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Abstract |
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Postoperative cardiac morbidity and mortality continue to pose considerable risks to surgical patients. Postoperative epidural analgesia is considered to have beneficial effects on cardiac outcomes. The use in high-risk cardiac patients remains controversial. No study has shown that postoperative epidural analgesia decreases postoperative myocardial infarction (PMI) or death. All studies are underpowered to show such a result, and the cost of conducting a large trial is prohibitive. We performed a metaanalysis to determine whether postoperative epidural analgesia continued for more than 24 h after surgery reduces PMI or in-hospital death. The available databases were searched for randomized controlled trials of epidural analgesia that was extended at least 24 h into the postoperative period. The search yielded 17 studies, of which 11 were randomized controlled trials comprising 1173 patients. Metaanalysis was conducted by using the fixed-effects model, calculating both an odds ratio and a rate difference. Postoperative epidural analgesia resulted in better analgesia for the first 24 h after surgery. The rate of PMI was 6.3%, with lower rates in the Epidural group (rate difference, -3.8%; 95% confidence interval [CI] -7.4%, -0.2%; P = 0.049). The frequency of in-hospital death was 3.3%, with no significant difference between Epidural and Nonepidural groups (rate difference, -1.3%; 95% CI, -3.8%, 1.2%, P = 0.091). Subgroup analysis of postoperative thoracic epidural analgesia showed a significant reduction in PMI in the Epidural group (rate difference, -5.3%; 95% CI, -9.9%, -0.7%; P = 0.04).
IMPLICATIONS: Postoperative epidural analgesia, especially thoracic epidural analgesia, continued for more than 24 h reduces postoperative myocardial infarctions.
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Introduction |
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Myocardial infarction is a leading cause of postoperative morbidity (1,2). The role of postoperative epidural analgesia in reducing perioperative risk is controversial. A recent systematic review (3) demonstrated reduced mortality in patients receiving neuraxial blockade. Most deaths were related to cardiovascular causes. The metaanalysis could not demonstrate a reduction in cardiac deaths. Postoperative myocardial infarction (PMI) is predominately non-Q wave and clinically silent, with the peak incidence within the first 24 h (4–10). PMI is usually preceded by prolonged ST depression, which is an accurate predictor of myocardial infarction (8–12).
Postoperative epidural analgesia has many features that would tend to reduce ischemia. Unfortunately, most studies have not extended the use of epidural analgesia into the critical first 24 h. All individual studies have lacked the statistical power to demonstrate a difference in PMI or death. Many epidural studies and all spinal anesthetic studies do not extend analgesia past the first 12 h. The cost of conducting such a study is prohibitive. Metaanalysis allows insight into this controversial subject (13).
This metaanalysis was designed to determine the effect of postoperative epidural analgesia on postoperative cardiac morbidity. Studies that used epidural analgesia for more than 24 h after surgery and reported either PMI or death as an outcome were included.
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Methods |
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Randomized controlled trials (RCTs) examining the role of postoperative epidural analgesia administered for 24 h or more after surgery and whose outcomes included PMI or death were retrieved. We searched MEDLINE (1966 to December 1998) without language restriction by using the Medical Subject Heading terms "pain, postoperative," "anesthesia, epidural," "postoperative complications," "myocardial infarction," "congestive heart failure," and "death." A prior search (14) of postoperative pain management had concluded that pertinent literature is found in this database only. In addition, all English-language anesthesia journals (Acta Anaesthesiologica Scandinavica, Anaesthesia, Anesthesiology, Anesthesia & Analgesia, British Journal of Anaesthesia, Canadian Journal of Anaesthesia,andRegional Anesthesia & Pain Medicine) since 1987 were hand-searched for articles and abstracts that prospectively examined postoperative epidural analgesia. Finally, the Science Citation Index was searched under the reference "Yeager et al., Anesthesiology 1987" (15).
All citations were reviewed by two of the authors. Disagreements were resolved by consensus. We included articles that used a randomized design, examined the role of postoperative epidural analgesia in humans, and reported PMI or death as outcomes. Because the peak incidence of PMI is in the first 24 h, we excluded studies that used epidural analgesia for <24 h after surgery.
