Epidural Analgesia for Postoperative Pain

Ultrasound-Guided Anterior Quadratus Lumborum Block at Lateral Supra-Arcuate Ligament vs Thoracic Epidural Analgesia after Open Liver Surgery: A Randomized, Controlled, Noninferiority Trial

BACKGROUND

Thoracic epidural analgesia (TEA) has demonstrated great analgesic benefits in open liver surgery. However, the increased risk of postoperative coagulopathy after open liver surgery has promoted interest in alternate analgesic research. We aimed to explore whether ultrasound-guided anterior quadratus lumborum block at the lateral supra-arcuate ligament (LAL-QLB) with intravenous analgesia was noninferior to TEA under multimodal analgesia after open liver surgery.

STUDY DESIGN

Seventy-four patients undergoing open liver surgery were randomized (1:1) to the LAL-QLB or TEA group in this open-label study. The primary outcome was the numeric rating scale during coughing at 24 hours postoperatively with a noninferiority limit of 1.

RESULTS

The mean difference of numeric rating scale during coughing at 24 hours postoperatively was 0.32 (95% CI -0.03 to 0.68), showing noninferiority. The TEA group had better pain scores at 1 and 6 hours, and the early postoperative pain of the LAL-QLB group was within the clinically acceptable limit with no differences at other time points. The LAL-QLB group received more opioids within 24 hours postoperatively. There were no differences in analgesia-related adverse reactions or rescue analgesia. Postoperative coagulopathy was responsible with 19.4% of delayed epidural removal. TEA outperformed LAL-QLB in terms of ambulation and bowel recovery. There were no differences in hospital stay or 30-day postoperative complications.

CONCLUSIONS

LAL-QLB provided noninferior analgesia at 24 hours postoperatively. Despite regarding coagulopathy and delayed epidural removal, TEA was found to be better than LAL-QLB for pain management after open liver surgery. Epidural removal required close coagulation test.

Tunneling Does Not Prevent Dislodgment of Epidural Catheters: A Randomized Trial

Background:

Epidural analgesia is preferred in postoperative pain control, but dislodgment is a major factor for failure. Tunneling is well known to control displacement of catheters. In this study, we evaluated if we can depend on tunneling in preventing dislodgment of epidural catheters.

Aims:

The aim is to study if tunneling is effective and safe in reducing the rate of epidural catheters' dislodgment.

Setting and Design:

The study was carried out at a single tertiary cancer center. The trial was parallel, simple randomized, controlled, and single blind. Allocation of treatments was generated using random number tables.

Subjects and Methods:

Two hundred patients undergoing major surgeries were randomized. Epidural catheters were affixed to the skin through subcutaneous tunneling to a length of 5 cm or using standard adhesive tape without tunneling. Patients were on follow-up for 6 days postsurgery according to policy.

Statistical Analysis Used:

Categorical variables were analyzed by Chi-square and Fisher's exact test. Student t-test was used for continuous variables.

Results and Conclusion:

A total of 200 patients were randomized, 92 patients received tunneled catheters and 108 received nontunneled catheters. Patients were between 20 and 85 years; 63% were male. The mean days of epidural analgesia were similar in both groups (2.7 compared to 2.5 days). About 7.6% of epidurals were dislodged in the tunneled group compared to 10.2% in the nontunneled group (P = 0.699). No differences were identified in the incidence of pain or adverse events between the groups. Tunneling did not improve the rates of dislodgment in epidural catheters. There were no safety concerns associated with tunneling epidural catheters.

Post-Pancreaticoduodenectomy Outcomes and Epidural Analgesia: A 5-year Single-Institution Experience

BACKGROUND

Optimal pain control post pancreaticoduodenectomy is a challenge. Epidural analgesia (EDA) is used increasingly, despite inherent risks and unclear effects on outcomes.

METHODS

All pancreaticoduodenectomies (PDs) performed from January 2013 through December 2017 were included. Clinical parameters were obtained from a retrospective review of a prospective clinical database, the American College of Surgeons NSQIP prospective institutional database, and medical record review. Chi-square, Fisher's exact test, and independent-samples t-tests were used for univariable analyses. Multivariable regression was performed.

