Letters to the Editor Is Epidural Anesthesia Redly Better for Major Vascular Surgery?

2. Ellis DJ,Millar WL,Reisner LS. A randomized double-blind comparison of epidural versus intravenous fentanyl infusion for analgesia after cesarean section. Anesthesiology 1990;72981-6.

To the Editor:

In Response:

Tuman et al. (1)have stated that ”epidural anesthesia and analgesia is associated with beneficial effects on coagulation status and postoperative outcome compared with intermittent ondemand opioid analgesia.” Their study compared both laboratory and clinical indicators of a hypercoagulable state after either general anesthesia and ondemand parenteral and/or oral narcotic administration or general plus epidural anesthesia followed by epidural opiate and local anesthetic administration. They suggest that the epidural group had a better outcome due to a decrease in stress (presumablysecondary to better pain control) in that group compared with the general anesthesia group. They imply that medications administered epidurally have a more beneficial effect than similar medications given by simpler routes. However, their data do not support this conclusion. As they provide neither objective data about the degree of comfort in the two groups of patients nor details of the pain management provided for patients in the general anesthesia group, it is possible that these patients received opiates by intramuscular injection too infrequently or in too small d o s e d common problems with typical postoperative pain management. Patients in the epidural group had a member of a postoperative pain management team supervise administration of the epidural medications. Furthermore, patients in the epidural group probably had a sigruficant degree of sympathetic blockade due to the bupivacaine infusion. Patients in the general anesthesia group apparently did not receive a similar sympathetic block (via oral or parented medication). It seems then that the observed beneficial result may be due to good pain control and sympathetic blockade, rather than due to the route of administration of the medications. Although epidural opiates are frequently used to manage postoperative pain, there is no controlled study comparing this method with other ndequate means of pain control that indicates that epidural administration has any advantages over effective pain control achieved by other means. In fact, in one controlled study comparing epidural and intravenous fentanyl after cesarean section (2), the techniques were not distinguishable. Benjamin H. Gorsky, MD

Dr.Gorsky raises questions regarding the interpretation of

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References 1. Tuman KJ,Mccarthy RJ,Mardr RJ,DeLaria CA, Patel RV, Ivankovich AD. E k k of epidural anesthesia and analgesia on coagulation and outcome after major dsurgery. Anesth Analg 1991;T3:69&704.

01992 by the International Anesthesia Research Society

the findingsof our recent study (1).He C O K ~ Ynotes that we demonstratedbetter outcomesafter major vascular surgery in patients managed with epidural anesthesia and analgesia (FAA)compared with a similar cohort of patients managed with “routine“ ondemand narcotic administrationpostoperatively. We strongly disagree with Gorsky when he states that our data do not support the conclusion that medications administed e p i d d y have a more beneficial effect than similar medications given by simpler routes. Our study demonstrates statistically and clinically important differences between the two treatment p u p s in the rates of cardiovascular, infectious, and o v e d postoperativecomplications. Our data present good evidence of a clear association between attenuation of hypenmagulabitity, a lower incidence of thrombotic events (peripheralarkrial graft, coronary artery or deep vein thromboses), and the use of FAA. We believe our methodology and outcome data speak for themselves: when administered to high-risk vascular surgical patients in the manner d e s c r i i , epidural anesthesia and analgesia is superior to routine ondemand narcotic analgesia administered after isoflurandfentanyl/N20anesthesia. The implication that any medication given e p i d d y will be more beneficial than a similar medication given by a simpler route would be a misinterpretation and overextrapolation of our conclusions. Our findings apply to a specified subset of patients underge ing particular operative procedures and receiving anesthetic and analgesic management amrding to defined protocols. Careful examination of our manuscript reveals that we indeed acknowledge that differences in degree of pain control may in part be associated with secondary effects that result in important coagulation and clinical outcome findings. As noted in the discussion of our manuscript, our ”. . . study design does not allow confirmation or rebuttal of the hypothesis that improved outcome in the setting described may have been related primarily to different degrees of postoperativeanalgesia.” Because our study was designed as an observational critique of the clinical outcome of two randomly assigned methods of perioperative anesthetic management, interpretation of the findings is limited because specific mechanisms were not sought to explain the intergroup differences. We disagree with Gorsky’s claim that ”. . . there is no controlled study comparing . . . [epidural opiates] . . . with other d e p u t e means of pain control that indicates that epidural administration has any advantages over effective pain control achieved by other means.” Salomaki et al. (2) Anesth Analg 1992;75:141-56

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Is epidural anesthesia really better for major vascular surgery?

Letters to the Editor Is Epidural Anesthesia Redly Better for Major Vascular Surgery? 2. Ellis DJ,Millar WL,Reisner LS. A randomized double-blind com...
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