All included papers were graded by using the scale of Jadad et al. (16), which is a five-point validated scale that assesses randomization, blinding, and withdrawals. Data were abstracted by one investigator. We abstracted the patient characteristics, details of the surgical and analgesic interventions, cardiac outcomes, and other effects of epidural analgesia (pain relief and coagulation).
All trials had a 2 x 2 outcome table that permitted the use of the Peto odds ratio (17) and the event rate difference with their 95% confidence interval (CI). A fixed effects model was chosen. Calculations were performed by using Review Manager 4.1 (Wintertree Software, Inc., Nepean, Ontario, Canada). We chose the rate difference as our primary statistic because it allows for an accurate representation when one group within a study has an event rate of zero. We used the Breslow-Day method (18) to assess heterogeneity. Subgroup analysis of the level of epidural placement (thoracic or lumbar) was also performed. Because the choice of studies to include and the choice of statistical model could affect the estimates of treatment effect, we performed two sensitivity analyses: one analysis used the fixed effects model, excluding the controversial study of Yeager et al. (15), and another analysis used the random effects model (19).
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Results |
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Our search found 204 studies. Of these studies, 17 were comparisons of postoperative epidural analgesia to a parenteral form of analgesia (15,20–35) and fulfilled the criteria of evaluating epidural analgesia with the specific cardiovascular outcomes. Reasons for exclusion included lack of randomization (20–24) and duplicate publication (25). Eleven RCTs (26–35) with a total of 1173 patients, comparing postoperative epidural analgesia to systemic analgesia, remained for analysis. Three studies (26–28) did not report PMI; all 11 studies reported death rate, although there were no deaths in 2 studies (29,30).
Table 1 summarizes the type of epidural, the surgical population, and the metaanalysis of the effect of postoperative epidural analgesia on PMI and death. Six studies used high lumbar or thoracic epidurals, and five used lumbar epidurals. Of the eight studies reporting PMI, two studies (15,29) observed no PMI in patients receiving epidural analgesia. The overall frequency of PMI was 6.3% in 685 patients.
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The Epidural group had fewer PMIs than the Control group (rate difference, -3.8%; 95% CI, -7.4%, -0.2%; P = 0.049). The overall death rate was 3.3% in 1173 patients, with no difference between the Epidural and Control groups (rate difference, -1.3%; 95% CI, -3.8%, 1.2%; P = 0.091). Figures 1 and 2 show the metaanalysis for the outcomes of in-hospital death and PMI, respectively. The Breslow-Day test for heterogeneity was negative.
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Subgroup analysis of patients receiving postoperative thoracic epidural analgesia showed a statistically significant reduction in PMI (Fig. 2) compared with systemic analgesia (rate difference, -5.3%; 95% CI, -9.9%, -0.7%; P = 0.04). There was no difference in death rates between the Thoracic Epidural and Control groups (rate difference, -2.0%; 95% CI, -5.3%, 1.2%; P = 0.11).
The sensitivity analysis is presented in Table 2. The odds ratios are within 7%. The use of the random effects model yields wider CIs, making the result not significant. Exclusion of the study of Yeager et al. (15) again yielded wide CIs.
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Analysis of the patient characteristics is listed in Table 3. Six studies, with 483 patients, reported a history of myocardial infarction. Twenty-eight percent of patients had a history of myocardial infarction. Twenty-one percent of these 483 patients had a history of angina. Twenty-two percent of patients were receiving a ß-blocker before surgery. Six percent of the 483 patients had a history of congestive heart failure. In four studies with 329 patients, 27% of patients had a history of chronic obstructive pulmonary disease. In five studies with 448 patients, 19% of patients had diabetes. No statistically significant differences in patient characteristics were seen between the Epidural and Control groups (Table 3).
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The analgesic efficacy of epidural analgesia, compared with systemic analgesia, was assessed in 4 (27,28,30,34) of the 11 RCTs. Three (27,30,34) of these studies showed statistically better analgesia in the Epidural group. In one study (28), the pain score for the Epidural group was mathematically lower, but this difference was not statistically significant. A metaanalysis was not necessary to show statistically significant improvement for the Epidural over the Control group in these four studies.
