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WhatIstheRoleofEpiduralAnalgesiainAbdominal
Surgery?
SusanMNimmoMBChBFRCAFFPMRCAFRCPEdinMScPainMedicine,LorraineSHarringtonMBChB
BScMRCPFRCA
ContEduAnaesthCritCareandPain.201414(5):224229.

WhatIstheRoleofEpiduralAnalgesiainAbdominalSurgery?
Manyofthebenefitsofeffectiveepiduralanalgesiaforopenabdominalsurgeryaresoundlyestablished.Awellmanaged
epiduralcanprovideexcellentanalgesiainthepostoperativeperiodallowingthepatienttobepainfreeatrestandwhen
mobilizing.Inaddition,epiduralblockwillobtundtheacutestressresponsetosurgery.Consequentlyalongwiththeanalgesic
benefits,patientsarelesslikelytosuffercardiac,respiratory,orgastrointestinalsideeffects.However,theincreasing
applicationoflaparoscopictechniquesformanymajorintraabdominalproceduresresultsinlesspainandshorterrecovery
timesthanopensurgery.Wenowhaveaclearerappreciationofthepotentialrisksofepiduralanalgesia.Anumberof
alternativelocalanaestheticbasedanalgesictechniqueshavebeendescribed.Inthecontextoftheseadvances,wediscuss
whetherinfactinabdominalsurgery,thereisstillatimeandaplaceforthethoracicepidural?

BenefitsofEpiduralAnalgesia1
Inthecontinuedsearchforoutcomebenefitsfromtheapplicationofeffectiveepiduralanalgesia,perhapsthemostobviousbut
frequentlyoverlookedbenefitisanalgesia(Fig.1).Patientswhohaveaneffectiveepiduralcanexperienceexcellentandoften
completepainreliefafteroperationwhiletheepiduralisrunning.Patientsreportreducedvisualanaloguepainscoresatrestand
onmovement,thislatterbeingbeneficialforearlymobilizationofpatients.Thefewstudiesseekingthepatient'sperspectiveon
postoperativeepiduralanalgesiashowahighlevelofsatisfactionandqualityofrecovery. [2]

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Figure1.

Benefitsofeffectiveepiduralanalgesia(levelofevidenceinsupportofthesefromarangeofsurgicalspecialities).

Thepresenceofanindwellingepiduralcatheterallowseitheracontinuousinfusionorbolusdosing,ormostcommonly,a
combinationofthetwo,allowinganalgesiatobecontinuedforseveraldaysasdeterminedbypatientrequirement.Adetailed
discussionofthedrugsanddosesusedforepiduralanalgesiaisbeyondthescopeofthisreview.

Aftertissueinjurysuchassurgery,ourbodiesrespondthroughacomplexneurohumoralresponse,theaimofwhichissurvival
fromtheacuteinjuryandtherepairoftissuedamage(Fig.2).However,intheperioperativepatient,componentsofthestress
responsemaybedetrimentalandcontributetopostoperativecomplications.Thiswillbemoresignificantinpatientswhoare
elderlyorwhohavemajorcomorbidities.

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Figure2.

Componentsofthestressresponsetosurgery.

Surgesofcatecholaminesresultinincreasingworkloadfortheheart,andconsequentincreasingmyocardialoxygen
requirements.Anoxygensupplydemandmismatchinpatientswithunderlyingcoronarydiseasecanleadtomyocardial
ischaemiaorinfarction,arrhythmias,andcardiacfailure.

Postoperativepatientsareathighriskfordevelopmentofthromboembolicdisease.Thisisduetoacombinationofperioperative
immobility,theirsurgicalconditionsuchasmalignancyorinflammatoryboweldisease,andthehypercoagulablestateresulting
fromactivationofthestressresponse.

Thecatabolicresponseleadstohyperglycaemia,postoperativenegativenitrogenbalance,andfatigue.Patientsarealso
immunocompromisedwitharesultantincreasedriskofpostoperativeinfection.

