A goal-directed algorithm based on advanced hemodynamic monitoring and continuous measurement of ScvO(2) facilitates early detection and correction of hemodynamic changes and influences the strategy for fluid therapy that can improve the course of post-operative period after coronary artery bypass grafting on the beating heart.
BackgroundOur aim was to assess the efficacy of thoracic epidural anesthesia (EA) followed by postoperative epidural infusion (EI) and patient-controlled epidural analgesia (PCEA) with ropivacaine/fentanyl in off-pump coronary artery bypass grafting (OPCAB).MethodsIn a prospective study, 93 patients were scheduled for OPCAB under propofol/fentanyl anesthesia and randomized to three postoperative analgesia regimens aiming at a visual analog scale (VAS) score < 30 mm at rest. The control group (n = 31) received intravenous fentanyl 10 μg/ml postoperatively 3-8 mL/h. After placement of an epidural catheter at the level of Th2-Th4 before OPCAB, a thoracic EI group (n = 31) received EA intraoperatively with ropivacaine 0.75% 1 mg/kg and fentanyl 1 μg/kg followed by continuous EI of ropivacaine 0.2% 3-8 mL/h and fentanyl 2 μg/mL postoperatively. The PCEA group (n = 31), in addition to EA and EI, received PCEA (ropivacaine/fentanyl bolus 1 mL, lock-out interval 12 min) postoperatively. Hemodynamics and blood gases were measured throughout 24 h after OPCAB.ResultsDuring OPCAB, EA decreased arterial pressure transiently, counteracted changes in global ejection fraction and accumulation of extravascular lung water, and reduced the consumption of propofol by 15%, fentanyl by 50% and nitroglycerin by a 7-fold, but increased the requirements in colloids and vasopressors by 2- and 3-fold, respectively (P < 0.05). After OPCAB, PCEA increased PaO2/FiO2 at 18 h and decreased the duration of mechanical ventilation by 32% compared with the control group (P < 0.05).ConclusionsIn OPCAB, EA with ropivacaine/fentanyl decreases arterial pressure transiently, optimizes myocardial performance and influences the perioperative fluid and vasoactive therapy. Postoperative EI combined with PCEA improves lung function and reduces time to extubation.Trial RegistrationNCT01384175
В о п р о с ы а н е с т е з и о л о г и и Цель исследования-оценить эффективность высокой грудной эпидуральной анестезии (ЭА) и анальгезии при аортоко ронарном шунтировании (АКШ) без искусственного кровообращения (ИК). Материал и методы. В исследование включено 93 больных, которым было выполнено АКШ без ИК. Больные были рандомизированы на три группы: 1-кон трольная (n=30) с эндотрахеальной сбалансированной анестезией пропофолом и фентанилом и послеоперационной вну тривенной анальгезией фентанилом; 2-эпидуральной инфузии (n=30) с комбинированной эндотрахеальной и эпиду ральной (ропивакаин 0,75%-10-12 мл и фентанил 2-3 мкг/кг) анестезией и послеоперационной инфузией в эпидуральное пространство ропивакаина 0,2% и фентанила 2 мкг/мл со скоростью 3-10 мл/ч; 3-эпидуральной инфузии с аутоанальгезией (n=30), где после АКШ дополнительно к эпидуральной инфузии ропивакаина и фентанила использо вали их введение в режиме аутоанальгезии. Результаты. В ходе АКШ в группах, получавших ЭА, отмечали меньшую выраженность артериальной гипертензии и депрессии миокарда (р<0,05). В этих группах интраоперационный расход пропофола снижался в среднем на 15%, фентанила-на 50%, нитроглицерина-в 7 раз. В то же время, частота исполь зования коллоидов и симпатомиметиков повышалась по сравнению с контрольной группой, cоответственно, в 2 и 3 раза (р<0,05). Артериальная оксигенация в послеоперационном периоде была выше при эпидуральной инфузии с аутоаналь гезией, а показатель лактата-в контрольной группе (р<0,05). Эпидуральная инфузия обеспечивала максимальное сни жение выраженности болевого синдрома; в группе с эпидуральной аутоанальгезией отмечали сокращение времени после операционной ИВЛ на 46% (р<0,05). Заключение. Эпидуральная анестезия и анальгезия при АКШ без ИК обеспечивают стабильность гемодинамики и оптимальное послеоперационное обезболивание. После АКШ эпидуральная инфузия с ау тоанальгезией улучшает функцию легких и тканевую перфузию, а также снижает длительность респираторной поддерж ки. Ключевые слова: аортокоронарное шунтирование, гемодинамика, эпидуральная анестезия, анальгезия. Objective: to evaluate the efficiency of high thoracic epidural anesthesia (EA) and analgesia during aortocoronary bypass surgery (ACBS) without extracorporeal circulation (EC). Subjects and methods. The study enrolled 93 patients who had undergone ACBS without EC. The patients were randomized to three groups: 1) 30 controls who had balanced endotra cheal anesthesia with propofol and fentanyl and postoperative intravenous analgesia with fentanyl; 2) 30 patients who received epidural infusion with combined endotracheal and epidural (0.75% ropivacaine, 10-12 ml, and fentanyl, 2-3 μg/kg) anesthesia and postoperative infusion of 0.2% ropivacaine and fentanyl, 2 μg/ml, into the epidural space at a rate of 3-10 ml/hr; 3) 30 patients who had epidural infusion with autoanalgesia in which autoanalgesia with ropivacaine and fentanyl were additionally used during their epidural infusion after ACBS. Results. The less severe degrees of arterial hypertension and myocardi...
The cardiovascular diseases have top-rated place amongst causes of death all around the world. The leading cardiovascular pathology is coronary artery disease; its course is dependent on severity of atherosclerotic lesion of coronary vessels. Coronary artery bypass grafting (CABG) is one from the most often performed medical techniques of coronary revascularization but has a high risk of perioperative respiratory complications, myocardial infarction, dysrhythmias, kidney dysfunction and other problems. High thoracic epidural anesthesia (HTEA) and analgesia provides sympathetic nerve block of cardiac dermatomes, decreases perioperative stress and pain after CABG, and has a protective role regarding cardiac and respiratory functions. These effects of HTEA are confirmed by a number of studies and systematic reviews. Apart from evident benefits of HTEA, there are restrictions for its use in cardiac surgery associated with increased risk of epidural hematoma followed by neurological consequences. In our review, we describe physiological effects and clinical aspects of using HTEA in coronary surgery.
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