Background Epidural analgesia offers greater pain relief compared to systemic opioid-based medications, but its effect on morbidity and mortality is unclear. Objectives To assess the benefits and harms of postoperative epidural analgesia in comparison with postoperative systemic opioid-based pain relief for adult patients who underwent elective abdominal aortic surgery. Search strategy We searched the Cochrane Central Register of Controlled Trials via OVID (CENTRAL) (The Cochrane Library, Issue 3, 2004); OVID MEDLINE (1966 to July 2004); and EMBASE ( 1980 to June 2004). We assessed non-English language reports and contacted researchers in the field. We did not seek unpublished data. Selection criteria We included all randomized controlled trials comparing postoperative epidural analgesia and postoperative systemic opioid-based analgesia for adult patients 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. Main results Thirteen studies involving 1224 patients met our inclusion criteria; 597 patients received epidural analgesia and 627 received systemic opioid analgesia. The epidural analgesia group showed significantly lower visual analogue scale for pain on movement ( up to postoperative day three), regardless of the site of epidural catheter and epidural formulation. Postoperative duration of tracheal intubation and mechanical ventilation was significantly shorter by about 20% in the epidural analgesia group. The overall incidence of cardiovascular complication; myocardial infarction; acute respiratory failure (defined as an extended need for mechanical ventilation); gastrointestinal complication; and renal insufficiency was significantly lower in the epidural analgesia group, especially in trials that used thoracic epidural analgesia. Authors' conclusions Epidural analgesia provides better pain relief (especially during movement) for up to three postoperative days. It reduces the duration of postoperative tracheal intubation by roughly 20%. The occurrence of prolonged postoperative mechanical ventilation, overall cardiac complication, myocardial infarction, gastric complication and renal complication was also reduced by epidural analgesia, especially thoracic. However, current evidence does not confirm the beneficial effect of epidural analgesia on postoperative mortality and other types of complications. Epidural analgesia provides greater pain relief and faster removal of a tracheal tube after open abdominal aortic surgery compared to systemic opioid-based pain relief. Surgery on the abdominal aorta (the main artery to the legs) requires aggressive postoperative pain management. Epidurals ( pain medications injected into the spinal canal) or systemic opioids (morphine-like drugs injected systemically) are most commonly used. The effect of these two methods on postoperative complications and mortality after abdominal aortic surgery has not been previously clarified. This review found that epidural analgesia reduces the postoperative duration of tracheal intubation by approximately 20%, and provides better pain management for up to three postoperative days regardless of the site of epidural catheter placement and epidural medications used. Epidural analgesia, especially thoracic epidural, also provided reduced incidences of postoperative cardiac complications; prolonged mechanical ventilation, ( use of a machine to improve the exchange of air between the lungs and the atmosphere); gastrointestinal complications; and renal insufficiency. However the mortality was unchanged. Most of the patients with epidural pain management also had epidural anaesthesia for the surgical procedure.
