Comparison of perioperative thoracic epidural fentanyl with bupivacaine and intravenous fentanyl for analgesia in patients undergoing coronary artery bypass grafting surgery

Abstract

Context:Two-thirds of patients undergoing coronary artery bypass grafting (CABG) surgery report moderate to severe pain, particularly with ambulatory or respiratory effort.Aims:The aim of this study is to compare the analgesic effect of perioperative thoracic epidural fentanyl with bupivacaine and intravenous fentanyl in patients undergoing CABG surgery.Settings and Design:The study was a prospective, randomized, nonblinded comparative study.Materials and Methods:A total of 60 patients coming under the American Society of Anesthesiologists Class III who were posted for CABG surgery were recruited in this study. The patients were randomized into one of two groups, higher thoracic epidural analgesia (HTEA) group receiving general anesthesia with thoracic epidural analgesia (TEA) in the postoperative period, and intravenous fentanyl analgesia group receiving general anesthesia with fentanyl infusion in the postoperative period. The pain was assessed at 4 h after extubation when the patient was fully awake, then at 8, 12, 18, and 24 h. Both groups received intravenous tramadol 100 mg as rescue analgesia whenever visual analog scale score was 5 and above. Heart rate, mean arterial pressure (MAP), sedation scores, and physiotherapy cooperation were also assessed.Statistical Analysis Used:The numerical data were analyzed using an independent t-test, repeated-measures ANOVA, and Mann–Whitney U-test.Results:Pain at rest and on cough was significantly lower in HTEA patients as compared to control group. Patients HTEA group got less frequent rescue analgesia than the control group. Physiotherapy cooperation was significantly better in HTEA patients at 4, 12, and 24 h postextubation. They also had significantly lower heart rate, MAP, and sedation scores.Conclusion:Perioperative TEA using fentanyl with bupivacaine provided optimal postoperative analgesia at rest and during coughing in patients following CABG surgery as compared to postoperative analgesia with intravenous fentanyl. It also resulted in optimal postoperative hemodynamic status, good cooperation to chest physiotherapy with less sedation.

Regional Analgesia for Cardiac Surgery Part 1. Current status of neuraxial and paravertebral blocks for adult cardiac surgery

“…Epidural analgesia facilitates fast-tracking in cardiac surgery through early extubation, shorter length of ICU, and hospital stay, providing significant cost advantages. 27,28 TEA was also associated with a reduced incidence of pulmonary complications. [29][30][31] Lenkutis et al 32 studied the effects of epidural analgesia on the extravascular lung water volume during cardiopulmonary bypass and related it to its ultimate effects on the duration of mechanical ventilation and incidence of postoperative pulmonary function.…”

Thoracic Epidural Anesthesia in Cardiac Surgery: A Systematic Review, Meta-Analysis, and Trial Sequential Analysis of Randomized Controlled Trials

“…We shortlisted 51 RCTs (2112 TEA and 2220 GA) in the meta-analysis (Figure 1). 6,7,20,21,36–82 The pooled age (TEA: 62.8 years; 95% CI, 60.8–64.8 versus GA: 62.7 years; 95% CI, 60.6–64.7), body mass index (BMI; TEA: 27.7; 95% CI, 26.8–28.7 versus GA: 27.9; 95% CI, 26.8–29.0), and left ventricular ejection fraction (LVEF, TEA: 55.1%; 95% CI, 51.8–58.3 versus GA: 54.8%; 95% CI, 49.8–59.8) were similar between both groups. Forty-three studies were solely on coronary artery bypass grafts, while 8 studies included other cardiac surgeries such as valve replacements, including combined coronary artery bypass and valve replacement surgeries.…”

Enhanced Recovery after Cardiac Surgery: An Update on Clinical Implications

“…Epidural and intrathecal administration of opioids have been shown to help attenuate perioperative stress responses. 25…”

“…They discovered thoracic epidural analgesia with fentanyl and bupivacaine provided optimal postoperative analgesia at rest and during coughing in patients following coronary bypass grafting surgery. 25 Negro Neto and colleagues studied the intrathecal administration of sufentanil for coronary artery bypass grafts (CABG) patients, measuring patients' hemodynamic variables, interleukin-6, blood levels of cardiac troponin I, tumor necrosis factor, and B-type natriuretic peptide during and after surgery. The results demonstrated that the sufentanil group required remarkably less dopamine support than the control group and less increases in remifentanil doses.…”