Three of the 11 RCTs reported postoperative ST changes as measured by continuous Holter monitoring. One study did not report the results of ST Holter monitoring, even though it was recorded. Together, the three studies reported a 25% incidence of postoperative ischemia with a decreased incidence of postoperative ischemia in the first 24 h in the Epidural group, although this was not statistically significant (rate difference, -7.5%; P = 0.19). One study reported duration of ischemia. The data showed a shorter mean duration of each ischemic event for patients receiving epidural analgesia. This difference was not found to be significant.
Two studies (28,29) reported postoperative coagulation data. Both studies found a statistically significant reduction in their respective variables favoring postoperative epidural analgesia.
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Discussion |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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This systematic review shows that postoperative epidural analgesia continued for 24 hours after surgery decreases PMI. Subgroup analysis suggests that thoracic epidural analgesia is superior to lumbar epidural analgesia in reducing PMI. The statistical significance of this metaanalysis is dependent on the model used (fixed effects versus random effects) and the studies included. We chose to use the rate difference as our primary statistic because it permits an accurate representation when one group has no events. The calculated odds ratio for studies is changed by an artificial value in studies where the event rate is zero for a group. Sensitivity analysis shows a consistent trend toward a reduction in PMI. The variation between the fixed and random effects models is <5%. The decrease in PMI noted in this study is similar to that suggested in a recent systematic review of centroneuraxial blockade (3). Our study differs from that report in several respects. First, our analysis is for 24 hours of postoperative epidural analgesia and specifically excludes studies of spinal anesthesia. Second, this analysis was designed specifically for cardiac morbidity, and third, it includes studies up to the year 1999.
The utility of postoperative epidural analgesia in reducing postoperative cardiac morbidity has created much controversy since Yeager et al. (15) concluded that postoperative epidural analgesia reduced the overall complication rate in high-risk patients. Their article generated much controversy with respect to its design (unblinded, poor analgesia in the control group), the decision to terminate the study early (a large difference between the two treatment groups), and the high rate of morbidity. We assessed the effect of excluding this article. The trend toward reduction in PMI is preserved, but this difference did not achieve significance. The remaining trials do not have the power to demonstrate a statistical difference at this level of morbidity.
The conduct of a metaanalysis must follow preset criteria. These include the formulation of a question a priori, a well described search technique, selection of studies, and accepted analysis of data. The methodology used in this study has been applied to other studies analyzing interventions to improve cardiac outcomes (3,36,37). We have taken care to avoid the bias that can occur from the inclusion of multiple publications involving identical patients. We believe that this study fulfills the criteria for a valid metaanalysis. We performed tests for data homogeneity by using the Breslow-Day method. We chose the fixed effects model as our primary analytic tool. This methodology has been used in other similar metaanalyses (3,14). We performed sensitivity analysis to assess the effect of different modeling. The random effects model is more conservative, but the results are similar and the net result within 5%.
The proportion of patients taking ß-blockers was identical in the Epidural and Control groups. The Epidural group had a more frequent incidence of angina (26.8% vs 15.4%), but this difference was not statistically significant (P = 0.051). These findings make it difficult to ascribe the difference with postoperative epidural analgesia to ß-adrenergic blocker usage. Further studies should add risk stratification, according to a predetermined risk index, to the randomization process to avoid any skewing of the patient populations.
Our results should be considered with caution. First, we have noted the difficulty in determining cardiac risk within the study populations on the basis of available data and the potential for bias. Second, none of these trials was double-blinded, and the evaluation of myocardial infarction could be influenced by treatment choice. We have analyzed the data by using both the fixed effects model and the random effects model with inclusion and exclusion of specific trials. There is a consistent reduction in the infarction rate no matter which method is used. As the model becomes more conservative, the studies lack the power to show statistical significance. We would further argue for inclusion of the study of Yeager et al. (15); contrary to belief, the infarction rate in this study (5.5%) was not higher than that in the other studies quoted. Exclusion does not alter the trend toward lower infarction rate but reduces the power to show significance.
