Does High Thoracic Epidural Analgesia with Levobupivacaine Preserve Myocardium? A Prospective Randomized Study

Abstract

Background. Our study aimed to compare HTEA and intravenous patient-controlled analgesia (PCA) in patients undergoing coronary bypass graft surgery (CABG), based on haemodynamic parameters and myocardial functions. Materials and Methods. The study included 34 patients that were scheduled for elective CABG, who were randomly divided into 2 groups. Anesthesia was induced and maintained with total intravenous anesthesia in both groups while intravenous PCA with morphine was administered in Group 1 and infusion of levobupivacaine was administered from the beginning of the anesthesia in Group 2 by thoracic epidural catheter. Blood samples were obtained presurgically, at 6 and 24 hours after surgery for troponin I, creatinine kinase-MB (CK-MB), total antioxidant capacity, and malondialdehyde. Postoperative pain was evaluated every 4 hours until 24 hours via VAS. Results. There were significant differences in troponin I or CK-MB values between the groups at postsurgery 6 h and 24 h. Heart rate and mean arterial pressure in Group 1 were significantly higher than in Group 2 at all measurements. Cardiac index in Group 2 was significantly higher than in Group 1 at all measurements. Conclusion. Patients that underwent CABG and received HTEA had better myocardial function and perioperative haemodynamic parameters than those who did not receive HTEA.

Regional Analgesia for Cardiac Surgery Part 1. Current status of neuraxial and paravertebral blocks for adult cardiac surgery

“…Epidural analgesia was also shown to be beneficial in protecting myocardium at the molecular level as evidenced by decreased mean elevation of troponin, CK-MB levels, and decreased incidence of ST abnormalities. 20,21 Jakobsen et al reported significantly lower levels of N-terminal pro-B-type natriuretic peptide (NT-proBNP) and improved hemodynamics with epidural analgesia group. 14 Improvement in catecholamine response, hemodynamics, and myocardial markers of injury were not always associated with decreased postoperative complications nor improved ICU length of stay and quality of recovery.…”

Practice Advisory for Preoperative and Intraoperative Pain Management of Cardiac Surgical Patients: Part 2

“…A reduction in the incidence of cardiac 126,133 and pulmonary 133 complications as well as duration of mechanical ventilation 120,[127][128][129]132 was also reported with the use of TEA (category A2-B evidence 127,128,132 / category A2-E evidence 126,129 and category B2-E evidence 120,133 ). Several meta-analyses reported similar benefits (category A1-E evidence).…”

“…Literature Findings. The majority of clinical trials concluded that TEA alone or in combination with GA in cardiac surgery may have a variable impact on pain scores, [120][121][122][123][124][125][126][127] opioid consumption, 120,121,128,129 ICU LOS, 124,128,130 and hospital LOS, 120,123,124,131,132 compared to the controls. These findings were reported as primary and secondary outcomes (category A2-B evidence 122,124,127,128 /category A2-E evidence 121,123,126,[129][130][131][132] and category B2-E evidence 120,125 ).…”

Thoracic Epidural Anesthesia in Cardiac Surgery: A Systematic Review, Meta-Analysis, and Trial Sequential Analysis of Randomized Controlled Trials

“…We shortlisted 51 RCTs (2112 TEA and 2220 GA) in the meta-analysis (Figure 1). 6,7,20,21,36–82 The pooled age (TEA: 62.8 years; 95% CI, 60.8–64.8 versus GA: 62.7 years; 95% CI, 60.6–64.7), body mass index (BMI; TEA: 27.7; 95% CI, 26.8–28.7 versus GA: 27.9; 95% CI, 26.8–29.0), and left ventricular ejection fraction (LVEF, TEA: 55.1%; 95% CI, 51.8–58.3 versus GA: 54.8%; 95% CI, 49.8–59.8) were similar between both groups. Forty-three studies were solely on coronary artery bypass grafts, while 8 studies included other cardiac surgeries such as valve replacements, including combined coronary artery bypass and valve replacement surgeries.…”