Regional techniques and outcome: what is the evidence?
Marie N. Hanna, Jamie D. Murphy, Kanupriya Kumar and Christopher L. Wu
Department of Anesthesiology and Critical Care
Medicine, The Johns Hopkins University, Baltimore,
Maryland, USA
Correspondence to Christopher L. Wu, MD, The Johns
Hopkins Hospital, Carnegie 280, 600 North Wolfe
Street, Baltimore, MD 21287, USA
Tel: +1 410 614 0401; fax: +1 410 614 1796;
e-mail: [email protected]
Current Opinion in Anaesthesiology 2009,
22:672–677
Purpose of review
Despite some controversy regarding the strength of the available data, the use of
regional anesthesia and analgesia does provide improvement in patient outcomes.
Although the majority of available data have examined the effect of epidural anesthesia
and analgesia on patient outcomes, an increasing number of studies recently have
investigated the effect of peripheral regional techniques on patient outcomes.
Recent findings
Data generally indicate that the perioperative use of regional anesthesia and analgesia
may be associated with improvement in both major (e.g. mortality, major morbidity)
outcomes and rehabilitation. The majority of evidence favors an ability of epidural
analgesia to reduce postoperative cardiovascular and pulmonary complications and
there is also consistent evidence that epidural analgesia with local anesthetics is
associated with faster resolution of postoperative ileus after major abdominal surgery.
Overall, regional analgesic techniques provide statistically superior analgesia compared
with systemic opioids.
Summary
Perioperative use of regional analgesic techniques may provide improvement in
conventional outcomes, although the benefit appears to be limited to high-risk patients
and those undergoing high-risk procedures. The benefits conferred by perioperative
regional anesthetic techniques need to be weighed against any potential risks and this
should be assessed on an individual basis.
Keywords
epidural, outcomes, peripheral nerve block
Curr Opin Anaesthesiol 22:672–677
ß 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
0952-7907
Introduction
Perioperative use of regional anesthesia and analgesia
may attenuate adverse perioperative pathophysiology
and improve patient outcomes. Overall, the data suggest
that the perioperative use of regional anesthesia and
analgesia may improve both conventional (i.e. mortality
and morbidity) and patient-centered outcomes. Although
the majority of available data have examined the effect of
epidural anesthesia and analgesia on patient outcomes, an
increasing number of studies recently have investigated
the effect of peripheral regional techniques on outcomes.
We will review the recent data on the effect of perioperative regional anesthesia and analgesia on both conventional and patient-centered outcomes.
Beneficial outcomes associated with regional
anesthesia and analgesia
Through the attenuation of perioperative pathophysiology and provision of superior analgesia, regional anesthesia–analgesia may improve patient outcomes; however,
the benefits of perioperative regional anesthesia–
0952-7907 ß 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
analgesia are most apparent in patients with decreased
physiologic reserves or who are undergoing higher risk
procedures (e.g. thoracotomy).
Mortality
Prior meta-analyses and database analyses have
examined the association of perioperative epidural
anesthesia–analgesia and patient mortality; however,
the overall effect of epidural analgesia and patient
mortality has been uncertain. The largest meta-analysis
of randomized controlled trials (RCTs) comparing
intraoperative neuraxial to general anesthesia (141
RCTs, 9559 patients) indicated a decrease in mortality
[1.9 vs. 2.8%; odds ratio (OR) ¼ 0.7, 95% confidence
interval (CI) 0.54–0.90] [1]; however, other smaller,
procedure-specific meta-analyses (e.g. open abdominal
aortic surgery, coronary artery bypass grafting, hip and
knee replacement surgery) have not shown any difference in mortality [2–5]. A 5% random sample of the
Medicare claims database found that the presence of
postoperative epidural analgesia was associated with a
significantly lower incidence for both 7-day mortality
DOI:10.1097/ACO.0b013e32832f330a
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Regional techniques and outcome Hanna et al. 673
(0.5 vs. 0.8%, OR ¼ 0.52, 95% CI 0.38–0.73) and 30-day
mortality (2.1 vs. 2.5%, OR ¼ 0.74, 95% CI 0.63–0.89),
with the benefit for decreased mortality apparent in
patients undergoing higher risk procedures (e.g. lung
resection, colectomy) but not in lower risk procedures
(e.g. total knee replacement, hysterectomy) [6].