Blockofafferentneuralinputfromthesiteofsurgerywithepiduralanalgesiahasabeneficialeffectinreducingtheneuro
hormonalaspectofthesurgicalstressresponse,withthepotentialforareductioninrespiratory,thromboembolic,and
cardiovasculareventsaftermajorsurgery.Thebeneficialeffectsofeffectiveepiduralanalgesiaonrespiratoryfunctionand
complicationsafterabdominalsurgeryarewellestablished.Theevidenceforareductioninthromboemboliccomplications
comesmainlyfromtheorthopaedicliterature.Studiesinabdominalsurgeryhaveshownonlyanonsignificanttrendtowards
reductionhowever,activemobilizationhasnotbeenpromotedinthese.Similarly,studiesassessingcardiovascular
complicationsafterabdominalsurgerysuggestanimprovementincardiovascularmorbidity.Arecentlypublishedretrospective
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subgroupanalysisofpatientswithepiduralanalgesiaincludedinthePOISEstudyhasactuallysuggestedanincreased
cardiovascularcomplicationrateinthethoracicepiduralgroup.Theyalsorecordedsignificanthypotensioninthisgroupwhich
mayhavebeenthemechanismforthis.Sinceavoidanceofhypotensionshouldbeagoalofmanagementofpatientswith
epiduralanalgesiaandsincespecificdetailsoftheepiduralblockincludingextentofblockandagentsusedhavenotbeen
recorded,theimportanceoftheseresultsisuncertain.Thispaperdoeshoweverraiseimportantissueswhichmandatefurther
studyandensuresthatrisksandbenefitsofsuchanalgesictechniquescontinuetobeappropriatelyquestioned.Reducingthe
neurohormonalinputtothepostoperativestressresponsewithepiduralanalgesiacanalsoimprovenitrogenbalance,fatigue,
andpostoperativemobility.Thecombinationofnormoglycaemiaandavoidanceofimmunosupressioncontributestoareduction
ininfectiouscomplications.

Abdominalsurgerywithhandlingofthegutpredisposespatientstodevelopingtheunpleasantandpotentiallylifethreatening
complicationofparalyticileus.Surgicalhandling,excessivei.v.fluidscausingboweloedema,increasedsympathetictone,and
systemicopioidscanallcontributetointestinalhypomotilityandileus.

Inopenabdominalsurgery,theuseofathoracicepiduralhasbeenshowntobeaneffectiveinterventioninreducingthe
incidenceanddurationofpostoperativeileus.Thisisduebothtothesympatheticblockproducedbyepidurallocalanaesthetic
andbytheavoidanceofsystemicopioids.Conversely,thereareconcernsthatepiduralhypotensionand/orvasopressoruseto
combatthiscouldcompromisehealingoftheanastomosisaftergastrointestinalresections.Itisthereforereassuringthatthere
isnopublishedevidenceforanassociationbetweenepiduralanalgesiaandanastomoticleak.Somestudieshave
demonstratedareducedrateofanastomoticbreakdownafterbowelresectioninpatientswithathoracicepidural.

Thedevelopmentofgutoedemamayalsobeafactorinanastomoticbreakdownandleak.Itisthereforeessentialthatindividual
unitshaveapolicytoeffectivelymanageepiduralrelatedhypotension,sothatexcessivei.v.fluidsarenotadministeredbeyond
thatrequiredforoptimalintravascularfilling.

Multimodal/EnhancedRecoveryProgrammes
Itisincreasinglyrecognizedthatinrecoveryfrommajorsurgery,thetrioofeffectivepainrelief,earlymobilization,andearly
recoveryofgastrointestinalfunctioniscrucial.Thesecomponentsofrecoveryareinextricablylinkedandifwearetogain
maximumbenefitforourpatientsfromeffectiveanalgesia,thentheseotherfactorsmustalsobeaddressedandachieved.Itwill
beapparentfromthisthatwhilegoodanalgesiawillaidrecovery,sideeffectsfromanalgesiahavethepotentialtoobstructthis
process.Thiswouldincludelimitingmobilitybyhavingpatientsattachedtopumpsandmonitorsassociatedwiththeanalgesic
techniquewhichisoftenaparticularissueforpatientsreceivingepiduralanalgesia.Increasingnumbersofstudiesare
confirmingbenefitfrommultimodalrecoveryprogrammesincludingtheuseofepiduralanalgesiaforabdominalsurgeryand
thesearedemonstratingimprovedqualityofrecovery,shorterlengthofhospitalstay,andreducedperioperativecomplications.
[3]

