Der Anaesthesist

, 60:950

Kardioprotektion durch thorakale Periduralanästhesie?

Metaanalyse
  • A. Gauss
  • S.K. Jahn
  • L.H.J. Eberhart
  • W. Stahl
  • M. Rockemann
  • M. Georgieff
  • F. Wagner
  • R. Meierhenrich
Regionalanästhesie

Zusammenfassung

Hintergrund

Bislang wird vermutet, dass der Einsatz einer thorakalen Periduralanästhesie (PDA) bei nichtherzchirurgischen Operationen kardioprotektive Effekte bietet. Zwei frühere Metaanalysen ergaben kontroverse Ergebnisse zum Einfluss einer PDA auf das Überleben. Ziel der aktuellen Metaanalyse auf der Basis prospektiver Studien war die Klärung der Frage, ob die thorakale PDA die kardiale Morbidität oder die Mortalität reduziert.

Material und Methoden

Es wurde eine systematische Literatursuche, basierend auf medizinischen Datenbanken (Medline, EBM-Reviews, Embase, Biosis und Biological Abstracts) durchgeführt. Relevante Studien wurden von 2 unabhängigen Untersuchern evaluiert. In die Metaanalyse wurden bis Ende 2008 publizierte randomisierte Studien mit der Frage des Einflusses einer thorakalen PDA auf das „outcome“ bei nichtherzchirurgischen Operationen eingeschlossen. Die Berechnungen erfolgten mit dem Statistikprogramm Review-Manager 4.1 unter Annahme fixer Effekte („fixed effects model“).

Ergebnisse

Es wurden 9 Studien mit 2768 Patienten in die Metaanalyse aufgenommen. Die thorakale PDA reduzierte die postoperative Mortalität nicht [“odds ratio“ (Peto OR): 1,08; 95%-Konfidenzintervall (95%-KI) 0,74–1,58]. Die Myokardinfarktrate wurde nur tendenziell, aber nicht signifikant gesenkt (Peto OR: 0,65; 95%-KI 0,4–1,05).

Schlussfolgerung

Aufgrund der vorliegenden Metaanalyse ergibt sich kein Hinweis, dass durch die thorakale PDA die perioperative Mortalität bei nichtherzchirurgischen Eingriffen gesenkt werden kann. Ein günstiger Effekt auf die Myokardinfarktrate bleibt weiterhin fraglich.

Schlüsselwörter

Anästhesie, epidural Myokardinfarkt Mortalität Morbidität Klinische Studien als Thema 

Cardioprotection by thoracic epidural anesthesia?

Meta-analysis

Abstract

Background

Thoracic epidural analgesia (EDA) is thought to provide cardioprotective effects in patients undergoing noncardiac surgery. The results of two previous meta-analysis showed controversial conclusions regarding the impact of EDA on perioperative survival. The purpose of the present meta-analysis was to evaluate, whether thoracic EDA has the potential to reduce perioperative cardiac morbidity or mortality on the basis of available randomized controlled trials.

Patients and methods

A systematic literature search was conducted in medical databases (Med-Line, EBM-Reviews, Embase, Biosis and Biological Abstracts) and relevant clinical trials including patients undergoing noncardiac surgery were evaluated by two independent investigators. All randomized controlled trials investigating the effects of thoracic EDA on perioperative outcome, published from 1980 up to the end of 2008 were included into this quantitative systematic review. Calculations were performed using the statistics program Review Manager 4.1 using a fixed-effects model.

Results

Nine studies with a total of 2,768 patients were included in the meta-analysis. Thoracic EDA did not reduce perioperative mortality [odds ratio (Peto OR): 1.08; 95% confidence interval (CI) 0.74–1.58]. Patients receiving thoracic EDA demonstrated a tendency to a lower rate of perioperative myocardial infarction. However, this effect of thoracic EDA did not reach statistical significance (Peto OR: 0.65; 95% CI 0.4–1.05).