More recently, another database analysis also found that
epidural anesthesia was associated with a reduction in 30day mortality [1.7 vs. 2.0%; relative risk (RR) ¼ 0.89, 95%
CI 0.81–0.98, P ¼ 0.02] [7]. The authors used a population-based linked administrative database to analyze a
retrospective cohort study of 259 037 patients (aged 40
years) who underwent elective intermediate-to-high risk
noncardiac surgical procedures over a 10-year period.
Although this most recent study does provide additional
evidence that epidural analgesia may be associated with a
decrease in perioperative mortality, these results should
be interpreted cautiously as the overall evidence for
reduction of mortality with epidural analgesia is inconsistent and there are methodologic issues with both metaanalysis and database analyses [6,8].
function and decrease arrhythmias after aortic cross
clamp release through increased expression of vascular
endothelial growth factor and inducible nitric oxide
synthase [12]. Thus, there is consistent evidence that
use of TEA may reduce the risk of cardiovascular morbidity in higher risk patients or those undergoing higher
risk surgical procedures, although these benefits should
be weighed against the risks of epidural hematoma on an
individual basis [8,13].
Pulmonary
Several older meta-analyses indicate that use of epidural
anesthesia–analgesia may significantly decrease the risk
of perioperative pulmonary morbidity including postoperative pulmonary complications, pulmonary infections [3,14], and respiratory failure [2]. Some large RCTs
also suggest some benefit for epidural analgesia in
decreasing postoperative pulmonary complications with
TEA [15,16]. These benefits may be related in part to the
superior analgesia [17,18] provided by regional techniques, which may result in improved pulmonary function and decreased atelectasis, particularly in patients
undergoing thoracic surgery [19,20].
Cardiovascular
At least three prior meta-analyses have indicated that the
use of thoracic epidural anesthesia and analgesia (TEA)
primarily utilizing a local anesthetic-based regimen may
be associated with a reduction in perioperative cardiovascular events in high-risk patients or those undergoing
high-risk procedures [1,3,9]. For instance, a meta-analysis
examining RCTs in which epidural analgesia was used for
a period of at least 24 h postoperatively, use of TEA (but
not lumbar epidural analgesia) was associated with a
significant reduction in the rate of myocardial infarction
(OR ¼ 0.43, 95% CI 0.19–0.97, P ¼ 0.04) [9]. Use of TEA
compared with systemic analgesia was associated with a
significant reduction in risk of cardiovascular complications (RR ¼ 0.74, 95% CI 0.56–0.97), myocardial infarction (RR ¼ 0.52, 95% CI 0.29–0.93) (open abdominal
aortic surgery) [2], and incidence of dysrhythmias (17.8
vs. 30%, OR ¼ 0.52, 95% CI 0.29–0.93) (coronary artery
bypass surgery) [3].
More recent studies continue to suggest a benefit for
regional anesthesia and analgesia in reducing cardiovascular events, although whether there is greater hemodynamic stability is uncertain [10]. In patients undergoing
off-pump coronary bypass graft surgery, patients who
were randomized to receive a combined thoracic epidural–general anesthesia regimen had a significant
reduction in epinephrine serum levels and lower incidence of perioperative dysrhythmias (3 vs. 23.7% for
general anesthesia only, P < 0.01) [11]. Although the
mechanisms for these benefits are uncertain, recent data
suggest that TEA may preserve cardiac/hemodynamic
More recent systematic reviews continue to indicate that
the use of perioperative regional analgesia (including
both epidural and paravertebral catheters) is associated
with a decrease in pulmonary complications in patients
undergoing abdominal and thoracic surgery. A metaanalysis examining the effects of epidural analgesia on
pulmonary complications after abdominal and thoracic
surgery noted that the odds of pneumonia were decreased
with epidural analgesia (OR ¼ 0.54; 95% CI 0.43–0.68),
independent of site of surgery or catheter insertion,
duration of analgesia, or regimen [21]. Although epidural analgesia reduced the need for prolonged ventilation or reintubation and improved lung function/blood
oxygenation, it was also associated with an increased risk
of hypotension, urinary retention, and pruritus [21].
