Chapter 75

Patients with severe medical conditions who undergo surgery are at a higher risk for perioperative morbidity and mortality. These patients have limited physiologic reserves, which may be overwhelmed by the perioperative stress from the trauma of surgery. The use of perioperative regional anesthesia and analgesia may attenuate detrimental perioperative pathophysiology and potentially diminish the incidence of adverse patient outcomes including mortality and major morbidity.1–4 Because only limited data are available on the effect of perioperative peripheral anesthesia and analgesia, this discussion, like much of the available data, focuses on the perioperative use of neuraxial, particularly epidural, anesthesia and analgesia. Nevertheless, the general concepts behind the benefits of perioperative neuraxial anesthesia and analgesia may ultimately be applicable to peripheral anesthesia and analgesia.

In general, perioperative regional anesthesia and analgesia (as opposed to general anesthesia followed by systemic opioids for postoperative pain control), especially that using a local anesthetic-based solution, can provide superior analgesia and attenuate adverse perioperative pathophysiology, particularly the neuroendocrine stress response. These benefits potentially can translate into decreased incidence of morbidity and mortality and to improved convalescence. Curiously, however, trials did not consistently document an improvement in these outcomes with the perioperative use of regional anesthesia and analgesia. Although some data support the use of perioperative epidural anesthesia and analgesia to decrease postoperative pulmonary, gastrointestinal, and cardiovascular complications,2–6 whether regional anesthesia is superior to general anesthesia in decreasing mortality is still controversial. Recent trials provide both supporting1 and refuting2,7 evidence. The various methodologic differences and problems present in available trial results influence both the interpretation and applicability of the trial results.8

A wide range of detrimental physiologic effects, such as the neuroendocrine stress response, hypercoagulation, immunosuppression, and impaired gastrointestinal and pulmonary function, occur as a result of surgical trauma. These effects contribute to the development of postoperative mortality and morbidity. Many of these adverse pathophysiologic responses begin in the intraoperative period and continue into the postoperative period, although the precise overall contribution of each period (intraoperative vs postoperative) to postoperative morbidity and mortality has not been fully evaluated. In a sense, these divisions (intraoperative vs postoperative) are artificial because most of these pathophysiologies follow a continuum from the intraoperative to postoperative period. However, elucidating the exact pathophysiology and differential contribution to postoperative morbidity and mortality would allow optimization of perioperative regional anesthesia and analgesia since different pathophysiologies will exhibit different peaks for the development of complications. For instance, the perioperative hypercoagulable state begins in the intraoperative period,9 but the majority of thromboembolic events occur well into the postoperative period. Likewise, the incidence of other complications, such as myocardial infarction and delirium, often peak in the postoperative period (eg, second or third postoperative day).10–12

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Clinical Pearls
 A recent meta-analysis of randomized studies examining the effect of intraoperative neuraxial vs general anesthesia on mortality demonstrated that use of perioperative neuraxial anesthesia reduced the overall mortality rate (primarily ...

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