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Impact of Epidural Analgesia on Mortality and Morbidity After Surgery: Systematic Review and Meta-analysis of Randomized Controlled Trials

Pöpping, Daniel M. MD*; Elia, Nadia MD, MSc; Van Aken, Hugo K. MD*; Marret, Emmanuel MD; Schug, Stephan A. MD§; Kranke, Peter MD, MBA; Wenk, Manuel MD*; Tramèr, Martin R. MD, DPhil

doi: 10.1097/SLA.0000000000000237
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Objective: To quantify benefit and harm of epidural analgesia, compared with systemic opioid analgesia, in adults having surgery under general anesthesia.

Background: It remains controversial whether adding epidural analgesia to general anesthesia decreases postoperative morbidity and mortality.

Methods: We searched CENTRAL, EMBASE, PubMed, CINAHL, and BIOSIS till July 2012. We included randomized controlled trials comparing epidural analgesia (with local anesthetics, lasting for ≥24 hours postoperatively) with systemic analgesia in adults having surgery under general anesthesia, and reporting on mortality or any morbidity endpoint.

Results: A total of 125 trials (9044 patients, 4525 received epidural analgesia) were eligible. In 10 trials (2201 patients; 87 deaths), reporting on mortality as a primary or secondary endpoint, the risk of death was decreased with epidural analgesia (3.1% vs 4.9%; odds ratio, 0.60; 95% confidence interval, 0.39–0.93). Epidural analgesia significantly decreased the risk of atrial fibrillation, supraventricular tachycardia, deep vein thrombosis, respiratory depression, atelectasis, pneumonia, ileus, and postoperative nausea and vomiting, and also improved recovery of bowel function, but significantly increased the risk of arterial hypotension, pruritus, urinary retention, and motor blockade. Technical failures occurred in 6.1% of patients.

Conclusions: In adults having surgery under general anesthesia, concomitant epidural analgesia reduces postoperative mortality and improves a multitude of cardiovascular, respiratory, and gastrointestinal morbidity endpoints compared with patients receiving systemic analgesia. Because adverse effects and technical failures cannot be ruled out, individual risk–benefit analyses and professional care are recommended.

Supplemental Digital Content is Available in the Text.According to a systematic review with meta-analyses, epidural analgesia reduces postoperative mortality and improves cardiovascular, respiratory, and gastrointestinal morbidity compared with systemic opioid-based analgesia.

*Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Germany

Faculty of Medicine, Institute of Social and Preventive Medicine, University of Geneva, Switzerland

Department of Anesthesia and Intensive Care, Tenon University Hospital, Assistance Publique Hôpitaux de Paris, France

§Anesthesiology Unit, School of Medicine and Pharmacology, University of Western Australia, Australia

Department of Anesthesia and Critical Care, University Hospital of Würzburg, Germany

Division of Anesthesiology, Geneva University Hospitals, and Faculty of Medicine, University of Geneva, Switzerland.

Reprints: Daniel M. Pöpping, MD, Klinik für Anästhesiologie, Operative Intensivmedizin und Schmerztherapie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, A1, D-48149 Münster, Germany. E-mail: poppind@uni-muenster.de.

Disclosure: Supported by the German Ministry of Education and Research (Grant No. 01KG1107). The funding organization has no role in the design and conduct of the study; the extraction, management, analysis, or interpretation of the data; or the preparation, review, or approval of the article. The authors declare no conflicts of interest.

Supplemental digital contents are available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.annalsofsurgery.com) and on the authors' webpage, at http://anesthesiologie.hug-ge.ch/data.htm.

© 2014 by Lippincott Williams & Wilkins.