Neuraxial block, death and serious cardiovascular morbidity in the POISE trial

BACKGROUND

This post hoc analysis aimed to determine whether neuraxial block was associated with a composite of cardiovascular death, non-fatal myocardial infarction (MI) and non-fatal cardiac arrest within 30 days of randomization in POISE trial patients.

METHODS

A total of 8351 non-cardiac surgical patients at high risk of cardiovascular complications were randomized to β-blocker or placebo. Neuraxial block was defined as spinal, lumbar or thoracic epidural anaesthesia. Logistic regression, with weighting using estimated propensity scores, was used to determine the association between neuraxial block and primary and secondary outcomes.

RESULTS

Neuraxial block was associated with an increased risk of the primary outcome [287 (7.3%) vs 229 (5.7%); odds ratio (OR), 1.24; 95% confidence interval (CI), 1.02-1.49; P=0.03] and MI [230 (5.9%) vs 177 (4.4%); OR, 1.32; 95% CI, 1.07-1.64; P=0.009] but not stroke [23 (0.6%) vs 32 (0.8%); OR, 0.76; 95% CI, 0.44-1.33; P=0.34], death [96 (2.5%) vs 111 (2.8%); OR, 0.87; 95% CI, 0.65-1.17; P=0.37] or clinically significant hypotension [522 (13.4%) vs 484 (12.1%); OR, 1.13; 95% CI, 0.99-1.30; P=0.08]. Thoracic epidural with general anaesthesia was associated with a worse primary outcome than general anaesthesia alone [86 (12.1%) vs 119 (5.4%); OR, 2.95; 95% CI, 2.00-4.35; P<0.001].

CONCLUSIONS

In patients at high risk of cardiovascular morbidity, neuraxial block was associated with an increased risk of adverse cardiovascular outcomes, which could be causal or because of residual confounding.

Neuraxial block and postoperative epidural analgesia: effects on outcomes in the POISE-2 trial†

BACKGROUND

We assessed associations between intraoperative neuraxial block and postoperative epidural analgesia, and a composite primary outcome of death or non-fatal myocardial infarction, at 30 days post-randomization in POISE-2 Trial subjects.

METHODS

10 010 high-risk noncardiac surgical patients were randomized aspirin or placebo and clonidine or placebo. Neuraxial block was defined as intraoperative spinal anaesthesia, or thoracic or lumbar epidural anaesthesia. Postoperative epidural analgesia was defined as postoperative epidural local anaesthetic and/or opioid administration. We used logistic regression with weighting using estimated propensity scores.

RESULTS

Neuraxial block was not associated with the primary outcome [7.5% vs 6.5%; odds ratio (OR), 0.89; 95% CI (confidence interval), 0.73-1.08; P=0.24], death (1.0% vs 1.4%; OR, 0.84; 95% CI, 0.53-1.35; P=0.48), myocardial infarction (6.9% vs 5.5%; OR, 0.91; 95% CI, 0.74-1.12; P=0.36) or stroke (0.3% vs 0.4%; OR, 1.05; 95% CI, 0.44-2.49; P=0.91). Neuraxial block was associated with less clinically important hypotension (39% vs 46%; OR, 0.90; 95% CI, 0.81-1.00; P=0.04). Postoperative epidural analgesia was not associated with the primary outcome (11.8% vs 6.2%; OR, 1.48; 95% CI, 0.89-2.48; P=0.13), death (1.3% vs 0.8%; OR, 0.84; 95% CI, 0.35-1.99; P=0.68], myocardial infarction (11.0% vs 5.7%; OR, 1.53; 95% CI, 0.90-2.61; P=0.11], stroke (0.4% vs 0.4%; OR, 0.65; 95% CI, 0.18-2.32; P=0.50] or clinically important hypotension (63% vs 36%; OR, 1.40; 95% CI, 0.95-2.09; P=0.09).

CONCLUSIONS

Neuraxial block and postoperative epidural analgesia were not associated with adverse cardiovascular outcomes among POISE-2 subjects.

Ultrasound-guided caudal blockade and sedation for paediatric surgery: a retrospective cohort study

Data on safety and success rates of ultrasound‐guided caudal blockade, performed on sedated children with an uninstrumented airway, are scarce. We performed a retrospective observational study of validated data from April 2014 to December 2020 in a paediatric cohort where the initial plan for anaesthetic management was sedation and caudal epidural without general anaesthesia or airway instrumentation. We examined success rates of this approach and rates of block failure and block‐related complications. In total, 2547 patients ≤ 15 years of chronological age met inclusion criteria. Among the 2547 cases, including 453 (17.8%) former preterm patients, caudal‐plus‐sedation success rate was 95.1%. The primary anaesthesia plan was abandoned for general anaesthesia in 124 cases. Pain‐related block failure in 83 (3.2%) was the most common cause for conversion. Complications included 39 respiratory events and 9 accidental spinal anaesthetics. Higher odds of pain‐related block failure were associated with higher body weight (adjusted OR 1.063, 95%CI 1.035–1.092, p < 0.001) as well as with mid‐abdominal surgery (e.g. umbilical hernia repair) (adjusted OR 15.11, 95%CI 7.69–29.7, p < 0.001), whereas extreme (< 28 weeks) former prematurity, regardless of chronological age, was associated with higher odds (adjusted OR 3.62, 95%CI 1.38–9.5, p = 0.009) for respiratory problems. Ultrasound‐guided caudal epidural, performed under sedation with an uninstrumented airway, is an effective technique in the daily clinical routine. Higher body weight and mid‐abdominal surgical procedures are risk factors for pain‐related block failure. Patients who, regardless of chronological age, had been born as extreme preterm babies are at the highest risk for respiratory events.

Cervical epidural analgesia in current anaesthesia practice: systematic review of its clinical utility and rationale, and technical considerations

Cervical epidural analgesia (CEA) is an analgesic technique, potentially useful for surgeries involving the upper body. Despite the inherent technical risks and systemic changes, it has been used for various surgeries. There have been no previously published systematic reviews aimed at assessing its clinical utility. This systematic review was performed to explore the perioperative benefits of CEA. The review was also aimed at identifying the rationale of its use, reported surgical indications and the method of use. We performed a literature search involving PubMed and Embase databases, to identify studies using CEA for surgical indications. Out of 467 potentially relevant articles, 73 articles were selected. Two independent investigators extracted data involving 5 randomized controlled trials, 17 observational comparative trials, and 51 case reports (series). The outcomes studied in most comparative studies were on effects of local anaesthetics and other agents, systemic effects, and feasibility of CEA. In one randomized controlled study, CEA was observed to decrease the resting pain scores after pharyngo-laryngeal surgeries. In a retrospective study, CEA was shown to decrease the cancer recurrence after pharyngeal-hypopharyngeal surgeries. The limited evidence, small studies, and the chosen outcomes do not allow for any specific recommendations based on the relative benefit or harm of CEA. Considering the potential for significant harm, in the face of better alternatives, its use must have a strong rationale mostly supported by unique patient and surgical demands. Future studies must aim to assess analgesic comparator effectiveness for clinically relevant outcomes.