Conclusions

The present meta-analysis did not prove any positive influence of thoracic EDA on perioperative in-hospital mortality in patients undergoing noncardiac surgery. Furthermore, it remains questionable if thoracic EDA has the potential to reduce the rate of perioperative myocardial infarction.

Keywords

Anesthesia, epidural Myocardial infarction Mortality Morbidity Clinical trials as topic 

Literatur

  1. 1.
    Atanassoff PG (1996) Effects of regional anesthesia on perioperative outcome. J Clin Anesth 8:446–455PubMedCrossRefGoogle Scholar
  2. 2.
    Atanassoff PG, Hartmannsgruber M, Brull SJ (1998) Differences in outcome in patients receiving general and regional anesthesia for orthopedic surgery. Yale Med Biol 71:597Google Scholar
  3. 3.
    Atanassoff PG, Otellin A, Printsev Y (1998) General anesthesia vs. epidural anesthesia with ropivacaine 0.2 percent for total knee replacement. Yale Med Biol 71:598Google Scholar
  4. 4.
    Audeau A, Newell P, Dobbs BR et al (2002) Postoperative epidural analgesia following elective major abdominal surgery in high risk patients: a retrospective cohort study. N Z Med J 115:69–72PubMedGoogle Scholar
  5. 5.
    Ballantyne J (1999) Does regional anesthesia improve outcome after surgery? Curr Opin Anaesthesiol 12:545–549PubMedCrossRefGoogle Scholar
  6. 6.
    Baron J-F, Bertrand M, Barré E et al (1991) Combined epidural and general anesthesia versus general anesthesia for abdominal aortic surgery. Anesthesiology 75:611–618PubMedCrossRefGoogle Scholar
  7. 7.
    Beattie WS, Badner NH, Choi P (2001) Epidural analgesia reduces postoperative myocardial infarction: a meta-analysis. Anesth Analg 93:853–858PubMedCrossRefGoogle Scholar
  8. 8.
    Beattie WS, Badner NH, Choi PT (2003) Meta-analysis demonstrates statistically significant reduction in postoperative myocardial infarction with the use of thoracic epidural analgesia. Anesth Analg 97:919–920PubMedCrossRefGoogle Scholar
  9. 9.
    Beattie WS, Buckley DN, Forrest JB (1993) Epidural morphine reduces the risk of postoperative myocardial ischaemia in patients with cardiac risk factors. Can J Anaesth 40:532–541PubMedCrossRefGoogle Scholar
  10. 10.
    Blomberg S, Emanuelsson H, Kvist H et al (1990) Effects of thoracic epidural anesthesia on coronary arteries and arterioles in patients with coronary artery disease. Anesthesiology 73:840–847PubMedCrossRefGoogle Scholar
  11. 11.
    Blomberg S, Emanuelsson H, Ricksten SE (1989) Thoracic epidural anesthesia and central hemodynamics in patients with unstable angina pectoris. Anesth Analg 69:558–562PubMedCrossRefGoogle Scholar
  12. 12.
    Bois S, Couture P, Boudreault D et al (1997) Epidural analgesia and intravenous patient-controlled analgesia result in similar rates of postoperative myocardial ischemia after aortic surgery. Anesth Analg 85:1233–1239PubMedGoogle Scholar
  13. 13.
    Brodner G, Meissner A, Rolf N et al (1997) Die thorakale Epiduralanästhesie – mehr als ein Anästhesieverfahren. Anaesthesist 46:751–762PubMedCrossRefGoogle Scholar
  14. 14.
    Caliskan E, Sener M, Bozdogan N et al (2008) Gogus-Kalp-Damar Anestezi Yogun Bakim Dernegi Derg 14:29–35Google Scholar
  15. 15.
    Cense HA, Lagarde SM, de Jong K et al (2006) Association of no epidural analgesia with postoperative morbidity and mortality after transthoracic esophageal cancer resection. J Am Coll Surg 202:395–400PubMedCrossRefGoogle Scholar
