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Meta-Analysis
. 2016 Jan 5;2016(1):CD005059.
doi: 10.1002/14651858.CD005059.pub4.

Epidural pain relief versus systemic opioid-based pain relief for abdominal aortic surgery

Joanne Guay  1 , Sandra Kopp
Affiliations
Meta-Analysis

Epidural pain relief versus systemic opioid-based pain relief for abdominal aortic surgery

Joanne Guay et al. Cochrane Database Syst Rev. .

Abstract

Background: Epidural analgesia offers greater pain relief compared to systemic opioid-based medications, but its effect on morbidity and mortality is unclear. This review was originally published in 2006 and was updated in 2012 and again in 2016.

Objectives: To assess the benefits and harms of postoperative epidural analgesia in comparison with postoperative systemic opioid-based analgesia for adults undergoing elective abdominal aortic surgery.

Search methods: In the updated review, we searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and five trial registers in November 2014, together with reference checking to identify additional studies.

Selection criteria: We included all randomized controlled trials comparing postoperative epidural analgesia and postoperative systemic opioid-based analgesia for adults who underwent elective open abdominal aortic surgery.

Data collection and analysis: Two authors independently assessed trial quality and extracted data. We contacted study authors for additional information and data when required. We assessed the level of evidence according to the scale provided by the GRADE working group.

Main results: We included 15 trials published from 1987 to 2009 with 1498 participants in this updated review. Participants had a mean age between 60.5 and 71.3 years. The percentage of women in the included studies varied from 0% to 28.1%. Adding an epidural to general anaesthesia for people undergoing abdominal aortic repair reduced myocardial infarction (risk ratio (RR) 0.54 (95% confidence interval (CI) 0.30 to 0.97); I(2) statistic = 0%; number needed to treat for one additional beneficial outcome (NNTB) 28 (95% CI 19 to 1423), visual or verbal analogical scale (VAS) scores up to three days after the surgery (mean difference (MD) -1.78 (95% CI -2.32 to -1.25); I(2) statistic = 0% for VAS scores on movement at postoperative day one), time to tracheal extubation (standardized mean difference (SMD) -0.42 (95% CI -0.70 to -0.15); I(2) statistic = 83%; equivalent to a mean reduction of 36 hours), postoperative respiratory failure (RR 0.69 (95% CI 0.56 to 0.85); I(2) statistic = 0%; NNTB 8 (95% CI 6 to 16)), gastrointestinal bleeding (OR 0.20 (95% CI 0.06 to 0.65); I(2) statistic = 0%; NNTB 32 (95% CI 27 to 74)) and time spent in the intensive care unit (SMD -0.23 (95% CI -0.41 to -0.06); I(2) statistic = 0%; equivalent to a mean reduction of six hours). We did not demonstrate a reduction in the mortality rate up to 30 days (RR 1.06 (95% CI 0.60 to 1.86); I(2) statistic = 0%). The level of evidence was low for mortality and time before tracheal extubation; moderate for myocardial infarction, respiratory failure and intensive care unit length of stay; and high for gastrointestinal bleeding and VAS scores.

Authors' conclusions: Epidural analgesia provided better pain management, reduced myocardial infarction, time to tracheal extubation, postoperative respiratory failure, gastrointestinal bleeding, and intensive care unit length of stay compared with systemic opioid-based drugs. For mortality, we did not find a difference at 30 days.

PubMed Disclaimer

Conflict of interest statement

Joanne Guay: I have had no direct relationship with any pharmaceutical company or equipment manufacturer in the past five years. I have not acted as witness expert in the past five years. I am not an author in any of the included or excluded studies. I do not hold any stock other than mutual funds. During the last five years, I have received fees as speaker for two lectures given at the University of Dalhousie: one on regional anaesthesia for carotid endarterectomy and the other on local anaesthetic‐related methaemoglobinaemia. My fees were paid by the University of Dalhousie. I am the editor of a multi authors textbook on anaesthesia (including notions on general and regional anaesthesia). I receive fees for a course on airway management at University of Quebec en Abitibi‐Temiscamingue.

Sandra Kopp: none known.

