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urinary retention and hypotension were increased (Marret et al, 2007 Level I). A large
retrospective cohort study of 12 817 patients after elective colectomy reported that
postoperative epidural analgesia significantly reduced 7‐day (OR 0.35) and 30‐day (OR 0.54)
mortality (Wu, Rowlingson et al, 2006 Level III‐2).
After lung resection, postoperative epidural analgesia reduced 7‐day (OR 0.39) and 30‐day
(OR 0.53) mortality significantly in a retrospective cohort study of 3500 patients (Wu, Sapirstein
et al, 2006 Level III‐2). TEA in patients after lobectomy resulted in better pain relief and
pulmonary function compared with IV morphine (Bauer et al, 2007 Level II). When started
preoperatively in comparison to postoperatively, TEA reduced the severity of acute post‐
thoracotomy pain, but not the incidence of chronic pain (Bong et al, 2005 Level I).
High TEA used for coronary artery bypass graft (CABG) surgery, resulted in reduced
postoperative pain (both at rest and with activity), risk of dysrhythmias, pulmonary
complications and time to extubation when compared with IV opioid analgesia; there were no
differences in mortality or the rate of myocardial infarction (Liu et al, 2004 Level I). A later study
confirmed better pain relief using TEA (continuous infusion) in CABG patients compared with
IV morphine PCA, with improved pulmonary function for the first 2 days and decreased
atelectasis (Tenenbein et al, 2008 Level II); another reported no difference in analgesia, morbidity
or pulmonary function when patient‐controlled TEA was compared with IV PCA (Hansdottir et
al, 2006 Level II). High TEA also improved left ventricular function (Schmidt et al, 2005 Level III‐3;
Jakobsen et al, 2009 Level III‐3) and myocardial oxygen availability (Lagunilla et al, 2006 Level II) in
patients with ischaemic heart disease prior to CABG surgery, and partly normalised myocardial
blood flow in response to sympathetic stimulation (Nygard et al, 2005 Level III‐3). However,
epidural analgesia in patients undergoing CABG surgery has not been shown to improve
ischaemic outcome (Barrington, Kluger et al, 2005 Level II).
Continuous TEA compared with continuous intrathecal thoracic analgesia after abdominal
cancer surgery resulted in similar efficacy and adverse effects (Mercadante et al, 2008 Level II).
Thoracic epidural analgesia in combination with NSAIDs and IV nutritional support after major
abdominal surgery has been shown to prevent protein loss compared with epidural analgesia CHAPTER 7
alone, or PCA with or without nutritional support (Barratt et al, 2002 Level II). Similarly, after
colonic surgery, TEA increased the anabolic effect of amino acid infusions in diabetic patients
(Lugli et al, 2008 Level II) and reduced whole body protein breakdown (Lattermann et al, 2007
Level II). However, although epidural anaesthesia/analgesia reduced insulin resistance in
comparison to general anaesthesia/systemic analgesia in patients who were insulin resistant
preoperatively, it did not affect insulin resistance in those who had no preoperative insulin
resistance (Donatelli et al, 2007 Level II).
Lumbar epidural analgesia is widely used to provide analgesia after orthopaedic and vascular
operations to the lower limbs and urological and other pelvic surgery.
After hip or knee replacement, epidural analgesia provides better pain relief than parenteral
opioids, in particular with movement (Choi et al, 2003 Level I). Although epidural infusions of
local anaesthetics alone or combined with opioids are better than opioids alone, there is
insufficient evidence to make conclusions about other outcomes. Used in vascular surgery,
lumbar epidural analgesia improves outcome by reducing incidence of graft occlusion (Tuman
et al, 1991 Level II; Christopherson et al, 1993 Level II). However, these findings have not been
confirmed by other investigators in retrospective reviews (Pierce et al, 1997 Level IV; Schunn et al,
1998 Level IV).
Level of administration
Thoracic epidural analgesia is widely used for the treatment of pain after major abdominal and
thoracic surgery. Administration of local anaesthetics into the thoracic epidural space resulted
Acute pain management: scientific evidence 183