In conclusion, postoperative epidural analgesia reduces PMI. Use of the more conservative random effects model continues to show a trend toward a reduction of PMI, but the trials assessed with this analytic tool do not possess the power to show a statistically significant difference. The purpose of this analysis was not to highlight the controversies in metaanalysis technique, but to evaluate whether further trials of postoperative epidural analgesia are warranted. The reduction of PMI by 40% in patients with thoracic epidural analgesia is consistent with the degree of benefit in the recent systematic review (3). These results are similar to other metaanalyses of epidural analgesia in different populations analyzing different outcomes (14,38).
The demonstration of reduced cardiac events with postoperative epidural analgesia is important because many high-risk patients cannot tolerate ß-adrenergic blockers, which also reduce PMI. Our findings suggest that in high-risk cardiac patients, epidural postoperative analgesia is warranted and should be used more widely. Further trials are warranted.
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Footnotes |
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Presented in part at the Canadian Anesthesiologists’ Society 54th Annual Meeting, Vancouver, Canada, June, 1997.
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References |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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- Mangano DT. Perioperative cardiac morbidity. Anesthesiology 1990; 72: 153–84.[Web of Science][Medline]
-
Mangano DT, Browner WS, Hollenberg MS, et al. Long term cardiac prognosis following non-cardiac surgery. JAMA 1992; 268: 233–9.
[Abstract/Free Full Text] -
Rodgers A, Walker N, Schug S, et al. Reduction of postoperative mortality and morbidity with epidural or spinal anesthesia: results from overview of randomized trials. BMJ 2000; 321: 1493–4.
[Abstract/Free Full Text] -
Mangano DT, Layug EL, Wallace A, et al. Effect of atenolol on mortality and cardiovascular morbidity after noncardiac surgery. N Engl J Med 1996; 335: 1713–20.
[Abstract/Free Full Text] - Badner NH, Knill RL, Brown JE, et al. Myocardial infarction after non-cardiac surgery. Anesthesiology 1998; 88: 572–8.[Web of Science][Medline]
- Charlson ME, MacKenzie CR, Ales K, et al. Surveillance for postoperative myocardial infarction after noncardiac operation. Surg Gynecol Obstet 1988; 167: 407–14.[Web of Science][Medline]
- Yeager RA, Monetta GL, Edwards JM, et al. Late survival after perioperative myocardial infarction complicating vascular surgery. J Vasc Surg 1994; 20: 589–604.
- Fleisher LA, Nelson AH, Rosenbaum SH. Postoperative myocardial ischemia: etiology of cardiac morbidity or manifestation of underlying disease? J Clin Anesth 1995; 7: 97–102.[Web of Science][Medline]
- Landesberg G, Luria MH, Cotev S, et al. Importance of long duration postoperative ST segment depression in cardiac morbidity after vascular surgery. Lancet 1993; 341: 715–9.[Web of Science][Medline]
- Pasternac PF, Grossi EA, Baumann FG, et al. The value of silent myocardial ischemia monitoring in prediction of perioperative myocardial infarction in patients undergoing peripheral vascular surgery. J Vasc Surg 1989; 10: 617–25.[Web of Science][Medline]
- Raby KE, Goldman L, Creager MA. Co-relation between peri-operative ischemia and major cardiac events after peripheral vascular surgery. N Engl J Med 1989; 321: 1296–300.[Abstract]
- Stone JG, Foex P, Sear JW, et al. Myocardial ischemia in untreated hypertensive patients: effect of a single small oral dose of a beta-adrenergic blocking agent. Anesthesiology 1988; 68: 495–500.[Web of Science][Medline]
- Petitti DB. Meta-analysis, decision analysis, and cost-effectiveness analysis: methods for quantitative synthesis in medicine. New York: Oxford University Press, 1994.