  16. 16.
    Cittanova ML, Soulier A, Hongnat JM et al (1989) Incidence and predictive hemodynamic factors in peroperative myocardial ischemia after thoracic peridural anesthesia combined with general anesthesia. Ann Fr Anesth Reanim 8(Suppl):R176PubMedGoogle Scholar
  17. 17.
    Cook TM, Counsell D, Wildsmith JA (2009) Major complications of central neuraxial block: report on the Third National Audit Project of the Royal College of Anaesthetists. Br J Anaesth 102:179–190PubMedCrossRefGoogle Scholar
  18. 18.
    Crawford ME, Moiniche S, Orbaek J et al (1996) Orthostatic hypotension during postoperative continuous thoracic epidural bupivacaine-morphine in patients undergoing abdominal surgery. Anesth Analg 83:1028–1032PubMedGoogle Scholar
  19. 19.
    Cullen ML, Staren ED, el-Ganzouri A et al (1985) Continuous epidural infusion for analgesia after major abdominal operations: a randomized, prospective, double-blind study. Surgery 98:718–728PubMedGoogle Scholar
  20. 20.
    Dabu-Bondoc SM (2004) Regional anesthesia and perioperative outcome: what is new? Curr Opin Anaesthesiol 17:435–439PubMedCrossRefGoogle Scholar
  21. 21.
    Davies MJ, Silbert BS, Mooney PJ et al (1993) Combined epidural and general anaesthesia versus general anaesthesia for abdominal aortic surgery: a prospective randomised trial. Anaesth Intensive Care 21:790–794PubMedGoogle Scholar
  22. 22.
    Davis RF, DeBoer LW, Maroko PR (1986) Thoracic epidural anesthesia reduces myocardial infarct size after coronary artery occlusion in dogs. Anesth Analg 65:711–717PubMedCrossRefGoogle Scholar
  23. 23.
    De Leon-Casasola OA (2003) When it comes to outcome, we need to define what a perioperative epidural technique is. Anesth Analg 96:315–318Google Scholar
  24. 24.
    De Leon-Casasola OA, Lema MJ, Karabella D et al (1995) Postoperative myocardial ischemia: epidural versus intravenous patient-controlled analgesia. A pilot project. Reg Anesth 20:105–112Google Scholar
  25. 25.
    Demirel CB, Kalayci M, Ozkocak I et al (2003) A prospective randomized study comparing perioperative outcome variables after epidural or general anesthesia for lumbar disc surgery. J Neurosurg Anesthesiol 15:185–192PubMedCrossRefGoogle Scholar
  26. 26.
    Ekatodramis G (2001) Regional anesthesia and analgesia: their role in postoperative outcome. Curr Top Med Chem 1:183–192PubMedGoogle Scholar
  27. 27.
    Freise H, Meissner A, Lauer S et al (2008) Thoracic epidural analgesia with low concentration of bupivacaine induces thoracic and lumbar sympathetic block: a randomized, double-blind clinical trial. Anesthesiology 109:1107–1112PubMedCrossRefGoogle Scholar
  28. 28.
    Ganapathy S, McCartney CJ, Beattie WS et al (2003) Best evidence in anesthetic practice. Prevention: epidural anesthesia and analgesia does not reduce 30-day all-cause mortality and major morbidity after abdominal surgery. Can J Anaesth 50:143–146PubMedCrossRefGoogle Scholar
  29. 29.
    Garnett RL, MacIntyre A, Lindsay P et al (1996) Perioperative ischaemia in aortic surgery: combined epidural/general anaesthesia and epidural analgesia vs general anaesthesia and i.v. analgesia. Can J Anaesth 43:769–777PubMedCrossRefGoogle Scholar
  30. 30.
    Gauss A, Röhm H-J, Schäuffelen A et al (2001) Electrocardiographic exercise stress testing for cardiac risk assessment in patients undergoing noncardiac surgery. Anesthesiology 94:38–46PubMedCrossRefGoogle Scholar
