We performed an open, prospective, randomized, controlled study of the incidence of major organ complications in 420 patients undergoing routine coronary artery bypass graft surgery with or without thoracic epidural anesthesia and analgesia (TEA). All patients received a standardized general anesthetic. Group TEA received TEA for 96 h. Group GA (general anesthesia) received narcotic analgesia for 72 h. Both groups received supplementary oral analgesia. Twelve patients were excluded-eight in Group TEA and four in Group GA-because of incomplete data collection. New supraventricular arrhythmias occurred in 21 of 206 patients (10.2%) in Group TEA compared with 45 of 202 patients (22.3%) in Group GA (P = 0.0012). Pulmonary function (maximal inspiratory lung volume) was better in Group TEA in a subset of 93 patients (P < 0.0001). Extubation was achieved earlier (P < 0.0001) and with significantly fewer lower respiratory tract infections in Group TEA (TEA = 31 of 206, GA = 59 of 202; P = 0.0007). There were significantly fewer patients with acute confusion (GA = 11 of 202, TEA = 3 of 206; P = 0.031) and acute renal failure (GA = 14 of 202, TEA = 4 of 206; P = 0.016) in the TEA group. The incidence of stroke was insignificantly less in the TEA group (GA = 6 of 202, TEA = 2 of 206; P = 0.17). There were no neurologic complications associated with the use of TEA. We conclude that continuous TEA significantly improves the quality of recovery after coronary artery bypass graft surgery compared with conventional narcotic analgesia.

SummaryWe have performed a retrospective analysis of the peri-operative course of 218 consecutive patients who underwent routine coronary artery bypass graft surgery in this institution. All patients received a standardised general anaesthetic using target-controlled infusions of alfentanil and propofol. One hundred patients also received thoracic epidural anaesthesia with bupivacaine and clonidine, started before surgery and continued for 5 days after surgery. The remaining 118 patients received target-controlled infusion of alfentanil for analgesia for the first 24 h after surgery, followed by intravenous patient-controlled morphine analgesia for a further 48 h. Using computerised patient medical records, we analysed the frequency of respiratory, neurological, renal, gastrointestinal, haematological and cardiovascular complications in these two groups. New arrhythmias requiring treatment occurred in 18% of the thoracic epidural anaesthesia group of patients compared with 32% of the general anaesthesia group (p 0.02). There was also a trend towards a reduced incidence of respiratory complications in the thoracic epidural anaesthesia group. The time to tracheal extubation was decreased in the epidural group, with the tracheas of 21% of the patients being extubated immediately after surgery compared with 2% in the general anaesthesia group (p < 0.001). There were no serious neurological problems resulting from the use of thoracic epidural analgesia.Keywords Anaesthetic techniques, regional; epidural, thoracic. Surgery ; coronary artery bypass grafts. Complications ; postoperative. ...................................................................................... Correspondence to: Dr N. B. Scott Accepted: 2 March 1997 In recent years there has been a growing interest in the use of thoracic epidural anaesthesia for coronary artery bypass surgery. Its potential advantages include excellent analgesia [1], improved pulmonary function [2], early tracheal extubation [2, 3] and cardiac protection as a result of sympathetic blockade [4]. Thoracic epidural anaesthesia decreases the stress response to sternotomy and cardiopulmonary bypass. Increased sympathetic activity may lead to an increase in arterial pressure, tachycardia and an imbalance between the myocardial oxygen demand and supply, with increased myocardial oxygen extraction and the possibility of ischaemic episodes. Moore et al. showed that plasma concentrations of adrenaline and noradrenaline did not increase in the first 24 h after cardiac surgery in patients receiving thoracic epidural anaesthesia compared with a conventional anaesthetic technique [5]. Other studies have shown that haemodynamic stability was maintained during and after surgery using thoracic epidural anaesthesia [6][7][8][9].Thoracic epidural anaesthesia has been shown to decrease pain and improve the endocardial to epicardial blood flow ratio, thereby decreasing the number of ischaemic episodes [10][11][12]. Thoracic epidural anaesthesia has also been shown to decrease infarct ...

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