ChronicPostsurgicalPain
Chronicpostsurgicalpain(CPSP)isnowrecognizedasasignificantproblem. [4]Recentresearchindicatesthatacute
postoperativepainandCPSParenotseparateentities,butrathertheyareacontinuumofthesamephenomenon.Severe
acutepostoperativepainisarecognizedriskfactorforthedevelopmentofCPSPinsusceptibleindividuals.Repetitive
nociceptivestimulationintheacutepostoperativeperiodleadstoperipheralandcentralsensitizationandinsomepatients,this
appearstobemaintainedbeyondtheacutepainepisoderesultinginchronicpain.Byblockingafferentnociceptiveinput,itis
anticipatedthatpainandsensitizationwillbereducedleadingtoareductionintheincidenceandseverityofCPSP.Similarly,it
isrecognizedthatupto10%ofpatientswillexperienceacuteneuropathicpainafterabdominalsurgery.Failuretorecognize
andmanagethismaybeacontributoryfactorforCPSPinsusceptibleindividuals.Considerableresearchisbeingtargetedat
thisimportantareabothtoassesswhichpatientsareatriskandwhetherpainmanagementstrategiescanreducethe
incidence.

Thesocioeconomicburdenofchronicpainisenormous,withpatientsexperiencingapoorqualityoflifewhilesufferingfroma
conditionthatisdifficulttotreat.MinimizingtheriskfactorsfordevelopmentofCPSPshouldbeaclinicalpriorityand
consideredwhenplanningtheapproachtoanaesthesiaandanalgesia.Whilemanyoftheriskfactorsareunavoidablesuchas
age,genetics,psychosocialcircumstance,otherssuchastypeofsurgery,anaesthetic,andperioperativeanalgesiaare
modifiable.Todate,thereislimitedpublishedevidenceontheefficacyofgoodperioperativeacutepainmanagementin
reducingCPSP.However,arecentlypublishedcasecontrolledseriesofmorethan100patientsdemonstratesareductionin
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chronicpostsurgicalpainafterabdominalsurgery,inpatientsmanagedwithepiduralanalgesia. [5]Inthefuture,ifpatientsat
highriskofCPSPcouldbeidentified,theymightbenefitfromthequalityofanalgesiaachievablewitheffectiveepiduralblock.

PostoperativeCognitiveDysfunctionandDelirium
Withagrowingelderlypopulationpresentingformajorsurgery,therisksforandavoidanceofpostoperativecognitive
dysfunction(POCD)becomeincreasinglyimportant.POCDisassociatedwithincreasedhospitallengthofstay,persistent
cognitivedefects,increasingphysicaldependence,andanincreasedrateofadmissiontonursinghomes.

Comparisonsoftheimpactofgeneralanaesthesiaandregionalanaesthesiaontheincidenceofpostoperativecognitive
dysfunctionsuggestthatpatientsundergoinggeneralanaesthesiaaremorelikelytosufferfromPOCD.Recentresearchin
depthofanaesthesiamonitoringhasshownthattheriskofPOCDcanbereducedbyreductionintheexposuretogeneral
anaestheticagents. [6]Wheregeneralanaesthesiaremainsnecessary,forexample,inabdominalsurgery,oneofthebenefitsof
epiduralanaesthesiaandanalgesiausedintraoperativelyisthatitreducesthedepthofgeneralanaesthesiarequiredanda
combinedtechniqueshouldthereforehaveabeneficialeffectinreducingPOCDanddelirium.