Another systematic review noted that paravertebral
analgesia was associated with a significant reduction in
the incidence of pulmonary complications compared with
systemic analgesia and continuous paravertebral block
was as effective as TEA with local anesthetic but with a
reduced incidence of hypotension [22].
Thus, meta-analyses and large RCTs suggest that use of
TEA analgesia may decrease the risk of perioperative
postoperative pulmonary complications; however, these
benefits may be limited to patients with decreased
physiologic reserves or those undergoing high-risk
surgery such as abdominal aortic or thoracic surgery.
Nevertheless, these benefits are not definitive, as quantitative meta-analyses are limited by heterogeneity in
study design and the relative small sample size [22]. In
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674 Regional anaesthesia
addition, over the past 35 years, the incidence of pneumonia with epidural analgesia remained about 8% but has
decreased from 34 to 12% with systemic analgesia, and, as
a result, the relative benefit of epidural analgesia has
diminished [21].
may contribute to the earlier rehabilitation in these
patients. Some other recent data also suggest that use
of perioperative regional analgesic techniques may be
associated with shorter hospital stays and reduction in
overall costs, although additional studies are needed to
confirm these findings [37,38,39].
Gastrointestinal
Prior data suggest that use of TEA with local anestheticbased solutions, compared with systemic and neuraxial
opioids, is associated with faster recovery of bowel function after open abdominal surgery [23–25]. An earlier
meta-analysis (22 RCTs, n ¼ 1023 patients) suggested
that TEA with local anesthetics was associated with
reduced time in return of gastrointestinal function (vs.
systemic opioids 37 h, 95% CI 55 to 19 h; vs. epidural opioids 24 h, 95% CI 38 to 10 h) [23]. A
subsequent meta-analysis noted that presence of epidural
analgesia significantly reduced pain and duration of ileus
but was associated with a significant increase in the
incidence of pruritus, urinary retention, and hypotension
[24].
More recent data also indicate that epidural analgesia is
associated with reduced pain [26,27]. Unlike that seen
for open abdominal procedures, the benefit of epidural
analgesia in facilitating return of gastrointestinal function
after laparoscopic procedures is equivocal [26,27]. Thus,
the available meta-analyses suggest that TEA with local
anesthetics (compared with both systemic and epidural
opioids) facilitates return of postoperative gastrointestinal function after open abdominal surgery by 24–37 h;
however, the overall effect of TEA on gastrointestinal
function after laparoscopic procedures and on other outcomes, such as length of stay, is unclear. The benefits of
TEA are maximized when combined as part of a multimodal approach to postoperative rehabilitation (i.e. ‘fasttrack surgery’ [28]).
Other outcomes
Some data suggest that surgery induces suppression of
antimetastatic cell-mediated immunity (CMI) at this
critical period, which is suggested to worsen patients’
prognosis [40]. It is clear that perioperative regional
anesthesia–analgesia may attenuate adverse metabolic,
inflammatory, and immunologic responses [41,42,43,
44] such that regional anesthesia–analgesia may diminish
perioperative immunosuppression [45,46]. Theoretically,
patients undergoing cancer surgery might benefit from
attenuation of perioperative immunosuppression (i.e.
longer survival) by regional anesthesia–analgesia. Two
retrospective analyses suggest that use of perioperative
regional anesthesia–analgesia is associated with a lower
risk of recurrence/metastasis and substantially less risk of
biochemical cancer recurrence [47,48].
Risks associated with regional anesthesia
and analgesia
Despite the benefits associated with using perioperative
regional anesthesia–analgesia, the potential risks from
each regional technique should be considered on an
individual basis. Although a comprehensive review of
risks from regional analgesic techniques are beyond the
scope of this review, the recent controversial topics
regarding complications and safety with regional techniques will be discussed.
