Thoracic Epidural Anesthesia for Cardiac Surgery: A Randomized Trial

Abstract

Background The addition of thoracic epidural anesthesia (TEA) to general anesthesia (GA) during cardiac surgery may have a beneficial effect on clinical outcomes. TEA in cardiac surgery, however, is controversial because the insertion of an epidural catheter in patients requiring full heparinization for cardiopulmonary bypass may lead to an epidural hematoma. The clinical effects of fast-track GA plus TEA were compared with those of with fast-track GA alone. Methods A randomized controlled trial was conducted in 654 elective cardiac surgical patients who were randomly assigned to combined GA and TEA versus GA alone. Follow-up was at 30 days and 1 yr after surgery. The primary endpoint was 30-day survival free from myocardial infarction, pulmonary complications, renal failure, and stroke. Results Thirty-day survival free from myocardial infarction, pulmonary complications, renal failure, and stroke was 85.2% in the TEA group and 89.7% in the GA group (P = 0.23). At 1 yr follow-up, survival free from myocardial infarction, pulmonary complications, renal failure, and stroke was 84.6% in the TEA group and 87.2% in the GA group (P = 0.42). Postoperative pain scores were low in both groups. Conclusions This study was unable to demonstrate a clinically relevant benefit of TEA on the frequency of major complications after elective cardiac surgery, compared with fast-track cardiac anesthesia without epidural anesthesia. Given the potentially devastating complications of an epidural hematoma after insertion of an epidural catheter, it is questionable whether this procedure should be applied routinely in cardiac surgical patients who require full heparinization.

Spinal epidural hematoma related to an epidural catheter in a cardiac surgery patient -A case report-

“…Due to insufficient data, it was unclear whether preoperative placement of an epidural catheter followed by full heparinization one to three hours later would decrease this risk [8]. Some authors have failed to demonstrate a clinically relevant benefit of thoracic epidural analgesia on the frequency of major complications after elective cardiac surgery, compares with fast-track cardiac anesthesia without epidural anesthesia [3]. Given the potentially devastating complications of an epidural hematoma after insertion of an epidural catheter, it is questionable whether this procedure should be applied routinely in cardiac surgical patients who required full heparinization.…”

“…There is concern, however, about its use in patients with perioperative anticoagulation, because of the risk of bleeding, which could cause serious adverse events like epidural hematoma and neurologic injury [2,3]. We describe here a spinal epidural hematoma related to epidural analgesia in an adult patient who underwent cardiac surgery.…”

Neurological complications of cardiac surgery

“…63 However, the largest randomized trial to date showed no clinically relevant benefit of TEA in 654 cardiac surgery patients. 64 Overall, TEA is rarely used in cardiac surgery due to risk of epidural hematoma formation in the setting of high-dose heparinization for CPB, and because of a lack of evidence for benefit over routine care.…”

Epidurals for Cardiac Surgery

“…Is it realistic for an anesthetic intervention to have a large effect on surgical morbidity or mortality, particularly in major operations where there are so many potential interplays of surgical technique, patient comorbidities, or postoperative care paradigms? Although Svircevic et al 1 have conducted the largest randomized trial of HTEA in cardiac surgery to date (654 patients), it was entirely predictable that they did not find a positive benefit of HTEA. Although their combined morbidity outcome was correctly estimated at approximately 15%, they powered this study to find a 50% reduction in combined incidence of myocardial infarction, pulmonary complications, renal failure, and stroke.…”

“…For a 15% baseline composite morbidity, and assuming a 15% reduction with an anesthetic intervention, 4,200 patients in each group would be required to demonstrate that no effect exists. The study by Svircevic et al 1 can be added to the series of studies that failed to demonstrate that an anesthetic intervention can make a very large difference in surgical outcomes, but remain substantially underpowered to show that no effect occurs.…”