The correct answer is:

Thoracic epidural analgesia

Educational Objective:

Know when thoracic epidural analgesia is appropriate in patients undergoing abdominal surgery.

Key Point:

In patients undergoing surgery for abdominal aortic aneurysm, thoracic epidural analgesia provides higher pain relief than opioids and may decrease the duration of endotracheal intubation.

Explanation:

For patients undergoing aortic surgery, strong clinical evidence suggests that thoracic epidural analgesia or anesthesia provides higher quality pain relief than opioids. Thoracic epidural analgesia may also decrease the duration of endotracheal intubation and mechanical ventilation.

The effectiveness of epidural analgesia or anesthesia has not been confirmed when a lumbar approached is used. In addition, the evidence is insufficient to recommend an epidural approach (when compared with the use of opioids) for surgical thoracic cases or for nonvascular abdominal procedures.

Remifentanil is a short-acting synthetic opioid that does not accumulate in cases of renal or hepatic dysfunction. Its analgesic properties are similar to any other opioid.

Ketamine is an agent that induces dissociative anesthesia. It is also a potent analgesic and a bronchodilator, but it is never used as monotherapy for pain; rather, it is used as an adjuvant to opioids.

References:

Barr J, Fraser GL, Puntillo K, et al; American College of Critical Care Medicine. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013;41(1):263-306.

Nishimori M, Low JH, Zheng H, Ballantyne JC. Epidural pain relief versus systemic opioid-based pain relief for abdominal aortic surgery. Cochrane Database Syst Rev. 2012 11;(7):CD005059.