Neurologic complications of regional
techniques
Rehabilitation
Use of regional anesthesia–analgesia may facilitate
patient rehabilitation particularly after orthopedic procedures despite the potential for complications such as
falls associated with peripheral nerve blocks [29]. Earlier
RCTs have suggested that use of either continuous
peripheral nerve catheters or epidural analgesia may
improve early rehabilitation and decrease the time until
readiness for discharge [30,31]. Recent studies confirm
earlier findings in that use of continuous peripheral nerve
analgesia can be used in an outpatient setting and results
in decreases in the time to reach important predefined
discharge criteria [32,33]. Compared with systemic
opioids, regional analgesic techniques result in superior
postoperative analgesia (vs. systemic opioids) and fewer
opioid-related side effects [17,18,33,34,35,36], which
Both neuraxial and peripheral regional techniques may
be associated with perioperative neurologic injury
[49,50,51]. Although the mechanisms of neurologic
injury are often unclear or multifactoral, nerve injury
may occur when local anesthetics are injected intrafascicularly into peripheral nerves (particularly if the concentration is high or duration of exposure is prolonged),
needle penetration of a nerve is combined with local
anesthetic administration within the nerve fascicle, or
there is direct compression by a pronged tourniquet
application [52]. Despite the wide range of risks that
may occur from regional techniques, the risks of regional
anesthesia most commonly disclosed to patients are
benign in nature and occur frequently, whereas severe
complications associated with these techniques are far
less commonly disclosed [53]. In addition, recent data
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Regional techniques and outcome Hanna et al. 675
suggest that there is little agreement among regional
anesthesiologists regarding their perceived incidence of
complications following regional techniques [54]. There
are recent societal practice advisories on neurologic complications in regional anesthesia and pain medicine which
include an evidence-based and expert opinion-based
section on performing procedures on anesthetized or
heavily sedated patients [55,56]. Finally, the clinician
should be aware of the early treatment with 10% intravenous fat emulsion (i.e. Intralipid), which may help
prevent cardiac arrest and speed successful resuscitation
efforts due to local anesthetic toxicity [57].
Improvement of ‘safety’ of regional
techniques with use of ultrasound?
The utilization of ultrasound to guide needle placement
and monitor the injection of local anesthetics has been
associated with an improvement in the success rate of
various peripheral nerve blocks [58,59]. In addition,
ultrasound has been used to facilitate neuraxial blocks
particularly in neonates and children [60,61]. Ultrasound-guided nerve blocks may result in not only higher
success but also in faster onset and progression of sensorimotor block without an increase in block procedure
time [62].
One of the important and unanswered questions regarding the use of ultrasound to guide nerve blocks is whether
this technique will actually result in a lower incidence or
severity of neurologic complications compared with other
currently used techniques such as nerve stimulation [63].
As with any newer technique, there will be a learning
curve when introducing ultrasound into a clinician’s
practice and as such clinicians will need to be familiar
with the anatomical landmarks for their blocks and be
cognizant of the potential artifacts and pitfall errors
associated with ultrasound-guided regional anesthesia
[64–67].
Conclusion
The use of regional anesthesia and analgesia may
improve perioperative patient outcomes. Although the
use of perioperative epidural anesthesia and analgesia
may improve cardiac, pulmonary, and gastrointestinal
outcomes, any benefits are limited to higher risk patient
and higher risk procedures. Use of continuous peripheral
regional analgesia may be associated with improvement
in patient rehabilitation. Although use of ultrasound may
be associated with an increase in success rate, whether
this technique may be associated with a decreased rate of
neurologic injury is uncertain. Future research should be
directed at emerging technologies [68] and the effect of
regional analgesic techniques on patient-reported outcomes [69,70].
Acknowledgement
The present study was supported by the Department of Anesthesiology
and Critical Care Medicine, The Johns Hopkins University, Baltimore,
MD, USA.
References and recommended reading
Papers of particular interest, published within the annual period of review, have
been highlighted as:
of special interest
of outstanding interest
Additional references related to this topic can also be found in the Current
World Literature section in this issue (pp. 696–697).
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