RESULTS

Six hundred and seventy-one consecutive PDs from a single institution were included (429 EDA, 242 non-EDA). On univariable analysis, EDA patients experienced significantly less wound disruption (0.2% vs 2.1%), unplanned intubation (3.0% vs 7.9%), pulmonary embolism (0.5% vs 2.5%), mechanical ventilation longer than 48 hours (2.1% vs 7.9%), septic shock (2.6% vs 5.8%), and lower pain scores. On multivariable regression (accounting for baseline group differences (ie sex, hypertension, preoperative transfusion, laboratory results, approach, and pancreatic duct size), EDA was associated with less superficial wound infections (odds ratio [OR] 0.34; 95% CI 0.14 to 0.83; p = 0.017), unplanned intubations (OR 0.36; 95% CI 0.14 to 0.88; p = 0.024), mechanical ventilation longer than 48 hours (OR 0.22; 95% CI 0.08 to 0.62; p = 0.004), and septic shock (OR 0.39; 95% CI 0.15 to 1.00; p = 0.050). Epidural analgesia improved pain scores post-PD days 1 to 3 (p < 0.001). No differences were seen in cardiac or renal complications; pancreatic fistula (B+C) or delayed gastric emptying, 30-/90-day mortality, length of stay, readmission, discharge destination, or unplanned reoperation.

CONCLUSIONS

Based on the largest single-institution series published to date, our data support the use of EDA for optimization of pain control. More importantly, our data document that EDA improved infectious and pulmonary complications significantly.

Factors Associated with Inadequate Pain Control among Postoperative Patients with Cancer

Postoperative pain is considered a major, complex and multidimensional problem that affects the clinical and functional outcomes of patients and may contribute to increased postoperative complications. The goal of this study was to determine the prevalence of inadequate pain control and to investigate the factors associated with inadequate pain control among postoperative cancer patients. A descriptive correlational, cross-sectional design was used. The study was conducted at four adult inpatient oncology departments at King Hussein Cancer Center, a nongovernmental, nonprofit, comprehensive hospital for treating cancer patients in Amman, Jordan. The convenience sample of 800 cancer patients selected comprised postoperative patients diagnosed with cancer and aged ≥18 years who were willing to participate and able to use the numeric rating scale. About 32.9% of patients had pain scores higher than 4/10 at rest, and 56.4% of patients had pain scores higher than 4/10 on movement. Data revealed that patients aged between 18 and 63 years (odds ratio [OR] = 0.196, p < .0005, and OR = 0.245, p < .0005) and chronic user patients (OR = 28.029, p < .0005, and OR = 10.332, p < .0005) had increased odds of poor pain control at rest and on movement, respectively. Administration of preemptive medications and of fentanyl and bupivacaine during the postoperative period was significantly associated with decreased odds of poor pain control. The intravenous route was associated with increased odds of poor pain control at rest and on movement (OR = 2.279, p = .016, and OR = 5.393, p = .012) compared with other routes, including combinations of the intravenous and oral or epidural route. Chronic use of pain medications and older age were predictors of inadequate pain control postoperatively. Administration of preemptive medications and of combinations of fentanyl and bupivacaine via the epidural route was associated with better pain control.

Continuous Femoral Nerve Blockade versus Epidural Analgesia for Postoperative Pain Relief in Knee Surgeries: A Randomized Controlled Study

Background:

Peripheral neural blockade provides effective analgesia with potentially less side effects than an epidural blockade. The present study was undertaken to compare continuous femoral nerve blockade (CFNB) with continuous epidural analgesia (CEA) for postoperative pain control in knee surgeries.

Materials and Methods:

The patients belonging to the American Society of Anesthesiologists Class I and II scheduled for various knee surgeries under spinal anesthesia were enrolled in this study. They were randomly divided into two equal groups of thirty patients each. The Group I patients received CFNB and in the Group II patients epidural catheter was placed preoperatively. Postoperatively, continuous infusion with 0.0625% bupivacaine and fentanyl 2 μg/ml started at 5 ml/h for 72 h in both the groups. Data on Visual Analog Scale (VAS) pain scores, hemodynamic changes, side effects at 0, 1, 6, 12, 24, 36, 48, 60, and 72 h and requirement of analgesic doses for the first 24 h of the surgery were noted.

Results:

In both the groups, pain was well controlled, mean VAS of pain were 0.2, 0.6, 2.47, 2.07, 2.73, 1.5, 1.43, 1.37, and 1.3 for femoral and 0.13, 0.93, 2.57, 2.17, 2.33, 1.6, 1.43, 1.30, and 1.33 for epidural group during 0, 1, 6, 12, 24, 36, 48, 60, and 72 h which was not statistically significant. Hemodynamics were stable throughout in both the groups. The patients in CEA had more incidences of pruritus and urinary retention.