  31. 31.
    Gogarten W, Vandermeulen E, Van Aken H et al (2010) Regional anaesthesia and antithrombotic agents: recommendations of the European Society of Anaesthesiology. Eur J Anaesthesiol 27:999–1015PubMedCrossRefGoogle Scholar
  32. 32.
    Gottlieb A, Sanga R, Whalley D et al (1994) Epidural anesthesia as an adjunct to general anesthesia does not improve outcome in aortic reconstruction. Anesthesiology 81:A64CrossRefGoogle Scholar
  33. 33.
    Grass JA (2000) The role of epidural anesthesia and analgesia in postoperative outcome. Anesthesiol Clin North America 18:407–428PubMedCrossRefGoogle Scholar
  34. 34.
    Hendolin H, Lahtinen J, Lansimies E et al (1987) The effect of thoracic epidural analgesia on postoperative stress and morbidity. Ann Chir Gynaecol 76:234–240PubMedGoogle Scholar
  35. 35.
    Higgins JPT, Green S (2008) Cochrane handbook for systematic reviews of interventions Version 5.0.0 (updated February 2008). The Cochrane collaboration. http://www.cochrane-handbook.org/Google Scholar
  36. 36.
    Holte K, Kehlet H (2002) Effect of postoperative epidural analgesia on surgical outcome. Minerva Anestesiol 68:157–161PubMedGoogle Scholar
  37. 37.
    Hotvedt R, Refsum H, Platou ES (1984) Cardiac electrophysiological and hemodynamic effects of beta-adrenoceptor blockade and thoracic epidural analgesia in the dog. Anesth Analg 63:817–824PubMedCrossRefGoogle Scholar
  38. 38.
    Jadad AR, Moore RA, Carroll D et al (1996) Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials 17:1–12PubMedCrossRefGoogle Scholar
  39. 39.
    Jomura K, Hamada T, Sugiki K et al (1997) Epidural anesthesia reduces mortality rate in the patients after emergency abdominal surgery. Masui 46:1602–1608PubMedGoogle Scholar
  40. 40.
    Kasama A, Fukui S, Nishioka S et al (1982) The epidural morphine anesthesia for abdominal surgery of the high risk and/or aged patients. Masui 31:1274–1280PubMedGoogle Scholar
  41. 41.
    Kolker AR, Hirsch CJ, Gingold BS et al (1997) Use of epidural anesthesia and spontaneous ventilation during transabdominal colon and rectal procedures in selected high-risk patient groups. Dis Colon Rectum 40:339–343PubMedCrossRefGoogle Scholar
  42. 42.
    Lagunilla J, Garcia-Bengochea JB, Fernandez AL et al (2006) High thoracic epidural blockade increases myocardial oxygen availability in coronary surgery patients. Acta Anaesthesiol Scand 50:780–786PubMedCrossRefGoogle Scholar
  43. 43.
    Landesberg G, Beattie WS, Mosseri M et al (2009) Perioperative myocardial infarction. Circulation 119:2936–2944PubMedCrossRefGoogle Scholar
  44. 44.
    Liu S, Carpenter RL, Neal JM (1995) Epidural anesthesia and analgesia. Their role in postoperative outcome. Anesthesiology 82:1474–1506PubMedCrossRefGoogle Scholar
  45. 45.
    Liu SS, Wu CL (2007) Effect of postoperative analgesia on major postoperative complications: a systematic update of the evidence. Anesth Analg 104:689–702PubMedCrossRefGoogle Scholar
  46. 46.
    Loick HM, Schmidt C, Van Aken H et al (1999) High thoracic epidural anesthesia, but not clonidine, attenuates the perioperative stress response via sympatholysis and reduces the release of troponin T in patients undergoing coronary artery bypass grafting. Anesth Analg 88:701–709PubMedGoogle Scholar
  47. 47.
