Evaluation of thoracic epidural analgesia in patients undergoing coronary artery bypass surgery – a prospective randomized trial

Abstract

IntroductionMost recent studies tend to confirm the beneficial effect of thoracic epidural analgesia (TEA) in cardiac surgery.AimTo assess whether intensive care unit TEA has an influence on the perioperative course following low-risk coronary artery surgery.Material and methodsThis prospective, randomized trial was performed in patients scheduled for low-risk coronary artery surgery. Eighty patients undergoing off-pump or on-pump coronary artery bypass surgery were prospectively randomized to receive either combined general and epidural anesthesia or general anesthesia only. Time of postoperative ventilations and intensive care unit stay was compared between the groups. For all comparisons (p < 0.05) was considered statistically significant.ResultsThe addition of TEA to general anesthesia significantly attenuated the stress response expressed by intraoperative heart rate, systolic blood pressure and cumulative doses of opioids. Time to the return of spontaneous respiration, time to extubation and time of stay in the postoperative care unit were all shorter in the study group, with no difference in hospital stay. Patients with TEA required midazolam less frequently (12.8% vs. 53.8%, p < 0.001). The percentage of patients given morphine in the study group was lower (46.2% vs. 89.7%, p < 0.001) and the mean dose given in patients receiving morphine was also lower (9.3 ±5.3 mg vs. 18.2 ±9.1 mg, p < 0.001).ConclusionsAddition of TEA to general anesthesia shortens the return of respiratory function, duration of mechanical ventilation and ICU stay in the postoperative period after coronary artery surgery, providing comparable hemodynamic stability to general anesthesia alone.

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.…”

The use of epidural anesthesia in coronary surgery: pro and contra. Review

“…По данным метаанализа Ho и соавт., медианные значения тромбоза вен нижней конечности и симптомной легочной эмболии в кардиохирургии составляют 3,2 и 0,6 % соответственно [69]. В целом ряде исследований показано, что эпидуральная анестезия за счет снижения операционного стресса может уменьшать выраженность гиперкоагуляционного синдрома [70,71] и частоту тромбоза вен нижней конечности [72,73]. Вместе с тем, несмотря на снижение коагуляционного потенциала, эпидуральная анестезия в кардиохирургии не увеличивает риск дренажной кровопотери и не повышает частоту гемотрансфузий при сравнении с общей анестезией [70,[74][75][76], а по данным некоторых работ, даже может способствовать их снижению [61,77].…”