PreventingCancerRecurrence7
Bothanaestheticandanalgesicagentsareknowntohaveimmunomodulatingeffects.Itisclearlyimportantthatinthecontext
ofincreasingnumbersofoperationstotreatcancer,theeffectofthisisinvestigatedtofacilitatetheoptimalchoiceof
perioperativeanaesthesiaandanalgesia.Anumberofretrospectivestudieshavesuggestedanimprovementindiseasefree
survivalwhereregionalanaesthesiaandanalgesiahasbeenused.Itispostulatedthatthereducedstressresponseoccurring
witharegionaltechniqueresultsinlesspostoperativeimmunocompromisewithconsequentreducedpotentialforthespreadof
micrometastasesatthetimeofsurgery.Alternatively,thebenefitmaybeinavoidingsystemicopioidtherapy,sinceitiswell
establishedthatmorphineandotheropioidsinhibittheactivityofnaturalkillercellsandothercellmediatedimmunityinvitro
andcouldhaveasimilareffectinvivohencefavouringspreadofmetastaticcells.Prospectivetrialsarecurrentlyunderwayto
determinewhethertheuseofaregionalanaesthetictechniquedoesreducetheriskofcancerrecurrence.Theresultsofthese
studiescouldhavesignificantimplicationsforthechoiceofpostoperativeanalgesia.

ComplicationsandDisadvantagesofEpiduralAnalgesia
Epiduralanalgesiaisnotfreeofriskhowever.In2009,theRoyalCollegeofAnaesthetistspublishedtheresultsoftheir3rd
NationalAuditProject,recordingandinvestigatingmajorcomplicationsofcentralneuraxialblockintheUK. [8]Itwasthelargest
everauditofitskindandallowedtheriskofmorbidityandmortalityafterneuraxialblocktobemoreaccuratelystratifiedthan
previously,asanaccuratedenominatorfigureforthenumberofblocksundertakeninayearwasachieved.

ThetotalnumberofneuraxialblocksperformedannuallyintheUKis~707000ofwhich,around98000areepiduralblocks
placedforperioperativeanalgesiainadults(excludingobstetrics)andacutepainmanagementforconditionssuchasrib
fracturesandacutepancreatitis.Inthisauditproject,atotalof84seriouscomplicationsrelatedtocentralneuraxialblockwere
reviewed.Perioperativecentralneuraxialblock,includingepidurals,accountedformorethan80%ofthetotalcomplications.
Severecomplications,thatispermanentneurologicaldeficitordeath,couldnotalwaysbedirectlyattributedtotheneuraxial
techniqueandthereforeresultsintheauditarereportedaspessimistic,thatis,assumingtheblockwasalwaysthecauseand
optimisticwhereunlikelycaseswereexcluded.Severecomplicationsincludedvertebralcanalhaematomas,spinalcord
ischaemia,vertebralcanalabscess,andotherneurologicalinjury.Interpretedpessimisticallyepiduralscausepermanentinjury
ordeathinthisgroupofpatientsinonein5800casesandoptimisticallyonein12200cases.

Avoidanceoforreductionintheriskofcomplicationsmustincludecarefulpatientselectionforepiduralanalgesiawithparticular
considerationofperioperativeanticoagulationandriskofinfection.Similarly,caremustbetakeninensuringaneffectiveaseptic
techniqueforepiduralinsertion.Currently,chlorhexidineisconsideredtheantisepticofchoiceforskinpreparation.The
possibilityofnerveinjurysecondarytointroductionofchlorhexidineintotheepiduralspacemandatesextracarewithitsuse,
particularlyensuringthattheepiduralneedleandcatheterdonotcomeintocontactwithchlorhexidineandthattheskinisfully
drybeforecommencingtheprocedure.Insertiontechniquemustbefastidiousinpreventingcomplications.Multipleattempts
shouldbeavoided,particularlyiftheinsertionisassociatedwithpainordysaesthesia.Finally,postoperativemanagementof
epiduralanalgesiamustbeadequatetobothoptimizethebenefitsofepiduralanalgesiaandtoidentifyanyproblemsatanearly
enoughstageforinvestigationandmanagementtobeundertakenintimetoavoidpermanentneurologicalinjury.Bestpractice

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guidelinesformanagementofepiduralanalgesiahavebeenpublishedandshouldbeadheredto. [9]

Carefulpatientselectionandmeticulouscarewithepiduralinsertionandmanagementshouldkeepcomplicationstothe
minimum.Itshouldbeborneinmindwhendecidingtouseepiduralanalgesiaforapatientthatthereareadvantagesasoutlined
andalsorisks,andthatthealternativeanalgesicregimensavailablearenotwithouttheirowncomplications.

