To the Editor: In his Clinical Crossroads discussion of a patient with severe pulmonary disease contemplating major abdominal surgery, Dr Smetana1 provides a concise review of preoperative assessment and perioperative risk reduction strategies for patients susceptible to postoperative pulmonary complications (PPCs). He cites evidence that he suggests favors the use of intraoperative neuraxial blockade (rather than general anesthesia) and postoperative epidural analgesia for reduction of PPCs in high-risk patients. However, conclusions regarding the superiority of these techniques must be interpreted cautiously.
In support of neuraxial (spinal or epidural) anesthesia, Smetana cites a meta-analysis by Rodgers et al2 that assimilates data from 141 randomized trials, but includes only 28 studies of general surgery (as opposed to orthopedic, urologic, or vascular surgery). Of these, only 2 involve spinal anesthesia. Alteration in postoperative pulmonary function is more significant in surgeries within the upper abdomen and thorax than the periphery, regardless of anesthetic technique.3 Thus the applicability of the meta-analysis by Rodgers et al to patients with pulmonary disease undergoing abdominal surgery may not be justified.
Regarding postoperative epidural analgesia in high-risk patients, a recent literature review concluded that “there is insufficient evidence to confirm or deny the ability of postoperative analgesic techniques to affect major postoperative mortality or morbidity.”4 Although PPCs represent an exception to this rule, the data suggest that the advantage of epidural techniques for major abdominal surgery is limited to thoracic insertion sites.4 An accepted clinical modality, the thoracic approach can nonetheless be more difficult technically and because of the theoretical potential for spinal cord injury may be riskier than the more common lumbar approach.5
Moreover, patients undergoing major vascular surgery, such as abdominal aortic aneurysm repair, are typically anticoagulated perioperatively. In such cases the ability to offer epidural analgesia is often greatly limited, as systemic anticoagulation represents an absolute contraindication to both preoperative insertion and postoperative withdrawal of an epidural catheter.6
Financial Disclosures: None reported.
Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature
Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal
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