Figures

1
1
Flow diagram of study selection. We excluded one trial (Lombardo 2009; quasi‐randomized trial; information obtained from the authors by the previous review authors), which was previously included in this review (Nishimori 2012). We added one new trial (Muehling 2009). Therefore, the number of studies included in this review remains unchanged. The search was reran in March 2017. Seven trials were excluded, one trial (Owczuk 2016) awaits classification and one trial (Li 2015) is ongoing. RCT: randomized controlled trial.
2
2
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
3
3
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
4
4
Visual/verbal analogical scores at rest on postoperative day 1. The difference between the intervention is higher in older studies (P value = 0.02). (This meta regression plot was not produced in RevMan. The figure was generated automatically by the software, and cannot be amended. The software has expressed the years as decimals.)
5
5
Meta‐regression on the hospital length of stay versus the year where the study was published. The effect seems to be better in the more recent study (P value = 0.04). Std diff in means: standardized mean difference. (This meta regression plot was not produced in RevMan. The figure was generated automatically by the software, and cannot be amended. The software has expressed the years as decimals.)
1.1
1.1. Analysis
Comparison 1 Epidural versus systemic opioid (overall comparison), Outcome 1 Postoperative mortality.
1.2
1.2. Analysis
Comparison 1 Epidural versus systemic opioid (overall comparison), Outcome 2 Myocardial ischaemia.
1.3
1.3. Analysis
Comparison 1 Epidural versus systemic opioid (overall comparison), Outcome 3 Myocardial infarction.
1.4
1.4. Analysis
Comparison 1 Epidural versus systemic opioid (overall comparison), Outcome 4 Congestive heart failure.
1.5
1.5. Analysis
Comparison 1 Epidural versus systemic opioid (overall comparison), Outcome 5 Ventricular arrhythmia.
1.6
1.6. Analysis
Comparison 1 Epidural versus systemic opioid (overall comparison), Outcome 6 Tracheal intubation time.
1.7
1.7. Analysis
Comparison 1 Epidural versus systemic opioid (overall comparison), Outcome 7 Acute respiratory failure.
1.8
1.8. Analysis
Comparison 1 Epidural versus systemic opioid (overall comparison), Outcome 8 Pneumonia.
1.9
1.9. Analysis
Comparison 1 Epidural versus systemic opioid (overall comparison), Outcome 9 Cerebrovascular complication.
1.10
1.10. Analysis
Comparison 1 Epidural versus systemic opioid (overall comparison), Outcome 10 Acute kidney injury.
1.11
1.11. Analysis
Comparison 1 Epidural versus systemic opioid (overall comparison), Outcome 11 Gastrointestinal haemorrhage.
1.12
1.12. Analysis
Comparison 1 Epidural versus systemic opioid (overall comparison), Outcome 12 Visual analogue scale (VAS) score at rest on day 1.
1.13
1.13. Analysis
Comparison 1 Epidural versus systemic opioid (overall comparison), Outcome 13 VAS score on movement on day 1.
1.14
1.14. Analysis
Comparison 1 Epidural versus systemic opioid (overall comparison), Outcome 14 VAS score at rest on day 2.
1.15
1.15. Analysis
Comparison 1 Epidural versus systemic opioid (overall comparison), Outcome 15 VAS score on movement on day 2.
1.16
1.16. Analysis
Comparison 1 Epidural versus systemic opioid (overall comparison), Outcome 16 VAS score at rest on day 3.
1.17
1.17. Analysis
Comparison 1 Epidural versus systemic opioid (overall comparison), Outcome 17 VAS score on movement on day 3.
1.18
1.18. Analysis
Comparison 1 Epidural versus systemic opioid (overall comparison), Outcome 18 Intensive care unit length of stay.
1.19
1.19. Analysis
Comparison 1 Epidural versus systemic opioid (overall comparison), Outcome 19 Hospital length of stay.
See this image and copyright information in PMC

Update of

References

References to studies included in this review

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    1. Seeling W, Ahnefeld FW, Rosenberg G, Heinrich H, Spilker D. Aortofemoral bifurcation bypass ‐ effect of anaesthesia procedure (NLA, thoracic continuous catheter peridural anaesthesia) on circulation, respiration and metabolism. Hemodynamic changes caused by peridural anaesthesia and anaesthesia induction [Aortofemoraler Bifurkationsbypass ‐ der Einfluss des Anaesthesieverfahrens (NLA, thorakale kontinuierliche Katheterperiduralanaesthesie) auf Kreislauf, Atmung und Stoffwechsel]. Anaesthesist 1985;34(5):217‐28. [PUBMED: 4025792] - PubMed
Seeling 1985b {published data only}
    1. Seeling W, Ahnefeld FW, Hamann H, Heinrich H, Hutschenreiter S, Rosenberg G, et al. Aortofemoral bifurcation bypass ‐ effect of the anesthesia procedure (NLA, thoracic continuous catheter peridural anesthesia) on circulation, respiration and metabolism. Intraoperative circulatory reactions [Aortofemoraler Bifurkationsbypass ‐ Der Einfluss des Anaesthesieverfahrens (NLA, thorakale kontinuierliche Katheterperiduralanaesthesie) auf Kreislauf, Atmung und Stoffwechsel. Intraoperatives Kreislaufverhalten]. Anaesthesist 1985;34(9):417‐28. [PUBMED: 3909840] - PubMed
Seeling 1986 {published data only}
    1. Seeling W, Ahnefeld FW, Grunert A, Heinrich H, Lotz P, Rosenberg G, et al. Aortofemoral bifurcation bypass. Effect of the anaesthesia procedure (NLA, thoracic continuous catheter peridural anesthesia) on circulation, respiration and metabolism. Homeostasis and oxygen transport [Aortofemoraler Bifurkationsbypass. Der Einfluss des Anaesthesie‐verfahrens (NLA, thorakale kontinuierliche Katheterperidural‐anaesthesie) auf Kreislauf, Atmung und Stoffwechsel. Homoostase und Sauerstofftransport]. Anaesthesist 1986;35(2):80‐92. [PUBMED: 3963358] - PubMed
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Seeling 1991 {published data only}
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References to studies awaiting assessment

Owczuk 2016 {published data only}
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References to ongoing studies

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References to other published versions of this review

Nishimori 2004
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