthesia.<\/p>\n<p>\u00a0<\/p>\n<p><strong>References<\/strong><\/p>\n<ul type=\"disc\">\n<li>\n<p>BaIIantyne JR, Carr DB, de Ferranti S et al. The comparative effects of postoperative analgesic therapies on pulmonary outcome: Cumulative meta-analysis of randomized controlled trials. Anesth Analg, 1998; 86: 598 \u2013 612.<\/p>\n<\/li>\n<li>\n<p>Beattie WS, Badner \u039d\u0397, Choi \u03a1. Epidural analgesia reduces postoperative myocardial infarction: \u0391 meta-analysis. Anesth Analg, 2001; 98: 853 \u2013 858.<\/p>\n<\/li>\n<li>\n<p>Buggy DJ, Smith G. Epidural anaesthesia and analgesia: better outcome after major surgery? Growing evidence suggests so. BMJ, 1999; 319: 531 \u2013 532.<\/p>\n<\/li>\n<li>\n<p>Capdevilla \u03a7, Barthelet \u03a5, Biboulet \u03a1, Ryckwaert \u03a5, Rubenovitch J, d \u0386th\u03afs F. Effects of perioperative analgesic technique on the surgical outcome and duration of rehabilitation after major knee surgery. Anesthesiology, 1999: 91: 8 \u2013 15.<\/p>\n<\/li>\n<li>\n<p>Neal JM, McDonald SB, Larkin KL, Polissar NL. Suprascapular nerve block prolongs analgesia after nonarthroscopic shoulder surgery but does not improve outcome. Anesth Analg, 2003; 96: 982 \u2013 986.<\/p>\n<\/li>\n<li>\n<p>Park WY, Thompson JS, Lee KK. Effect of epidural anesthesia and analgesia on perioperative outcome. Annals of Surgery, 2001; 234: 560 \u2013 571.<\/p>\n<\/li>\n<li>\n<p>Peyton PJ, Myles PS, Silbert BS, Riggs JA, Jamrozik \u039a, Parsons R. Perioperative epidural analgesia and outcome after major abdominal surgery in high-risk patients. Anesth Analg, 2003; 96: 548 \u2013 554.<\/p>\n<\/li>\n<li>\n<p>Rigg JR, Jamrozik \u039a, Mules PS, Silbert BS, Peyton PJ, Parsons RW, Collins KS. Epidural anaesthesia and analgesia and outcome of major surgery: a randomized trial. Lancet, 2000; 359: 1276 \u2013 1282.<\/p>\n<\/li>\n<li>\n<p>Rodgers \u0391, Walker \u039d, Schug S, McKee \u0391, Kehlet \u0397, van \u0396undert \u0391, Sage D, Futter \u039c, Saville G, Clark \u03a4, Mac Mahon S. Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomized trials. BMJ, 2000; 321: 1493 \u2013 1437.<\/p>\n<\/li>\n<li>\n<p>Singelyn FJ, Deyaert \u039c, Joris D, Gouverneur JM. Effects of intravenous patient controlled analgesia with morphine, continuous epidural analgesia, and continuous three-in-one block on postoperative pain and knee rehabilitation after unilateral total knee arthroplasty. Anesth Analg, 1998; 87: 88 \u2013 92.<\/p>\n<\/li>\n<li>\n<p>Scott \u039d\u0392, Turfrey DJ, Ray DAA, Nzewi \u039f, Sutcliffe \u039d\u03a1, Lal \u0391\u0392, Norrie \u0399, Nagels WJB, Ramayya GP. \u0391 prospective randomized study of the potential benefits of thoracic epidural anesthesia and analgesia in patients undergoing coronary artery bypass grafting. Anesth Analg, 2001; 93: 528 \u2013 535.<\/p>\n<\/li>\n<li>\n<p>Warlthier DC, Pagel PS, Kersten JR. Approaches to the prevention of perioperative myocardial ischemia. Anesthesiology, 2000; 92: 253 \u2013 259.\u00a0<\/p>\n<\/li>\n<\/ul>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\n\t\n<\/div>\n\t<div id=\"gap-231916806\" class=\"gap-element clearfix\" style=\"display:block; height:auto;\">\n\t\t\n<style>\n#gap-231916806 {\n  padding-top: 30px;\n}\n<\/style>\n\t<\/div>\n\t\n<div class=\"social-icons share-icons share-row relative full-width text-center\" ><a href=\"https:\/\/www.facebook.com\/sharer.php?u=https:\/\/www.esrahellas.gr\/en\/esra-highlights\/systematic-reviews-in-regional-anaesthesia-regional-anaesthesia-and-outcome\/\" data-label=\"Facebook\" onclick=\"window.open(this.href,this.title,'width=500,height=500,top=300px,left=300px'); return false;\" target=\"_blank\" class=\"icon primary button circle tooltip facebook\" title=\"Share on Facebook\" aria-label=\"Share on Facebook\" rel=\"noopener nofollow\"><i class=\"icon-facebook\" aria-hidden=\"true\"><\/i><\/a><a href=\"https:\/\/twitter.com\/share?url=https:\/\/www.esrahellas.gr\/en\/esra-highlights\/systematic-reviews-in-regional-anaesthesia-regional-anaesthesia-and-outcome\/\" onclick=\"window.open(this.href,this.title,'width=500,height=500,top=300px,left=300px'); return false;\" target=\"_blank\" class=\"icon primary button circle tooltip twitter\" title=\"Share on Twitter\" aria-label=\"Share on Twitter\" rel=\"noopener nofollow\"><i class=\"icon-twitter\" aria-hidden=\"true\"><\/i><\/a><a href=\"mailto:?subject=SYSTEMATIC%20REVIEWS%20IN%20REGIONAL%20ANAESTHESIA%3A%20%20REGIONAL%20ANAESTHESIA%20AND%20OUTCOME&body=Check%20this%20out%3A%20https%3A%2F%2Fwww.esrahellas.gr%2Fen%2Fesra-highlights%2Fsystematic-reviews-in-regional-anaesthesia-regional-anaesthesia-and-outcome%2F\" class=\"icon primary button circle tooltip email\" title=\"Email to a Friend\" aria-label=\"Email to a Friend\" rel=\"nofollow\"><i class=\"icon-envelop\" aria-hidden=\"true\"><\/i><\/a><a href=\"https:\/\/www.linkedin.com\/shareArticle?mini=true&url=https:\/\/www.esrahellas.gr\/en\/esra-highlights\/systematic-reviews-in-regional-anaesthesia-regional-anaesthesia-and-outcome\/&title=SYSTEMATIC%20REVIEWS%20IN%20REGIONAL%20ANAESTHESIA%3A%20%20REGIONAL%20ANAESTHESIA%20AND%20OUTCOME\" onclick=\"window.open(this.href,this.title,'width=500,height=500,top=300px,left=300px'); return false;\" target=\"_blank\" class=\"icon primary button circle tooltip linkedin\" title=\"Share on LinkedIn\" aria-label=\"Share on LinkedIn\" rel=\"noopener nofollow\"><i class=\"icon-linkedin\" aria-hidden=\"true\"><\/i><\/a><\/div>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":3182,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"page-blank.php","meta":{"footnotes":"","_links_to":"","_links_to_target":""},"class_list":["post-3267","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.0 - 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