Nonanalgesic benefits of combined thoracic epidural analgesia with general anesthesia in high risk elderly off pump coronary artery bypass patients

Abstract

Objective:Epidural anesthesia is a central neuraxial block technique with many applications. It is a versatile anesthetic technique, with applications in surgery, obstetrics and pain control. Its versatility means it can be used as an anesthetic, as an analgesic adjuvant to general anesthesia, and for postoperative analgesia. Off pump coronary artery bypass (OPCAB) surgery triggers a systemic stress response as seen in coronary artery bypass grafting (CABG). Thoracic epidural anesthesia (TEA), combined with general anesthesia (GA) attenuates the stress response to CABG. There is Reduction in levels of Plasma epinephrine, Cortisol and catecholamine surge, tumor necrosis factor-Alpha(TNF ά), interleukin-6 and leucocyte count.Design:A prospective randomised non blind study.Setting:A clinical study in a multi specialty hospital.Participants:Eighty six patients.Material and Methods/intervention:The study was approved by hospital research ethics committee and written informed consent was obtained from all patients. Patients were randomised to receive either GA plus epidural (study group) or GA only (control group). Inclusion Criteria (for participants) were -Age ≥ 70 years, Patient posted for OPCAB surgery, and patient with comorbidities (diabetes mellitus, chronic obstructive pulmonary disease, cerebrovascular disease, peripheral vascular disease, renal dysfunction). Serum concentration of Interlukin: – 6, TNF ά, cortisol, Troponin – I, CK-MB, and HsCRP (highly sensitive C reactive protein), was compared for both the group and venous blood samples were collected and compared just after induction, at day 2, and day 5 postoperatively. Time to mobilization, extubation, total intensive care unit stay and hospital stay were noted and compared. Independent t test was used for statistical analysis.Primary Outcomes:Postoperative complications, total intensive care unit stay and hospital stay.Secondary Outcome:Stress response.Result:Study group showed decreased Interlukin – 6 at day 2, TNF ά at day 2 and 5, troponin I at day 5, and decreased total hospital stay (p < 0.05).Conclusion:Thoracic epidural anesthesia decreases stress and inflammatory response to surgery and decreases hospital stay. However a large multicentre study may be needed to confirm it.

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

“…In the study group patients were extubated on average 5 h after the procedure compared to 10 hours in the control group ( p < 0.001). These results are basically comparable to literature data though an direct comparison is difficult as methods of postoperative care are very variable among the authors reporting in this field [ 11 , 20 , 21 ]. Some authors applied naloxone in the postoperative period.…”

“…This study has several important limitations. Firstly, the sample size is far too small to draw firm conclusions, although the number of patients was comparable to the most recent studies in this field [ 18 , 20 ]. Secondly, for this study we selected a low-risk population, with satisfactory results regardless of the methods used.…”

“…Secondly, for this study we selected a low-risk population, with satisfactory results regardless of the methods used. Finally, it is worth pointing out that all the selected endpoints are only secondary (similarly to many other studies in this field) [ 18 , 20 , 21 ]. The effect of TEA on the improvement of treatment outcomes has not been demonstrated.…”

“…Recent literature shows renewed interest in the use of epidurals in cardiac surgery [ 10 , 11 , 18 – 21 ]. The reasons for that are complex and associated with ageing of the population of cardiac surgery patients, which is combined with the increased number of additional risks [ 20 ], especially chronic obstructive respiratory disease [ 22 , 23 ]. There is growing evidence that TEA is associated with significant advantages that could potentially change the course of the early postoperative period [ 20 , 21 , 24 ], but the number of reports on epidurals in cardiac surgery is still insufficient.…”

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

“…In our study, troponin levels were low in both groups and without a significant difference between the groups. In one recent study, mean serum levels of Troponin I and inflammatory markers were reported to be significantly lower in patients receiving HTEA as an adjunct to general anesthesia compared to those receiving general anesthesia alone during off-pump CABG [8]. However, like ours, this study also revealed quite low mean Troponin I levels in the postoperative period and the authors reported that the difference in Troponin levels was significant only at 5 th postoperative day (0.64 vs. 0.12 in control and study groups, respectively, p< 0.05).…”