Myocardial, Inflammatory, and Stress Responses in Off-Pump Coronary Artery Bypass Graft Surgery With Thoracic Epidural Anesthesia

Caputo, Massimo; Alwair, Hazaim; Rogers, Chris; Ginty, Mark; Monk, C.R.; Tomkins, Sally; Mokhtari, Amir; Angelini, Gianni D

doi:10.1016/j.athoracsur.2008.12.047

Cited by 29 publications

(19 citation statements)

References 15 publications

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“…It has been suggested that thoracic epidural analgesia (TEA) reduces the stress response to surgery (157), although this is controversial, because it has not been shown universally (e.g., in patients undergoing cardiac surgery) (158). Still, several investigators have proposed that this analgesic modality may reduce the incidence of complications, including AKI.…”

Section: Prevention Of Aki Nonpharmacologic Strategiesmentioning

confidence: 99%

AKI Associated with Cardiac Surgery

Thiele¹,

Isbell²,

Rosner

2015

Clinical Journal of the American Society of Nephrology

254

198

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Approximately 18% of patients undergoing cardiac surgery experience AKI (on the basis of modern standardized definitions of AKI), and approximately 2%-6% will require hemodialysis. The development of AKI after cardiac surgery portends poor short-and long-term prognoses, with those developing RIFLE failure or AKI Network stage III having an almost 2-fold increase in the risk of death. AKI is caused by a variety of factors, including nephrotoxins, hypoxia, mechanical trauma, inflammation, cardiopulmonary bypass, and hemodynamic instability, and it may be affected by the clinician's choice of fluids and vasoactive agents as well as the transfusion strategy used. The risk of AKI may be ameliorated by avoidance of nephrotoxins, achievement of adequate glucose control preoperatively, and use of goal-directed therapy hemodynamic strategies. Remote ischemic preconditioning is an exciting future strategy, but more work is needed before widespread implementation. Unfortunately, there are no pharmacologic agents known to reduce the risk of AKI or treat established AKI.

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Section: Prevention Of Aki Nonpharmacologic Strategiesmentioning

confidence: 99%

AKI Associated with Cardiac Surgery

Thiele¹,

Isbell²,

Rosner

2015

Clinical Journal of the American Society of Nephrology

254

198

View full text Add to dashboard Cite

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“…Exclusion of 2 studies in which POAF did not served as the primary endpoint yielded similar results (RR 0.64, 95% CI 0.26 to 1.58; P = 0.33), with substantial evidence of heterogeneity (I 2 = 82%, P = 0.004) [18,19]. After exclusion of 2 studies with low-quality studies (Jadad score ≤ 2), the results were still maintained (RR 0.73, 95% CI 0.37 to 1.44; P = 0.36), yet heterogeneity was still present (I 2 = 68%, P = 0.04) [15,17].…”

Section: Resultsmentioning

confidence: 93%

“…For the remaining 10 RCTs, five of these were also excluded because POAF was not well defined and the monitoring of POAF was not specified clearly [10-14]. Finally, five RCTs that met our inclusion criteria were included in the present meta-analysis [15-19]. The flowchart of studies included in meta-analysis was shown in Figure 1.…”

Section: Resultsmentioning

confidence: 99%

“…The size of the RCT ranged from 50 to 163 (total 540). Three studies in this meta-analysis enrolled patients undergoing CABG with CPB technique [15,16,18], the remaining two studies included patients undergoing CABG with OPCAB technique [17,19]. The quality of the included studies was assessed by the Jadad score.…”

Section: Resultsmentioning

confidence: 99%

“…As TEA reduces sympathetic activity, it seems to be a promising non-pharmacologic intervention to reduce the incidence of POAF and could be beneficial in patients at increased risk of perioperative arrhythmias [9]. However, the studies regarding TEA in preventing POAF conveyed mixed and inconclusive results [10-19]. We therefore performed a meta-analysis based on relevant randomized controlled trials to evaluate the efficacy of TEA in preventing POAF in adult patients undergoing CABG.…”

Section: Introductionmentioning

confidence: 99%

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Meta-analysis of randomized controlled trials on the efficacy of thoracic epidural anesthesia in preventing atrial fibrillation after coronary artery bypass grafting

Wei

Huang

et al. 2012

BMC Cardiovasc Disord

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BackgroundPostoperative atrial fibrillation (POAF) is one of the most common complications in patients undergoing coronary artery bypass grafting (CABG). The goal of this meta-analysis was to evaluate the efficacy of thoracic epidural anesthesia (TEA) in preventing POAF in adult patients undergoing CABG.MethodsMEDLINE and EMBASE were searched to identify randomized controlled trails in adult patients undergoing CABG who were randomly assigned to receive general anesthesia plus thoracic epidural anesthesia (GA + TEA) or general anesthesia only (GA). Two authors independently extracted data using a standardized Excel file. The primary outcome measure was the incidence of POAF. We used DerSimonian-Laird random-effects models to compute summary risk ratios with 95% confidence intervals.ResultsFive studies involving 540 patients met our inclusion criteria. No significant difference in the incidence of POAF was observed between the two groups (risk ratio, 0.61; 95% confidence interval, 0.33 to 1.12; P = 0.11), with significant heterogeneity among the studies (I2 = 73%, P = 0.005). Sensitivity analyses by primary endpoint, methodological quality and surgical technique yielded similar results.ConclusionsThe limited evidence suggests that TEA shows no beneficial efficacy in preventing POAF in adult patients undergoing CABG. However, the results of this meta-analysis should be interpreted with caution due to significant heterogeneity of the studies included. Thus, the potential infuence of TEA on the incidence of atrial fibrillation following CABG warrants further investigation.

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