Update neuraxial anaesthesia and analgesia - less benefit, more risk?

Although it appears that the use of neuraxial regional anaesthesia or analgesia does not reduce mortality, it does offer the patient numerous other benefits. In particular in high-risk patients undergoing major abdominal and vascular surgical procedures, cardiopulmonary complications are reduced. In addition, positive effects on such parameters as postoperative pain relief, mobility and patient comfort are evident. However, one must be aware of the fact that serious complications, although rare, do seem to occur more frequently than previously believed. The timely diagnosis and management of these complications can prevent permanent harm to the patient. To this end, organisational measures including standardised protocols, departmental guidelines and interdisciplinary cooperation and consultations are necessary. With a view to minimising risk, in addition to ensuring atraumatic puncture, patients must be carefully selected and an individual benefit-risk analysis performed. This is particularly necessary in elderly surgical patients with coronary artery disease receiving anti-platelet medication who require additional thromboembolism prophylaxis. In view of reported complications of neuraxial regional anaesthesia in recent years, the use of neuraxial regional anaesthesia is likely to decline. This will probably apply in particular to lower extremity procedures, since peripheral continuous nerve blocks offer excellent postoperative pain relief and are safer than lumbar epidural analgesia. The future will show whether paravertebral and abdominal wall nerve blocks are reasonable alternatives to thoracic epidural analgesia for major thoracic and abdominal surgery.