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Minerva Anestesiologica 2020 May 18

DOI: 10.23736/S0375-9393.20.14324-4


language: English

Epidural anesthesia is no longer the standard of care in abdominal surgery with ERAS. What are the alternatives?

Michel F. WAGEMANS 1, Willem K. SCHOLTEN 2, Markus W. HOLLMANN 3 , Antonius H. KUIPERS 4

1 Department of Anesthesiology, Pain Medicine and Palliative Care, Reinier de Graaf, Delft, the Netherlands; 2 Independent Consultant, Medicines and Controlled Substances, Willem Scholten Consultancy, Lopik, the Netherlands; 3 Department of Anesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; 4 Department of Anesthesiology, ZiekenhuisGroep Twente ZGT, Almelo, the Netherlands


BACKGROUND: Epidural anesthesia has been considered the gold standard for perioperative analgesia, but the implementation of ERAS protocols and a shift from open to laparoscopic surgery have diminished the advantage of epidural anesthesia.
EVIDENCE ACQUISITION: The authors summarize data from two newer meta-analyses and discuss the consequences for the role of EA in the perioperative setting. These meta-analyses enabled to distinguish between pre- and post-ERAS outcomes. Endpoints related to open and laparoscopic abdominal surgery were retrieved. General data, also applicable on abdominal surgery, were included. Data on other types of surgery were ignored.
EVIDENCE SYNTHESIS: Two meta-analyses met the subject and inclusion criteria of the search. They demonstrate no difference between epidural analgesia and the control for most investigated endpoints.Analgesia employing epidural techniques is often not clinically superior to its alternatives; is associated with a small but relevant number of serious complications; and has a relatively high failure rate. Data show that the distinction between pre-ERAS and ERAS is essential for understanding the role of EA in intestinal surgery.
CONCLUSIONS: Since ERAS was introduced, the advantages of epidural anesthesia vanished while the incidence of serious neurological complications is higher than previously thought. The authors conclude that epidural anesthesia in abdominal surgery has become less preferred, and is limited to patients and types of surgery known to be accompanied with difficult pain management. This requires the use of other methods for analgesia, such as intravenous ketamine, peripheral nerve blocks, continuous wound infiltration, intrathecal morphine, and intravenous, and non-invasive PCA.

KEY WORDS: Epidural anesthesia; Enhanced recovery after surgery; Patient controlled analgesia; Adverse effects; Perioperative pain; Alternatives to epidural anesthesia

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