- Ballantyne JC, Carr DB, de Ferranti S, et al. The comparative effects of postoperative analgesic therapies on pulmonary outcomes: cumulative meta-analysis of randomized controlled trials. Anesth Analg 1998; 86: 598–612.[Abstract]
- Yeager MP, Glass DD, Neff RK, et al. Epidural anesthesia and analgesia in high-risk surgical patients. Anesthesiology 1987; 66: 729–36.[Web of Science][Medline]
- Jadad AR, Moore A, Carroll D, et al. Assessing the quality of randomized clinical trials: is blinding necessary? Control Clin Trials 1996; 17: 1–12.[Web of Science][Medline]
- Yusuf S, Peto R, Lewis J, et al. Beta blockade during and after myocardial infarction: an overview of the randomized trials. Prog Cardiovasc Dis 1985; 27: 335–71.[Web of Science][Medline]
- Breslow NE, Day NE. Statistical methods in cancer research: the analysis of case-control studies. Vol 1. Lyons: International Agency for Research on Cancer, 1980.
- DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials 1986; 7: 177–88.[Web of Science][Medline]
- Beattie WS, Buckley DN, Forrest JB, et al. Epidural morphine reduces the risk of postoperative myocardial ischemia in patients with cardiac risk factors. Can J Anaesth 1993; 40: 532–41.[Web of Science][Medline]
- Mason RA, Newton GB, Cassel W, et al. Combined epidural and general anesthesia in aortic surgery. J Vasc Surg 1990; 31: 442–7.
- Rivers SP, Scher LA, Sheehan E, et al. Epidural versus general anesthesia for infra-inguinal arterial reconstruction. J Vasc Surg 1991; 14: 765–70.
- deLeon-Casasola OA, Lema MJ, Karabella D, et al. Postoperative myocardial ischemia: epidural versus intravenous patient-controlled analgesia—a pilot project. Reg Anesth 1995; 20: 105–12.[Web of Science][Medline]
- Major CP, Greer MS, Russell WL, et al. Postoperative pulmonary complications and morbidity after abdominal aneurysmectomy: a comparison of postoperative epidural versus parenteral opioid analgesia. Am Surg 1996; 62: 45–51.[Web of Science][Medline]
- Rosenfeld BA, Beattie C, Christopherson R, et al. The effects of different anesthetic regimens on fibrinolysis and the development of postoperative arterial thrombosis. Anesthesiology 1993; 79: 435–43.[Web of Science][Medline]
- Hjortso NC, Nuemann P, Frosig F, et al. A controlled study of the effect of epidural analgesia with local anaesthetics and morphine on morbidity after abdominal surgery. Acta Anaesthesiol Scand 1985; 29: 790–6.[Web of Science][Medline]
-
Reinhardt K, Foehring U, Kersting T, et al. Effects of thoracic epidural anesthesia on systemic hemodynamic function and systemic oxygen supply-demand relationship. Anesth Analg 1989; 69: 360–9.
[Abstract/Free Full Text] - Seeling W, Bothner U, Rockemann M, et al. Patientenkontrollierte Analgesie versus Epiduralanalgesie mit Bupivacain oder Morphin nach grossen abdominellen Eingriffen: kein Unterschied in der postoperativen Morbiditat. Anaesthesist 1991; 40: 614–23.[Web of Science][Medline]
-
Tuman KJ, McCarthy RJ, March RJ, et al. Effects of epi-dural anesthesia and analgesia on coagulation and outcome after major vascular surgery. Anesth Analg 1991; 73: 696–704.
