Thoracic epidural analgesia in obese patients with body mass index of more than 30 kg/m ² for off pump coronary artery bypass surgery

Abstract

Perioperative Thoracic epidural analgesia (TEA) is an important part of a multimodal approach to improve analgesia and patient outcome after cardiac and thoracic surgery. This is particularly important for obese patients undergoing off pump coronary artery bypass surgery (OPCAB). We conducted a randomized clinical trial at tertiary care cardiac institute to compare the effect of TEA and conventional opioid based analgesia on perioperative lung functions and pain scores in obese patients undergoing OPCAB. Sixty obese patients with body mass index >30 kg/m2 for elective OPCAB were randomized into two groups (n=30 each). Patients in both the groups received general anesthesia but in group 1, TEA was also administered. We performed spirometry as preoperative assessment and at six hours, 24 hours, second, third, fourth and fifth day after extubation, along with arterial blood gases analysis. Visual analogue scale at rest and on coughing was recorded to assess the degree of analgesia. The other parameters observed were: time to endotracheal extubation, oxygen withdrawal time and intensive care unit length of stay. On statistical analysis there was a significant difference in Vital Capacity at six hours, 24 hours, second and third day postextubation. Forced vital capacity and forced expiratory volume in one second followed the same pattern for first four postoperative days and peak expiratory flow rate remained statistically high till second postoperative day. ABG values and PaO2/FiO2 ratio were statistically higher in the study group up to five days. Visual analogue scale at rest and on coughing was significantly lower till fourth and third postoperative day respectively. Tracheal extubation time, oxygen withdrawal time and ICU stay were significantly less in group 1. The use of TEA resulted in better analgesia, early tracheal extubation and shorter ICU stay and should be considered for obese patients undergoing OPCAB.

Epidural anesthesia and postoperative analgesia with ropivacaine and fentanyl in off-pump coronary artery bypass grafting: a randomized, controlled study

“…These results are in accordance with other studies of EA in coronary surgery and can be explained by a wide range of confounding factors that are able to influence the length of hospitalization [8,10-17]. However, according to Sharma et al , the use of epidural analgesia in obese patients can shorten the ICU stay after OPCAB [13]. This effect was explained by a reduced incidence of respiratory complications in this category of high-risk patients.…”

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

“…[ 18 ] We have also found TEA to be beneficial technique in patients with COPD and obesity (body mass index of more than 30 kg/m 2 ) undergoing OPCAB surgery with better analgesia and pulmonary function test postoperatively. [ 19 ] A study on 60 patients undergoing CABG on the pump with TEA versus TEA + GA observed comparable ventilator time, ICU stay, pain, and cardiopulmonary complications in both groups of patients. [ 20 ] OPCAB also triggers a systemic stress response as seen in CCABG.…”

The outcome of thoracic epidural anesthesia in elderly patients undergoing coronary artery bypass graft surgery

“…Median sternotomy leads to uncoordinated rib cage expansion and respiratory muscle weakness. [4] Basal atelectasis, which occurs after induction of general anesthesia, may persist into the postoperative period and is characterized by increased ventilation perfusion (V/Q) mismatch. [5]…”

“…[2] TEA attenuates postoperative pulmonary complications that follow thoracic surgeries. [4] TEA improves the FVC and FEV1 following thoracotomy. [6] To the best of our knowledge, there are no reports on elderly patients undergoing CABG.…”