ThebenefitofNAP3isthatitallowsustomakeamoreaccurateriskassessmentinconsideringepiduralanalgesiaforanyone
individualpatient,basedonlikelybenefitvsrisk.

Afurtherdisadvantageofepiduralanalgesiaisfailuretoachieveanacceptablelevelofpainrelief.Ithasbeenestimatedthat
onlyaroundtwothirdsofattemptedepiduralplacementsresultineffectiveanalgesiaforthedurationoftimeintended. [10]The
insertionofathoracicepiduralisaskilledprocedure.Althoughatcompletionoftraining,allanaesthetistsshouldbecompetent
atinsertingthoracicepiduralsunlesstheprocedureisrepeatedoften,theskillmaybelost.Patientsmaynotbeableto
achievetheoptimumpositionforinsertion,ormayhaveanatomythatmakesinsertiondifficultorevenimpossible.Theuseof
ultrasoundmayimprovesuccessratesofinsertion,particularlyinanatomicallychallengingpatients,butisnotyetin
widespreaduse,andinitselfrequiresahighleveloftrainingandskill.

Oncesuccessfullyestablished,epiduralanalgesiarequiresconstantattentionfromskillednursesandanaesthetistsofteninan
acutepainservicetoachieveandmaintainoptimalanalgesia.Attentionmustalsobedirectedtolimitingoravoidingsideeffects
suchashypotensionormotorblock,whichwillreducethebenefitsofthetechniquebypreventingthepatientfrommobilizing
effectivelyafteroperation.

Onthisbackground,thereisacontinuingsearchfornewlocalanaestheticbasedtechniquestoprovideequivalentanalgesia,
withabettersafetyprofileandapplicabletopatientsforwhomanepiduraliscontraindicated.

Inaddition,surgicalpracticecontinuestoevolveandmanymajorsurgicalproceduresincludingnephrectomyandcolorectal
resectioncanbeachievedusingminimallyinvasivelaparoscopictechniques.Sincethelevelanddurationofpainandthestress
responseareallreduced,thebenefittoriskbalanceforepiduralanalgesiabecomeslessfavourable.Similarly,asdemonstrated
bysomestudiesdiscussedbelow,itisoftenmorecomplicatedtomobilizepatientsattachedtoepiduralpumpsandassociated
dripsandmonitoringthanitistoachievethisforpatientswithoutencumbrancesothatepiduralanalgesiamightactuallyslow
recoveryintheseinstances.Asaresult,epiduralanalgesiaisprobablynottheanalgesiaofchoiceformostlaparoscopic
procedures.

AlternativeLocalAnaestheticTechniquesforAbdominalSurgery
Theseincludetransversusabdominisplane(TAP)blocks,rectussheathblocks,andwoundinfiltration.Thereisalsoincreasing
interestintheuseofi.v.lidocaineinfusionsperioperatively.

Abdominalwallblocksareusuallyperformedasasingleshottechniquedepositinglocalanaestheticaroundthenerves
supplyingtheanteriorabdominalwallandparietalperitoneum.Thus,theskinandconsequentsiteofoperativeincisioncanbe
effectivelyblockedbylocalanaesthetic.Theincreasingavailabilityanduseofultrasoundhasallowedoperatorstoperformthis
techniquebasedondirectvisualization,improvingaccuracy,comparedwiththepreviouslandmarkand'pop'techniques.
Alternatively,theblockcanbeplacedunderdirectvisionbythesurgeon.TheuseofTAPblocksinparticularhasbeenshown
toprovideeffectiveanalgesiaatrestandonmovementwhenusedaspartofamultimodalstrategyforsurgerybelowthelevel
oftheumbilicus.Subcostalplacementisalsodescribedandcanprovideanalgesiaforhigherincisions.Patientsbenefitfrom
reducedopioidconsumption,reducedpainscores,anddecreaseddurationofadmission,comparedwiththosenotreceivinga
block.Usingsingleshottechniques,thedurationoftheseeffectsislimitedtothefirst824hafteroperation.Whilethismaybe
adequateforlaparoscopicprocedures,itisunlikelytobesoforopensurgery.Theseblockshowevercanbeprolongedbythe
placementofcathetersallowinginfusionsorbolusesoflocalanaesthetictobeadministeredforlongerperiods.