[Abstract/Free Full Text] - Boylan JF, Katz J, Kavanagh BP, et al. Epidural bupivacaine-morphine analgesia versus patient controlled analgesia following abdominal aortic surgery: analgesic, respiratory, and myocardial effects. Anesthesiology 1998; 89: 585–93.[Web of Science][Medline]
- Christopherson R, Beattie C, Frank SM. Perioperative morbidity in patients randomized to epidural or general anesthesia for lower extremity vascular surgery. Anesthesiology 1993; 79: 422–34.[Web of Science][Medline]
- Bode RH, Lewis KP, Zarich SW, et al. Cardiac outcomes after peripheral vascular surgery: comparison of general and regional anaesthesia. Anesthesiology 1996; 84: 3–13.[Web of Science][Medline]
- Garnett RL, MacIntyre A, Lindsay P, et al. Perioperative ischemia in aortic surgery: combined epidural/general anaesthesia and epidural analgesia vs general anaesthesia and iv analgesia. Can J Anaesth 1996; 43: 769–77.[Web of Science][Medline]
- Bois S, Couture P, Boudreault D. Epidural analgesia and intravenous patient-controlled analgesia result in similar rates of postoperative myocardial ischemia after aortic surgery. Anesth Analg 1997; 85: 1233–9.[Abstract]
- Davies MJ, Silbert BS, Mooney PJ. Combined epidural and general anesthesia versus general anaesthesia for abdominal aortic surgery: a prospective randomized trial. Anaesth Intensive Care 1993; 21: 790–4.[Web of Science][Medline]
- Secondary prevention of vascular disease by prolonged antiplatelet treatment. Antiplatelet Trialists’ Collaboration. BMJ 1988; 296: 320–32.
-
Yusuf S, Collins R, Peto R, et al. Intravenous and intracoronary fibrinolytic therapy in acute myocardial infarction: overview of results on mortality, reinfarction and side-effects from 33 randomized controlled trials. Eur Heart J 1985; 6: 556–85.
[Abstract/Free Full Text] - Murray DW, Britton AR, Bulstrode CJK. Thromboprophylaxis and death after total hip replacement. J Bone Joint Surg Br 1996; 78: B863–70.
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 B. M. Block, S. S. Liu, A. J. Rowlingson, A. R. Cowan, J. A. Cowan Jr, and C. L. Wu Efficacy of Postoperative Epidural Analgesia: A Meta-analysis JAMA, November 12, 2003; 290(18): 2455 - 2463. [Abstract] [Full Text] [PDF]
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W. S. Beattie, N. H. Badner, and P. T-L. Choi Meta-Analysis Demonstrates Statistically Significant Reduction in Postoperative Myocardial Infarction with the Use of Thoracic Epidural Analgesia Anesth. Analg., September 1, 2003; 97(3): 919 - 920. [Full Text] [PDF]
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M.-H. Fleron, R. B. Weiskopf, M. Bertrand, S. Mouren, D. Eyraud, G. Godet, B. Riou, E. Kieffer, and P. Coriat A Comparison of Intrathecal Opioid and Intravenous Analgesia for the Incidence of Cardiovascular, Respiratory, and Renal Complications After Abdominal Aortic Surgery Anesth. Analg., July 1, 2003; 97(1): 2 - 12. [Abstract] [Full Text] [PDF]
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O. A. de Leon-Casasola When It Comes to Outcome, We Need to Define What a Perioperative Epidural Technique Is Anesth. Analg., February 1, 2003; 96(2): 315 - 318. [Full Text] [PDF]
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P. J. Peyton, P. S. Myles, B. S. Silbert, J. A. Rigg, K. Jamrozik, and a. R. Parsons Perioperative Epidural Analgesia and Outcome After Major Abdominal Surgery in High-Risk Patients Anesth. Analg., February 1, 2003; 96(2): 548 - 54. [Abstract] [Full Text] [PDF]
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C. Royse, A. Royse, P. Soeding, D. Blake, and J. Pang Prospective randomized trial of high thoracic epidural analgesia for coronary artery bypass surgery Ann. Thorac. Surg., January 1, 2003; 75(1): 93 - 100. [Abstract] [Full Text] [PDF]
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P.-G. Chassot, A. Delabays, and D. R. Spahn Preoperative evaluation of patients with, or at risk of, coronary artery disease undergoing non-cardiac surgery Br. J. Anaesth., November 1, 2002; 89(5): 747 - 759. [Abstract] [Full Text] [PDF]
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M. U. Werner, L. Soholm, P. Rotboll-Nielsen, and H. Kehlet Does an Acute Pain Service Improve Postoperative Outcome? Anesth. Analg., November 1, 2002; 95(5): 1361 - 1372. [Full Text] [PDF]
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