BACKGROUND Coronary artery disease (CAD) is one of the most common causes of mortality and morbidity amongst cardiovascular diseases in both developed and developing countries. The prevalence of CAD in India is 14% in urban and 7.4% in rural populations. Perioperative advantage of TEA (thoracic epidural anaesthesia) is enhanced coronary perfusion, improved myocardial oxygen balance and reduced incidence of tachyarrhythmia and myocardial ischemia through sympatholysis.
METHODS108 patients for OPCAB were selected and divided into two groups (GA and GATE). In GATE group, Epidural insertion was done in the evening, 1 day before surgery. Neuraxial block was achieved from T1 to T10 segments with epidural 10 ml infusion of 0.5% bupivacaine with 0.5 mcg/kg fentanyl as bolus dose over a period of 10 minutes followed by infusion of 0.25% bupivacaine with fentanyl 2 mcg/ml@5 ml/hr intraoperatively. In GA Group, maintenance dose of intravenous fentanyl 1 mcg/kg + midazolam 0.03 mg/kg were given intermittently and when there was increase in mean arterial pressure or heart rate above 20% from the baseline. All patients were induced with Thiopental 2.5 mg/kg + Fentanyl 3 mcg/kg + Midazolam 0.03 mg/kg + Vecuronium 0.1 mg/kg, ventilated with 100 % O2 for 3 minutes and intubated with cuffed endotracheal tube of appropriate size. Before skin incision, injection fentanyl 1 mcg/kg, vecuronium 0.02 mg/kg were repeated and surgery was started. Anaesthesia was maintained with air (50%) + oxygen (50%) + isoflurane 1% dial conc.+ intermittent bolus dose of vecuronium 0.02 mg/kg. Heparin (150 IU/kg) was administered via central venous line after completion of LIMA harvesting to achieve an activated clotting time of 250-350s. At the end of the surgery patient were shifted to CVTS-ICU and ventilated with SIMV volume control with pressure support mode.
RESULTSSuperior haemodynamic stability could be achieved via thoracic epidural anaesthesia. heart rate at baseline (p value= 0.563) and after induction (p value= 0.438) were similar and comparable in both the groups. There is more haemodynamic variability during circumflex or obtuse marginal anastomosis (GA -85.78±7.32 & GATE -77.06±8.33). The median duration of surgery in GATE group is 5 hours 30 minutes (IQR-0-1.00) which is significantly higher than GA group with 5 hours (IQR-0-0.63). In GATE group 83.34% of the patients were extubated earlier within 8 hours as compared to 62.96% in GA group.
CONCLUSIONSWe have observed that combined thoracic epidural anaesthesia with general anaesthesia reduces stress response to intubation, better perioperative haemodynamic stability and earlier extubation.
HOW TO CITE THIS ARTICLE:Charan N, Chaudhary M, Sonkusale M, et al. A prospective study of intraoperative comparison between general anaesthesia with conventional opioid and thoracic epidural anaesthesia for off pump coronary artery bypass surgery.
Introduction: Postdural Puncture Headache (PDPH) is the most common complication of dural puncture. Clinical studies have shown that use of small guage needles with pencil point tip is associated with lower incidence and severity of PDPH than with cutting tip needles. Aim: To compare the incidence and severity of PDPH between 25G cutting (Quincke) and 25G non cutting (Whitacre) needles. Materials and Methods: In this randomised controlled study conducted at Jawaharlal Nehru Institute of Medical SciencesImphal, Manipur, India from September 2019 to September 2021. A total of 150 patients of both sexes, age <60 years and American Society of Anaesthesiologists (ASA) grade I and II, undergoing lower abdominal or lower limb surgeries under spinal anaesthesia were enrolled for this study and divided into two groups with 75 patients in each group. Spinal anaesthesia was performed with 25G Quincke needle in one group and 25G Whitacre needle used in other group to compare the incidence and severity of PDPH (severity was determined by limitation of patient activity and treatment required). Results: Overall 14 patients (9.33%) developed PDPH – 2 in the Whitacre spinal needle (2.6%), and 12 in the Quincke spinal needle (16%), with p-value of 0.009. The incidence of failed spinal anaesthesia was significantly higher with Whitacre spinal needle 12 (16%) than with Quincke needle 4 (5.3%), with p-value of 0.03. Incidence of PDPH was more in female patients 12 (14.8%) compared with male patients 2 (2.9%),with p-value of 0.018. Severity of PDPH ranged from mild (n=10) to moderate (n=2) in Quincke needle group, whereas in Whitacre group patients had only mild form of PDPH (n=2). Conclusion: Incidence and severity of PDPH was significantly lower in 25G Whitacre spinal needle than 25G Quincke needle. Failure rate of spinal anaesthesia was more in Whitacre needle than in Quincke needle.
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