    Major CP Jr, Greer MS, Russell WL et al (1996) Postoperative pulmonary complications and morbidity after abdominal aneurysmectomy: a comparison of postoperative epidural versus parenteral opioid analgesia. Am Surg 62:45–51PubMedGoogle Scholar
  48. 48.
    Manolio TA, Beattie C, Christopherson R et al (1989) Regional versus general anesthesia in high-risk surgical patients: the need for a clinical trial. J Clin Anesth 1:414–421PubMedCrossRefGoogle Scholar
  49. 49.
    Mason RA, Newton GB, Cassel W et al (1990) Combined epidural and general anesthesia in aortic surgery. J Cardiovasc Surg (Torino) 31:442–447Google Scholar
  50. 50.
    Meierhenrich R, Wagner F, Schütz W et al (2009) The effects of thoracic epidural anesthesia on hepatic blood flow in patients under general anesthesia. Anesth Analg 108:1331–1337PubMedCrossRefGoogle Scholar
  51. 51.
    Meissner A, Rolf N, Van Aken H (1997) Thoracic epidural anesthesia and the patient with heart disease: benefits, risks, and controversies. Anesth Analg 85:517–528PubMedGoogle Scholar
  52. 52.
    Moher D, Cook DJ, Eastwood S et al (1999) Improving the quality of reports of meta-analyses of randomised controlled trials: the QUOROM statement. Quality of Reporting of Meta-analyses. Lancet 354:1896–1900PubMedCrossRefGoogle Scholar
  53. 53.
    Nishimori M, Ballantyne JC, Low JH (2006) Epidural pain relief versus systemic opioid-based pain relief for abdominal aortic surgery. Cochrane Database Syst Rev 3:CD005059PubMedGoogle Scholar
  54. 54.
    Norris EJ, Beattie C, Perler BA et al (2001) Double-masked randomized trial comparing alternate combinations of intraoperative anesthesia and postoperative analgesia in abdominal aortic surgery. Anesthesiology 95:1054–1067PubMedCrossRefGoogle Scholar
  55. 55.
    Nygard E, Kofoed KF, Freiberg J et al (2005) Effects of high thoracic epidural analgesia on myocardial blood flow in patients with ischemic heart disease. Circulation 111:2165–2170PubMedCrossRefGoogle Scholar
  56. 56.
    Olausson K, Magnusdottir H, Lurje L et al (1997) Anti-ischemic and anti-anginal effects of thoracic epidural anesthesia versus those of conventional medical therapy in the treatment of severe refractory unstable angina pectoris. Circulation 96:2178–2182PubMedGoogle Scholar
  57. 57.
    Park WY, Thompson JS, Lee KK (2001) Effect of epidural anesthesia and analgesia on perioperative outcome: a randomized, controlled Veterans Affairs cooperative study. Ann Surg 234:560–569PubMedCrossRefGoogle Scholar
  58. 58.
    Peyton PJ, Myles PS, Silbert BS et al (2003) Perioperative epidural analgesia and outcome after major abdominal surgery in high-risk patients. Anesth Analg 96:548–554PubMedGoogle Scholar
  59. 59.
    Poldermans D, Bax JJ, Boersma E et al (2010) Guidelines for pre-operative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery: the Task Force for Preoperative Cardiac Risk Assessment and Perioperative Cardiac Management in Non-cardiac Surgery of the European Society of Cardiology (ESC) and endorsed by the European Society of Anaesthesiology (ESA). Eur J Anaesthesiol 27:92–137PubMedCrossRefGoogle Scholar
  60. 60.
    Reinhart K, Foehring U, Kersting T et al (1989) Effects of thoracic epidural anesthesia on systemic hemodynamic function and systemic oxygen supply-demand relationship. Anesth Analg 69:360–369PubMedCrossRefGoogle Scholar
  61. 61.