Conclusion:

CFNB provides postoperative analgesia equivalent to that obtained with a CEA but with fewer side effects.

A nationwide analysis of the use and outcomes of perioperative epidural analgesia in patients undergoing hepatic and pancreatic surgery

BACKGROUND

We sought to define trends in the use of epidural analgesia (EA) for hepatopancreatic procedures, as well as to characterize inpatient outcomes relative to the use of EA.

METHODS

The Nationwide Inpatient Sample database was queried to identify all elective hepatopancreatic surgeries between 2000 and 2012. In-hospital outcomes were compared among patients receiving EA vs conventional analgesia using propensity matching.

RESULTS

EA utilization was 7.4% (n = 3,961). The use of EA among minimally invasive procedures increased from 3.8% in 2000 to 9.1% in 2012. The odds of sepsis (odds ratio [OR] .72, 95% confidence interval [CI] .56 to .93), respiratory failure (OR .79, 95% CI .69 to .91), and postoperative pneumonia (OR .77, 95% CI .61 to .98), as well as overall in-hospital mortality (OR .72, 95% CI .56 to .93) were lower in the EA cohort (all P < .05). In contrast, no association was noted between EA and postoperative hemorrhage (OR .81, 95% CI .65 to 1.01, P = .06).

CONCLUSIONS

EA use among patients undergoing hepatopancreatic procedures remains low. After controlling for confounding factors, EA remained associated with a reduction in specific pulmonary-related complications, as well as in-hospital mortality.

Peri-operative epidural may not be the preferred form of analgesia in select patients undergoing pancreaticoduodenectomy

BACKGROUND AND OBJECTIVES

Epidural analgesia has become the preferred method of pain management for major abdominal surgery. However, the superior form of analgesia for pancreaticoduodenecomy (PD), with regard to non-analgesic outcomes, has been debated. In this study, we compare outcomes of epidural and intravenous analgesia for PD and identify pre-operative factors leading to early epidural discontinuation.

METHODS

A retrospective review was performed on 163 patients undergoing PD between 2007 and 2011. We performed regression analyses to measure the predictive success of two groups of analgesia on morbidity and mortality and to identify predictors of epidural failure.

RESULTS

Intravenous analgesia alone was given to 14 (9%) patients and 149 patients (91%) received epidural analgesia alone or in conjunction with intravenous analgesia. Morbidity and mortality were not significantly different between the two groups. Early epidural discontinuation was necessary in 22 patients (15%). Those older than 72 and with a BMI < 20 (n = 5) had their epidural discontinued in 80% of cases compared to 12% not meeting these criteria. However, early epidural discontinuation was not associated with increased morbidity and mortality.

CONCLUSION

Epidural analgesia may be contraindicated in elderly, underweight patients undergoing PD given their increased risk of epidural-induced hypotension or malfunction.

Evaluation of analgesic effect of local administration of morphine after iliac crest bone graft harvesting: A double blind study

Background and Objective:

Pain is a complex process influenced by both physiological and psychological factors. In spite of an armamentarium of analgesic drugs and techniques available to combat post-operative pain, appropriate selection, and effective management for relief of post-operative pain still poses unique challenges. The discovery of peripheral opioid receptors has led to growing interest in the use of locally applied opioids (intra-articular, intra-pleural, intra-peritoneal, and perineural) for managing acute pain. As bone graft harvesting is associated with significant post-operative pain and there is a paucity of literature on the use of peripheral opioids at the iliac crest bone harvesting site, the present study was planned to evaluate the analgesic efficacy of local administration of morphine after iliac crest bone graft harvesting.

Materials and Methods:

A total of 60 patients, 20-50 years of age scheduled to undergo elective surgery for delayed and non-union fracture both bone leg with bone grafting under general anaesthesia (GA) were randomly assigned to one of the four groups of 15 patients each: group 1: 2.5 ml normal saline (NS) +2.5 ml NS infiltrated into the harvest site at 2 sites + 1 ml NS intramuscularly (i/m); Group 2: 2.5 ml NS + 2.5 ml NS infiltrated into the harvest site at 2 sites + 5 mg morphine in 1 ml i/m.; Group 3: 2.5 mg (2.5 ml) morphine + 2.5 mg (2.5 ml) morphine infiltrated into the harvest site at 2 sites + 1 ml NS i/m; Group 4: 0.5 mg naloxone (2.5 ml) +5 mg (2.5 ml) morphine infiltrated into the harvest site at 2 sites + 1 ml NS i/m. Pain from the bone graft site and operative site was assessed for 24 h post-operatively.

