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Thoracic epidural anesthesia in cardiac surgery--current standing.

Annals of Cardiac Anaesthesia  Vol. 12:2  Jul-Dec-2009 pain relief, or improving quality of recovery? This question has recently been addressed by Wijeysundera and colleagues,[6] who performed a propensity scored analysis of mortality in patients receiving postoperative epidural analgesia for noncardiac surgery. They raise a point that a powerful study to detect a small (0.2% absolute reduction) mortality risk reduction in high risk patients would require, a study of 55,000 patients in each group. They found a small reduction in mortality in the patients receiving epidural analgesia (number needed to save one life was 477). The incidence of spinal hematoma was rare (0.02%), and was not significantly different between those receiving epidurals or not. The authors point out that their study should not be used as evidence that epidurals will save lives, as the effect size was small and the numbers required were large. However, the implication is that for every patient damaged with an epidural, perhaps nine lives can be saved. The fear that epidurals are inherently more dangerous than conventional treatments has not been substantiated in this large cohort study. Even in cardiac surgery, the fear that systemic anticoagulation will increase, the risk of hematoma has not been borne out over the last 20 years. In an accompanying editorial by Barrington and Scott,[7] the issue of lives saved to patients damaged lead them to conclude that, “in many cases, pain relief alone is an unambiguous clinical indication for postoperative epidural analgesia”.