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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 . . . [Full Text of this Article]

Robert F. Atkins, MD
rfa@comcast.net
Department of Anesthesiology
Abington Memorial Hospital
Abington, Pennsylvania

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