    Rigg JR, Jamrozik K, Myles PS et al (2000) Design of the multicenter Australian study of epidural anesthesia and analgesia in major surgery: the MASTER trial. Control Clin Trials 21:244–256PubMedCrossRefGoogle Scholar
  62. 62.
    Rigg JR, Jamrozik K, Myles PS et al (2002) Epidural anaesthesia and analgesia and outcome of major surgery: a randomised trial. Lancet 359:1276–1282PubMedCrossRefGoogle Scholar
  63. 63.
    Rimaitis K, Pavalkis D (2006) Does epidural anaesthesia and analgesia really improve surgical outcome after colorectal cancer surgery? Acta Chir Iugosl 53:85–89PubMedCrossRefGoogle Scholar
  64. 64.
    Rockemann MG, Seeling W, Bothner U et al (1991) Postoperative outcome after abdominal surgery: patient controlled analgesia versus epidural analgesia with morphine or bupivacaine/morphine. Anesthesiology 75(Suppl):A1088CrossRefGoogle Scholar
  65. 65.
    Rodgers A, Walker N, Schug S et al (2000) Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials. BMJ 321:1493–1497PubMedCrossRefGoogle Scholar
  66. 66.
    Saada M, Catoire P, Bonnet F et al (1992) Effect of thoracic epidural anesthesia combined with general anesthesia on segmental wall motion assessed by transesophageal echocardiography. Anesth Analg 75:329–335PubMedCrossRefGoogle Scholar
  67. 67.
    Saada M, Duval AM, Bonnet F et al (1989) Abnormalities in myocardial segmental wall motion during lumbar epidural anesthesia. Anesthesiology 71:26–32PubMedCrossRefGoogle Scholar
  68. 68.
    Sabate A, Biescas J, Vila C et al (1995) Laparoscopic cholecystectomy in high risk patients: a randomized comparison between epidural analgesia and general anaesthesia. Br J Anaesth 74(Suppl):A172Google Scholar
  69. 69.
    Schmidt C, Hinder F, Van Aken H et al (2005) The effect of high thoracic epidural anesthesia on systolic and diastolic left ventricular function in patients with coronary artery disease. Anesth Analg 100:1561–1569PubMedCrossRefGoogle Scholar
  70. 70.
    Seeling W, Altemeyer KH, Berg S et al (1982) Die kontinuierliche thorakale Periduralanästhesie zur intra- und postoperativen Analgesie. Anaesthesist 31:439–448PubMedGoogle Scholar
  71. 71.
    Seeling W, Bothner U, Eifert B et al (1991) Patientenkontrollierte Analgesie versus Epiduralanalgesie mit Bupivacain oder Morphin nach großen abdominellen Eingriffen. Kein Unterschied in der postoperativen Morbidität. Anaesthesist 40:614–623PubMedGoogle Scholar
  72. 72.
    Seeling W, Bruckmooser KP, Hüfner C et al (1990) Keine Verminderung postoperativer Komplikationen nach Katheterepiduralanalgesie nach großen abdominellen Eingriffen. Anaesthesist 39:33–40PubMedGoogle Scholar
  73. 73.
    Sojljakova M, Andonov V, Basevska R et al (1987) General and high epidural anesthesia in relation to general anesthesia in patients at risk in abdominal surgery. Acta Chir Iugosl 34(Suppl 2):177–182PubMedGoogle Scholar
  74. 74.
    Stenseth R, Berg EM, Bjella L et al (1993) The influence of thoracic epidural analgesia alone and in combination with general anesthesia on cardiovascular function and myocardial metabolism in patients receiving beta-adrenergic blockers. Anesth Analg 77:463–468PubMedCrossRefGoogle Scholar
  75. 75.
    Svircevic V, van Dijk D, Nierich AP et al (2011) Meta-analysis of thoracic epidural anesthesia versus general anesthesia for cardiac surgery. Anesthesiology 114:271–282PubMedCrossRefGoogle Scholar
  76. 76.
    Taniguchi M, Kasaba T, Takasaki M (1997) Epidural anesthesia enhances sympathetic nerve activity in the unanesthetized segments in cats. Anesth Analg 84:391–397PubMedGoogle Scholar
