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September 12, 2007

COPD and Abdominal Surgery—Reply

Author Affiliations

Letters Section Editor: Robert M. Golub, MD, Senior Editor.

JAMA. 2007;298(10):1158-1159. doi:10.1001/jama.298.10.1159-a

In Reply: Dr Atkins correctly points out limitations in the literature regarding neuraxial blockade as a strategy to reduce PPCs. The Clinical Crossroads article stated that the data were mixed but that general anesthesia was a probable risk factor. The article acknowledged several limitations of the meta-analysis by Rodgers et al1 and the finding of contradictory results from more recent studies. In that meta-analysis, the authors identified 28 studies of general surgery and 22 studies of vascular surgery. More than half of the vascular surgery studies were of patients undergoing aortic aneurysm repair or aortobifemoral bypass. These procedures, which involve abdominal incisions, confer a higher risk of PPCs than nonabdominal surgeries.2 Restricting the findings of Rodgers et al to these 40 studies (n = 3691), the results appear similar to those of the entire meta-analysis. This finding has applicability to the patient who was contemplating abdominal surgery. However, the evidence base in support of the benefit of neuraxial blockade must be considered incomplete and tentative. Future studies should include patients undergoing high-risk surgery and be sufficiently powered to detect clinically meaningful differences in PPC rates.