From The Lancet; April 13, 2002
Epidural anaesthesia and analgesia and outcome of major surgery: a randomised trial
John R A Rigg, Konrad Jamrozik, Paul S Myles, Brendan S Silbert, Phillip J Peyton, Richard W Parsons, Karen S Collins, for the MASTER Anaesthesia Trial Study Group*
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*Members listed at the end of the report Department of Public Health, University of Western Australia, Crawley, Western Australia (J R A Rigg FANZCA, Prof K Jamrozik FAFPHM, R W Parsons PhD, K S Collins BNurs); Imperial College Faculty of Medicine, London, UK (Prof K Jamrozik); Department of Anaesthesia, Alfred Hospital, and Monash University, Melbourne (P S Myles FANZCA); St Vincent's Hospital, Melbourne (B S Silbert FANZCA); and Austin and Repatriation Medical Centre, Melbourne, Victoria, Australia (P J Peyton FANZCA)
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Correspondence to: Dr John Rigg, Office of Safety and Quality, St John of God Health Care, 175 Cambridge Street, Subiaco, WA 6008 Australia (e-mail:john.rigg@sjog.org.au)
Summary
Background Epidural block is widely used to manage major abdominal surgery and postoperative analgesia, but its risks and benefits are uncertain. We compared adverse outcomes in high-risk patients managed for major surgery with epidural block or alternative analgesic regimens with general anaesthesia in a multicentre randomised trial.
Methods 915 patients undergoing major abdominal surgery with one of nine defined comorbid states to identify high-risk status were randomly assigned intraoperative epidural anaesthesia and postoperative epidural analgesia for 72 h with general anaesthesia (site of epidural selected to provide optimum block) or control. The primary endpoint was death at 30 days or major postsurgical morbidity. Analysis by intention to treat involved 447 patients assigned epidural and 441 control.
Findings 255 patients (57·1%) in the epidural group and 268 (60·7%) in the control group had at least one morbidity endpoint or died (p=0·29). Mortality at 30 days was low in both groups (epidural 23 [5·1%], control 19 [4·3%], p=0·67). Only one of eight categories of morbid endpoints in individual systems (respiratory failure) occurred less frequently in patients managed with epidural techniques (23% vs 30%, p=0·02). Postoperative epidural analgesia was associated with lower pain scores during the first 3 postoperative days. There were no major adverse consequences of epidural-catheter insertion.
Interpretation Most adverse morbid outcomes in high-risk patients undergoing major abdominal surgery are not reduced by use of combined epidural and general anaesthesia and postoperative epidural analgesia. However, the improvement in analgesia, reduction in respiratory failure, and the low risk of serious adverse consequences suggest that many high-risk patients undergoing major intra-abdominal surgery will receive substantial benefit from combined general and epidural anaesthesia intraoperatively with continuing postoperative epidural analgesia.
Lancet 2002; 359: 1276-82