Results:

The patients who had received morphine infiltration (Group 3) had significantly less pain scores at the graft site at 4, 6, and 10 post-operative hours. They also had significantly less morphine consumption and overall better pain relief as compared to the other groups.

Conclusions:

Morphine administered peripherally provided better analgesia as compared to that given systemically and this effect was noticeable after 4 h post-operatively.

Epidural analgesia provides better pain management after live liver donation: a retrospective study

Despite the increase in surgical volumes of live liver donation, there has been very little documentation of the postoperative pain experience. The primary aim of this study was to examine the difference in acute postoperative pain intensity and adverse effects between patients who received intravenous patient-controlled analgesia (IV PCA) or patient-controlled epidural analgesia (PCEA) for pain control after live liver donation surgery. A retrospective chart review was performed of 226 consecutive patients who underwent right living donor hepatic surgery at the Toronto General Hospital, Toronto, Canada. Patients who received as their primary postoperative analgesic modality IV PCA (n = 158) were compared to patients who received PCEA (n = 68). Demographic profiles for the 2 groups were similar with respect to age, sex, and body mass index at the time of surgery. For the first 3 postoperative days, pain intensity was significantly lower in patients who received epidural analgesia (P < 0.01). Clinically significant moderate pain (defined as a Numeric Rating Scale pain score >4) was reported more frequently in the IV PCA group (P < 0.05) along with increased sedation (P < 0.05). Pruritus was reported more frequently in the PCEA group of patients compared to the IV PCA group (P < 0.05). Significant between-group differences were not found for the incidence of postoperative vomiting, the time at which patients began fluid intake, the time to initial ambulation, or the length of hospital stay. In conclusion, epidural analgesia provides better postoperative pain relief, less sedation, but more pruritus than IV PCA after live liver donation.

For patients undergoing pancreatoduodenectomy, epidural anesthesia and analgesia improves pain but increases rates of intensive care unit admissions and alterations in analgesics

OBJECTIVES

For some procedures, epidural anesthesia and analgesia (EAA) improves clinical outcomes. It is used during pancreatoduodenectomy (PD) to mitigate morbidities and shorten hospitalizations. Although widespread, the use of this practice has not been examined extensively. The objective of this study was to do so.

METHODS

A retrospective review of 42 patients who underwent PD was performed. Patients with and without EAA were compared. End points included intraoperative blood losses, perioperative fluid requirements, intensive care unit admissions, pain, bowel function, lengths of stay, morbidities, and mortalities.

RESULTS

Eighteen patients received EAA; 24 did not. Patients with EAA who reported less pain on postoperative day 2 (P = 0.03) were more likely to require intensive care unit admissions (P = 0.02) and required more frequent alterations of analgesics (P = 0.0001001). Epidural anesthesia and analgesia was associated with a nonsignificant increase in blood losses and fluid requirements. The groups did not differ in bowel function, lengths of stay, morbidities, or mortalities.

CONCLUSIONS

For patients undergoing PD, EAA was not associated with clinical benefits except for a modest reduction in postoperative pain, which was limited to a single day. Therefore, in this study, the clinical benefits of EAA seem underwhelming.

[Safety and effectiveness of acute postoperative pain treatment in a series of 3670 patients]

OBJECTIVES

To improve the safety and effectiveness of acute postoperative pain treatment in patients under the care of our acute pain clinic, we set 3 objectives: to establish a computerized registry updated daily for all patients treated in the unit, to define categories of quality indicators for assessing the results of acute postoperative pain treatment, and to compare our results with those reported in the literature.

PATIENTS AND METHODS

Prospective study of all patients treated by our pain clinic from May 2004 through June 2007. We analyzed 19 previously defined indicators in 4 categories: case characteristics, effectiveness, safety, and patient satisfaction. We then compared the results to those in the literature.

RESULTS

A total of 3670 patients were included. Results for the most important indicators were as follows: mean follow-up time, 3.1 days (range 1-12 days); effectiveness, 92%; severe pain (>7 on a numerical scale) at rest, 1%; moderate pain (4-6 on the scale) on movement, 31%; accidental catheter removal, 6%; and medication error, 0.4%.

CONCLUSIONS

Daily follow-up and recording of data for patients treated by the acute pain unit facilitates the evaluation of our clinical practice and contributes with improving safety and effectiveness. Comparison with reports in the literature reveals the great heterogeneity of quality assurance indicators that have been defined.