Thereisalsoincreasinginterestintheuseofcathetersplaceddirectlyinthesurgicalwoundforadministrationoflocal
anaestheticafteroperation.Itislikelythattheplacementofthesecathetersisimportant,withmoreeffectiveanalgesia
achievedifthecatheterisplacedpreperitoneally.Thepositionofthecathetershouldbespecifiedwhendiscussingthis
technique.Again,somestudieshaveshownwoundcatheterstobeveryeffectiveinbothimprovingqualityofanalgesiaand
opioidsparingaspartofamultimodalanalgesicpackage.

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Alternatively,lidocainecanbesafelyandeffectivelyinfusedi.v.toprovideanalgesia.Studieshaveshownthatpatientsreceiving
i.v.lidocaineinfusioncanhaveimprovedpainscoresat24hpostoperation,shorterdurationofhospitaladmission,anda
significantlyreducedincidenceofpostoperativeboweldysfunction.Althoughlidocaineisknowntohaveanalgesic,anti
inflammatory,andantihyperalgesicproperties,theexactmechanismofitsactioninthissituationisunknown.Lidocaine
infusionsareusedasapartofmultimodalanalgesiaandpatientsmaystillrequiresignificantopioid.

Todate,thereareonlyafewsmallstudiesdirectlycomparingepiduralanalgesiawithalternativelocalanaesthetictechniques:

AcomparisonofsubcostalTAPblockswithepiduralanalgesiaencouraginglyshowedsimilarpainscoresinthetwo
groups.However,theTAPgrouprequiredmorerescueanalgesia.Ananalgesicblockwasnotachievedin30%ofthe
TAPpatientsanditisconfoundingthatbothgroupsreceivedepiduralbupivacaineintraoperatively. [11]

Inastudycomparingepiduralanalgesiavsi.v.lidocaineinfusioninpatientsundergoingopencolonicresection
postoperativepain,recoveryofbowelfunctionanddurationofhospitalstaywerethesameinbothgroups.However,all
patientsreceivedPCAopioidsforbreakthroughpainraisingconcernsastowhetherallofthepatientsreceivingepidural
analgesiahadoptimalmanagementofthis. [12]

Inacomparisonofepiduralanalgesiawithlocalanaestheticviaanintraabdominalretropubiccatheter,epidural
analgesiaprovidedsuperiorpainreliefafterradicalprostatectomy,butrecoveryandhospitaldischargewerethesamein
bothgroups. [13]

Inastudyofpatientsundergoingliverresectioncomparingepiduralanalgesiawithcontinuouslocalanaestheticwound
infiltrationforpostoperativeanalgesia,theepiduralgrouphadsuperioranalgesia,butthewoundcathetergroupfulfilled
dischargecriteriamorequickly,andwenthomesignificantlyearlier. [14]These'woundcatheters'wereplacedbythe
surgeonsafteroperationinthetransversusplaneandposteriorrectussheath.

WhatQuestionsandIssuesDoTheseStudiesRaise?
Analgesiaperseisnottheonlyendpointrequiredforeffectivepostoperativerecoveryandwhilegoodanalgesiaisextremely
importantbothforrecoveryandforpatientsatisfaction,thereisabalancetobeachievedbetweenthisandotherpatientfactors
suchasmobilityandrecoveryofgutfunction.

Whatistheoptimalanalgesiaregimen,foranindividualpatient,toachieveanacceptablelevelofpainrelief,whilealso
optimizingrecovery?