  77. 77.
    Toft P, Jorgensen A (1987) Continuous thoracic epidural analgesia for the control of pain in myocardial infarction. Intensive Care Med 13:388–389PubMedCrossRefGoogle Scholar
  78. 78.
    Tuman KJ, McCarthy RJ, March RJ et al (1991) Effects of epidural anesthesia and analgesia on coagulation and outcome after major vascular surgery. Anesth Analg 73:696–704PubMedCrossRefGoogle Scholar
  79. 79.
    Tuman KJ, McCarthy RJ, March RJ et al (1992) Effects of epidural anesthesia and analgesia on coagulation and outcome after major vascular surgery. Surv Anesthesiol 36:299–300CrossRefGoogle Scholar
  80. 80.
    Watson A, Allen PR (1994) Influence of thoracic epidural analgesia on outcome after resection for esophageal cancer. Surgery 115:429–432PubMedGoogle Scholar
  81. 81.
    Wiessner C, Gastmeier J, Seifert S et al (2005) The benefits of thoracic epidural analgesia within a collaborate clinical pathway in patients undergoing liver surgery. Anesthesiology 103:A1053Google Scholar
  82. 82.
    Wiessner DLRJ, Heller AR, Wirth MP et al (2005) Continuous thoracic epidural anesthesia reduces the incidence and duration of postoperative gastrointestinal dysfunction in patients undergoing radical cystectomy. Anesthesiology 103:A995Google Scholar
  83. 83.
    Wijeysundera DN, Beattie WS, Austin PC et al (2008) Epidural anaesthesia and survival after intermediate-to-high risk non-cardiac surgery: a population-based cohort study. Lancet 372:562–569PubMedCrossRefGoogle Scholar
  84. 84.
    Wu CL, Cohen SR, Richman JM et al (2005) Efficacy of postoperative patient-controlled and continuous infusion epidural analgesia versus intravenous patient-controlled analgesia with opioids: a meta-analysis. Anesthesiology 103:1079–1088PubMedCrossRefGoogle Scholar
  85. 85.
    Wu CL, Hurley RW, Anderson GF et al (2004) Effect of postoperative epidural analgesia on morbidity and mortality following surgery in Medicare patients. Reg Anesth Pain Med 29:525–533PubMedGoogle Scholar
  86. 86.
    Wu CL, Rowlingson AJ, Herbert R et al (2006) Correlation of postoperative epidural analgesia on morbidity and mortality after colectomy in Medicare patients. J Clin Anesth 18:594–599PubMedCrossRefGoogle Scholar
  87. 87.
    Wu CL, Sapirstein A, Herbert R et al (2006) Effect of postoperative epidural analgesia on morbidity and mortality after lung resection in Medicare patients. J Clin Anesth 18:515–520PubMedCrossRefGoogle Scholar
  88. 88.
    Yeager MP, Cronenwett JL (1992) Effect of anesthetic technique on outcome after abdominal aortic surgery. J Vasc Surg 15:875–878PubMedCrossRefGoogle Scholar
  89. 89.
    Yeager MP, Glass DD, Neff RK et al (1987) Epidural anesthesia and analgesia in high-risk surgical patients. Anesthesiology 66:729–736PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2011

Authors and Affiliations

  • A. Gauss
    • 1
  • S.K. Jahn
    • 2
  • L.H.J. Eberhart
    • 3
  • W. Stahl
    • 1
  • M. Rockemann
    • 1
  • M. Georgieff
    • 1
  • F. Wagner
    • 1
  • R. Meierhenrich
    • 1
  1. 1.Klinik für AnästhesiologieUniversitätsklinikum UlmUlmDeutschland
  2. 2.Spital ZimmerbergHorgenSchweiz
  3. 3.Klinik für Anästhesie und IntensivtherapieUniversitätsklinikum Gießen u. Marburg GmbHMarburgDeutschland

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