Epidural analgesia in hepatic resection

BACKGROUND

Randomized trials show equivocal benefit of epidural analgesia (EA) for patients undergoing abdominal operations. Partial hepatectomy is often performed using low central venous pressure anesthesia to reduce intraoperative blood loss. We examined effects of pain management strategy on blood pressure, transfusion, and complications in patients undergoing hepatic resection with either EA or IV analgesia (IVA).

STUDY DESIGN

Data on patients undergoing hepatectomy from 2001 to 2004 at Emory University Hospital were analyzed according to route of perioperative pain management. Patient and treatment factors were analyzed for associations with transfusion and morbidity.

RESULTS

From 2001 through 2004, 367 patients underwent elective partial hepatectomy at Emory University Hospital. EA patients were more likely to be older, men, and with malignancy. There were no differences between the groups in extent of resection, operative time, blood loss, or starting hematocrit level. The EA group had lower mean arterial pressure in recovery (86.6+/-14.0 mmHg versus 94.5+/-13.2 mmHg, p < 0.001) and were more likely to be transfused with packed red cells during the hospital course (44.5% versus 27.9%, p < 0.001). On multivariate analysis, age greater than 65 years, American Society of Anesthesiologists grade>2, starting hematocrit<38%, operative time>300 minutes, blood loss>1 L, and use of EA were associated with increased numbers of patients receiving packed red blood cells. Complications and length of stay were similar for both groups.

CONCLUSIONS

Epidural analgesia was independently associated with increased risk of packed red blood cell transfusion after hepatectomy. EA did not appear to minimize complications or shorten hospital stay. Caution should be exercised when considering EA use in hepatic resection.

Evaluation of a continuous epidural analgesia program for postoperative pain in children

A continuous epidural analgesia (CEA) program was developed for pediatric patients cared for outside of a critical care environment. Stable patients can be successfully monitored in the inpatient areas provided sufficient education and support is offered to allow for safe administration, monitoring, and evaluation of patient outcomes. The CEA program was developed in collaboration with the departments of nursing, anesthesiology, and pharmacy and was introduced on a 1-year trial basis on the surgical patient service unit. A retrospective record review was conducted of patients offered CEA over the first 2 years of the program to determine the safety and efficacy of the program. This article describes the development, implementation, and evaluation of the CEA program for surgical patients in a tertiary pediatric hospital. The safety and efficacy of the program as well as the benefits, challenges, and lessons learned are discussed.

Influence of pain treatment by epidural fentanyl and bupivacaine on homing of opioid-containing leukocytes to surgical wounds

Endogenous opioids released from leukocytes extravasating into injured tissue can interact with peripheral opioid receptors to inhibit nociception. Animal studies have shown that the homing of opioid-producing leukocytes to the injured site is modulated by spinal blockade of noxious input. This study investigated whether epidural analgesia (EDA) influences the migration of beta-endorphin (END) and/or met-enkephalin (ENK)-containing leukocytes into the subcutaneous wound tissue of patients undergoing abdominal surgery. In part I patients received general anesthesia combined either with intra- and postoperative EDA (with bupivacaine and fentanyl) or with postoperative patient controlled intravenous analgesia (PCIA; with the opioid piritramide). In part II patients received general anesthesia combined with either epidural fentanyl or bupivacaine which was continued postoperatively. Samples of cutanous and subcutanous tissue were taken from the wound site at the beginning, at the end and at various times after surgery, and were examined by immunohistochemistry for the presence of END and ENK. We found that (i) epidural bupivacaine, fentanyl and PCIA provided similar and clinically acceptable postoperative pain relief; (ii) compared to PCIA, epidural bupivacaine or fentanyl did not change the gross inflammatory reaction within the surgical wound; (iii) opioid-containing leukocytes were almost absent in normal subcutaneous tissue but migrated to the inflamed wound tissue in ascending numbers within a few hours, reaching a peak at about 24 h after surgery; (iv) compared to PCIA, EDA resulted in significantly decreased homing of END-containing leukocytes to the injured site at 24 h after surgery; and (v) the magnitude of this decrease was similar regardless of the epidural medication. These findings suggest that nociceptive but not sympathetic neurons are primarily involved in the attraction of opioid-containing leukocytes during early stages of inflammation.