Wemustensurethatwedonotembracenewanalgesiatechniquessimplybecausetheyappearsaferandeasierthanepidural
analgesia.Itisapparentfromstudiestodatethatthereissomecompromiseintermsofqualityofanalgesiawhenapplying
thesetechniques.

So,isitacceptabletocompromiseonanalgesiaintheinterestsofimprovedsafety?Doesthisvaryfordifferentpatient
groupsandsurgicalprocedures?

Opioidanalgesiacanbeveryeffective,buttherearesomepatientswhoarepoorlytolerantofopioidsandcannotachievea
goodbalanceofanalgesiavssideeffects.

Howmuchopioidsparingisbeneficialtopatients?Inapatient,whofrompreviousexperienceisknowntorespondpoorly
toopioidanalgesia,isitbettertouseatechniquewhichavoidsratherthanreducessystemicopioiduse?

Wenowhaveextensivedetailontherisksandcomplicationsofepiduralanalgesia.Thisisnotthecasewithalternativelocal
anaesthetictechniquesandwhilegenerallythesewouldappeartobesafer,theyarenotwithoutthepotentialforproblems.

Whataretherisksandcomplicationsofthesetechniques?

Conclusions

Highriskpatientswithsignificantcardiorespiratorycomorbidity,orextremeage,particularlyiftheyareundergoingopen

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surgeryundoubtedlybenefitfromthequalityofanalgesiaprovidedbyaneffectiveepiduralandaremorelikelytobenefit
fromassociatedearlymobilizationandnutrition.

Patientsforwhomsevereacutepainislikely,orforwhomopioids,nonsteroidalantiinflammatorydrugs,orbothare
poorlytoleratedgainhugebenefits.

Thosepatientswhohaveahighriskofprogressionfromacutetochronicpainmayalsobenefit,althoughfurther
investigationoftheroleofacutepainmanagementandidentificationofthesepatientsisneededhere.

Oncetheresultsofongoingprospectivestudiesareanalysed,theuseofregionaltechniquesmayneedtobeconsidered
inthecontextofreductionoftheriskofcancerrecurrence.

Therewillbeagroupofpatientswhoofalltheanalgesicoptionsavailablesimplychoosetohaveanepidural.

Inconclusion,andtoanswerthequestionposedatthestartofthisarticle,yes,unequivocallythereisstillaplaceforepidural
analgesiainpatientshavingabdominalsurgery.

Inpatientswhosepainismanagedwithepiduralanalgesia,itisessentialthattheoptimumbenefitfromtheepiduralisachieved
whilealsominimizingrisksfromit.Currentevidencesuggeststhatoptimalbenefitwillresultifepiduralanalgesiaiscombined
withactivemanagementofotheraspectsofrecoveryinamultimodalrecoveryprogrammeandwherepossible,theepidural
itselfshouldnotslowdownrehabilitation.

Epiduralanalgesiashouldremainanintegralpartofouranalgesicarmamentariumforuseinappropriatelyselectedpatients.
Thevariousotherlocalanalgesictechniquesprovideuswithusefulalternativesallowingindividualizedtailoringofanalgesiato
thepatientandthesurgicalprocedurebothtoprovidegoodpainreliefbutalso,importantlytofacilitaterecovery.

Sidebar
KeyPoints

Epiduralanalgesiacanprovideexcellentanalgesiaafterabdominalsurgery.

Epiduralanalgesiapositivelycontributestorecoverybyfacilitatingmobilizationandrecoveryofgutfunction.

Epiduralanalgesiacanreducepulmonary,cardiovascular,thromboembolic,andgastrointestinalcomplicationsoccurring
afterabdominalsurgery.

NAP3hasprovideduswithamoreaccurateassessmentoftherisksofperioperativeepiduralanalgesia.

Alternativelocalanaesthetictechniquesmaybebeneficialaspartofmultimodalanalgesiainpatientsforwhomepidural
analgesiaisnotconsideredappropriateorinwhomepiduralanalgesiacannotbeachieved.

References

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Press.Allrightsreserved.

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