High Thoracic Epidural in Cardiac Anesthesia

Abstract

High thoracic epidural analgesia (HTEA) offers a distinctive opportunity to enhance postoperative recovery for the thoracic surgery patient. In the modern hospital setting with day of admission surgery, the logistics of insertion of the epidural catheter has become increasingly difficult. The greatest limitation to its use might be the believed increased risk of epidural hematoma associated with anticoagulation during cardiopulmonary bypass. The aim of this review is to give an overview of complications and effect on outcomes with focus on cardiac performance and postoperative glycemic control and kidney function. Patients with epidurals may have improved postoperative pulmonary function and shorter ventilation time, while impact on length of stay in the intensive care unit and hospital is not as evident. HTEA is effective in pain management, attenuates perioperative stress and seems to improve postoperative blood glucose control. Whether HTEA improves recovery and facilitates fast-track is still to be confirmed. With regard to serious postoperative complications, there is evidence of reduction in supraventricular arrhythmias and lower frequency of postoperative acute kidney injury and dialysis. There are some indications of lower short term mortality and frequency of postoperative myocardial infarctions, but only as a combined outcome. The present short-term mortality of 1% to 2% should be compared with the most pessimistic frequency of epidural hematoma being 1 in 4600 patients.

Efectividad de la analgesia controlada por el paciente en el dolor agudo y crónico de los pacientes después de cirugía cardiaca: estudio prospectivo

“…Se han descrito otras opciones analgésicas efectivas desde un punto de vista multimodal (23,24), sin que haya suficiente evidencia para su recomendación generalizada. Se ha utilizado la analgesia epidural (25), la pregabalina (26), la oxicodona vía oral (27), la dexmedetomidina o la analgesia regional (bloqueo paravertebral (28), bloqueo intercostal o bloqueo paraesternal (29)).…”

Improved Recovery Protocols in Cardiac Surgery: A Systematic Review and Meta-Analysis of Observational and Quasi-Experimental Studies

“…In cardiac surgery, such fasttrack and ultra fast-track programs are not applied to all cardiac surgical procedures or to all patients. [17,[19][20][21][22][23][24][25][26] Between 2017 and 2019, publications on the results of ERAS programs in cardiac surgery increased. [6,14,19,23,[27][28][29][30][31][32][33] World leaders in the specialty recognized the need to adapt the original ERAS programs to cardiac surgery patient characteristics and to each type of intervention, and to generalize a protocol based on the best scientifi c evidence.…”

High Thoracic Epidural Analgesia as an Adjunct to General Anesthesia in Patients Undergoing Off-Pump Coronary Artery Bypass Grafting

“…Further studies demonstrated that use of HTEA attenuated surgical stress response and thus provided hemodynamic stabilization and anti-arrhythmic effect during CABG. However, its potential complications such as epidural hematoma or abscess and procedural difficulties with epidural catheter placement and anesthetic failures have limited the use of HTEA following the initial reports [5].…”