Pharmacology of drugs formulated with DepoFoam: a sustained release drug delivery system for parenteral administration using multivesicular liposome technology

Lamellar liposome technology has been used for several decades to produce sustained-release drug formulations for parenteral administration. Multivesicular liposomes are structurally distinct from lamellar liposomes and consist of an aggregation of hundreds of water-filled polyhedral compartments separated by bi-layered lipid septa. The unique architecture of multivesicular liposomes allows encapsulating drug with greater efficiency, provides robust structural stability and ensures reliable, steady and prolonged drug release. The favourable characteristics of multivesicular liposomes have resulted in many drug formulations exploiting this technology, which is proprietary and referred to as DepoFoam. Currently, two formulations using multivesicular liposome technology are approved by the US FDA for clinical use, and many more formulations are at an experimental developmental stage. The first clinically available formulation contains the antineoplastic agent cytarabine (DepoCyt) for its intrathecal injection in the treatment of malignant lymphomatous meningitis. Intrathecal injection of DepoCyt reliably results in the sustained release of cytarabine and produces cytotoxic concentrations in cerebrospinal fluid (CSF) that are maintained for at least 2 weeks. Early efficacy data suggest that DepoCyt is fairly well tolerated, and its use allows reduced dosing frequency from twice a week to once every other week and may improve the outcome compared with frequent intrathecal injections of unencapsulated cytarabine. The second available formulation contains morphine (DepoDur) for its single epidural injection in the treatment of postoperative pain. While animal studies confirm that epidural injection of DepoDur results in the sustained release of morphine into CSF, the CSF pharmacokinetics have not been determined in humans. Clinical studies suggest that the use of DepoDur decreases the amount of systemically administered analgesics needed for adequate postoperative pain control. It may also provide superior pain control during the first 1-2 postoperative days compared with epidural administration of unencapsulated morphine or intravenous administration of an opioid. However, at this timepoint the overall clinical utility of DepoDur has yet to be defined and some safety concerns remain because of the unknown CSF pharmacokinetics of DepoDur in humans. The versatility of multivesicular liposome technology is reflected by the many agents including small inorganic and organic molecules and macromolecules including proteins that have successfully been encapsulated. Data concerning many experimental formulations containing antineoplastic, antibacterial and antiviral agents underscore the sustained, steady and reliable release of these compounds from multivesicular liposomes after injection by the intrathecal, subcutaneous, intramuscular, intraperitoneal and intraocular routes. Contingent on the specific formulation and manufacturing process, agents were released over a period of hours to weeks as reflected by a 2- to 400-fold increase in elimination half life. Published data further suggest that the encapsulation process preserves bioactivity of agents as delicate as proteins and supports the view that examined multivesicular liposomes were non-toxic at studied doses. The task ahead will be to examine whether the beneficial structural and pharmacokinetic properties of multivesicular liposome formulations will translate into improved clinical outcomes, either because of decreased drug toxicity or increased drug efficacy.

Regional anaesthesia and perioperative outcome

PURPOSE OF REVIEW

The ongoing debate on the outcome benefits of regional anaesthesia and analgesia over general anaesthesia and systemic analgesia has led to a large number of recently published papers, in particular systematic reviews and meta-analyses that justify a review of the current status of the debate.

RECENT FINDINGS

Meta-analyses have shown consistently improved analgesia with epidural techniques, but the results are by far less consistent with regard to other outcomes, in particular morbidity and mortality. Specific outcomes in specific types of surgery, however, such as bowel recovery after abdominal surgery, can be improved by neuraxial blockade, which also remains the technique of choice for obstetric analgesia and anaesthesia. In certain indications, peripheral nerve blocks may have the potential to replace neuraxial blocks while maintaining the benefits of the regional technique, such as paravertebral blocks for thoracotomies.

SUMMARY

Although there are a considerable number of recent publications on the topic, the complex issues around the effect of regional anaesthesia on outcome is not completely resolved, possibly because the data are often not procedure specific. In addition, however, it may be that our current literature cannot provide a definitive answer.

[Current opinion in epidural analgesia influence on incidence of complications after major abdominal surgery]

Review article summarizes current knowledge of general and epidural anaesthesia combination for major abdominal surgery and incidence of postoperative complications. Continuous epidural local anaesthetics especially through thoracic placed epidural catheter decrease opioids use and as part of "acute rehabilitation" plays important role in postoperative recovery. Most of the studies showed tion is not dependent on kind of anaesthesia and analgesia. Successfully treated postoperative pain prevents chronic postoperative pain, which is best achieved in abdominal surgery with thoracic epidural use.