PERIOPERATIVE MORBIDITY IN PATIENTS RANDOMIZED TO EPIDURAL OR GENERAL-ANESTHESIA FOR LOWER-EXTREMITY VASCULAR-SURGERY

Background. Perioperative morbidity may be modifiable in high risk pat ients by the anesthesiologist's choice of either regional or general a nesthesia. This clinical trial compared outcomes between epidural (EA) and general (GA) anesthesia/analgesia regimens in a group of patients at high risk for cardiac and other morbidity who were undergoing simi larly stressful surgical procedures. Methods: One hundred patients sch eduled for elective vascular reconstruction of the lower extremities w ere randomized to receive either EA for surgery followed by epidural a nalgesia, or GA for surgery followed by intravenous patient-controlled analgesia. Hemodynamic monitoring, blood pressure, and heart rate lim its were determined prior to randomization. Management of anesthesia i n the immediate postoperative period was standardized. The data collec ted included continuous electrocardiographic monitoring from the day b efore surgery through the third postoperative day, serial electrocardi ograms, and cardiac enzymes. Cardiac ischemia, myocardial infarction, unstable angina, and cardiac death were identified by a cardiologist b linded to the type of anesthesia received. Other major morbidity was d etermined at the time of hospital discharge and at 1 and 6 months afte r surgery. Results: Eleven patients who received GA required regraftin g or an embolectomy during their hospital stay, compared with two pati ents who received EA. This association of GA with reoperation remained significant after adjustment for baseline differences. Cardiac outcom es were similar in the two groups with respect to perioperative death (1 EA and 1 GA), death within 6 months (4 EA and 3 GA), nonfatal myoca rdial infarction within 7 days (2 EA and 2 GA), unstable angina (0 EA and 2 GA), and myocardial ischemia following randomization (17 EA and 23 GA). Rates of major infections in the two groups (1 EA and 2 GA), r enal failure (3 EA and 3 GA), and pulmonary complications (3 EA and 7 GA) also were similar. Conclusions. Carefully conducted epidural and g eneral anesthesia appear to be associated with comparable rates of car diac and most other morbidity in patients undergoing lower extremity v ascular surgery. However, compared with general anesthesia, epidural a nesthesia is associated with a lower incidence of reoperation for inad equate tissue perfusion and, therefore, may be advantageous for this s urgical population.