Abstract ID: A15

Abstract Title: Effect of Postoperative Epidural Analgesia on Morbidity and Mortality Following Surgery in Medicare Patients

Poster Type: Discussion


ABSTRACT BODY

Introduction:
The majority of available randomized controlled trials (RCT) and meta-analyses of trials examining the efficacy of epidural analgesia (EA) in decreasing perioperative morbidity and mortality have focused on the intraoperative period[1] with few examining the role of postoperative EA on patient outcomes[2,3]. With limitations in RCTs to determine whether EA can decrease mortality[4], we performed a database analysis of Medicare surgical patient to determine if there is an association between EA and mortality.
Materials and Methods:
A 5% nationally random sample of Medicare beneficiaries from 1997-2001 was analyzed to identify patients undergoing various procedures: lobectomy-lung, complete pneumonectomy, partial excision-large intestine, intra-/antesternal anastomosis-esophagus, total/revision of TKR, total/radical abdominal hysterectomy, partial/radical pancreaticoduodnectomy, partial and complete nephrectomy, partial/complete cystectomy, hepatotomy/lpbectomy of the liver, partial/total gastrectomy, radical retropubic prostatectomy. Patients were divided into two groups depending on the presence or absence of postoperative EA based on the presence of the CPT code 01996. Emergency surgical cases and patient undergoing pneumonectomy were excluded. Baseline characteristics (demographic and cormorbidities [5]) were compared. The rate of major morbidity (acute myocardial infarction, angina, cardiac dysrhythmias, heart failure, pneumonia, pulmonary edema, respiratory failure, deep venous thrombosis, pulmonary embolism, sepsis, acute renal failure, somnolence, acute cerebrovascular event, transient organic syndrome, and paralytic ileus) and death at 7 and 30 days following the procedure were compared. Multivariate regression analysis incorporating race, gender, age, comorbidities, hospital size, hospital teaching status, and hospital technology status was performed to determine if the presence of EA had an independent effect on mortality.
Results:
Multivariate regression analysis revealed that there was no difference between the groups with regard to overall major morbidity with the exception of an increase in pneumonia at 30-days for the epidural group (OR=1.91,p=0.023); however, the presence of EA was associated with a significantly lower odds of death at 7 days (OR=0.52,p=0.0001) and 30 days (OR=0.74,p=0.0005) after surgery.
Discussion:
Although EA was not associated a lower incidence morbidity, the presence of epidural analgesia was associated with significantly lower odds of death at 7 and 30 days after surgery. The increase in pneumonia in the EA group does not corroborate prior data demonstrating a decrease in the incidence of respiratory failure and pneumonia with EA[1,3,6]. It is unclear whether the physiologic benefits of EA[4,7] contributed to a decrease in mortality as the current analysis does not show a decrease in these complications although there many limitations in using administrative databases[8].
References:
1. Rodgers A.BMJ 2000;321:1493
2. Norris EJ.Anesthesiology 2001;95:1054
3. Rigg JR.Lancet 2000;359:1272
4. Wu CL.Anesth Analg 2000;91:1232
5. Elixhauser A.Med Care 1998;36:8
6. Ballantyne JC.Anesth Analg 1998;;86:598
7. Liu S.Anesthesiology 1995;82:1474
8. Wu CL.RAPM 2003;28:271

ATTACHED FILES

A15_ASRA-01996-all procedures-table.doc





Reg Anesth Pain Med 2004; 29(2):A15