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Regional Anesthesia

Most important, an effective analgesic (i.e. one that blunts the stress response) regimen must be included in the peri-operative plan. ACC/AHA Guidelines 2002

Although this statement was initially part of the 2002 guidelines, it still remains applicable today. In fact, the 2007 guidelines once again do not suggest any particular analgesic technique, but rather state that the choice of patient management is best left to the discretion of the anesthesia care team.

There has only been one double blind RCT conducted regarding perioperative epidural analgesia. In this study, Breslow (35) was able to show a reduction in the stress response for 24 hours using a single dose of epidural morphine. Subsequently, 4 separate meta-analyses outlining the effects of peri-operative regional anesthesia were published (29-32). These studies demonstrated superiority in regards to both respiratory and cardiac complications as well as postoperative analgesia. However, since the publication of the last of these meta-analyses, 4 apparently negative trials were published. Both the MASTER and the VA cooperative trials suggested that there was very little cardiac benefit. Unfortunately, although these trials were the largest trials conducted to date, they were still underpowered to show a cardiac or death benefit! More recently, in a large population based trial of epidural analgesia, a small decrease, of borderline significance, in mortality was noted (48).  These results should be interpreted as showing that epidural analgesia is safe and should be used for indications other than for improving survival (excellent analgesia or improved post operative rehabilitation) In summary, the beneficial effects of epidural analgesia is associated with small cardiovascular benefits at best . Thus the best recommendation at the present time is to provide good pain relief using methods that one is most familiar and comfortable with.

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