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BMJ 2008; 337 doi: (Published 18 August 2008) Cite this as: BMJ 2008;337:a1338

Epidural anaesthesia and analgesia slightly improve postoperative mortality

Evidence of harms and benefits of epidural perioperative anaesthesia and analgesia in non-cardiac surgery has been going both ways. On one hand they provide better postoperative pain relief than parenteral opioid therapy, prevent lung related complications, and reduce the response to surgical stress, but on the other they are associated with rare but serious complications. A population based, retrospective, cohort study in Ontario, Canada, has looked into epidural anaesthesia’s effect on a new outcome—30 day postoperative mortality.

The 259 037 participants, aged at least 40 years, underwent elective non-cardiac surgery of intermediate to high risk between 1994 and 2004. The researchers used propensity scores to match and compare people who had epidural anaesthesia or analgesia with those who did not.

Epidural anaesthesia and analgesia were mildly protective: 1.7% of people who received such treatment died within 30 days of surgery, compared with 2.0% of people who did not (relative risk 0.89 (95% CI 0.81 to 0·98), P=0.02). The small absolute benefit (risk reduction of 0.2% with a number needed to treat of 477) doesn’t support the use of epidural anaesthesia or analgesia as a means of improving survival in people undergoing non-cardiac surgery. However, argue the authors, the study does support their safety when they are used for other reasons, such as postoperative pain control, when they also might confer a small survival benefit.

School based group treatment reduces post-traumatic stress in children exposed to conflict

Mental health interventions for children exposed to armed conflict are recognised as important parts of secondary prevention of adverse mental health outcomes. More such interventions are being implemented in conflict ridden regions, but few have been tested for effectiveness in controlled studies. In a theme issue of JAMA on violence and human rights, a new cluster randomised trial helps fill this knowledge …

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