Thoracic Epidural Anesthesia During Coronary Artery Bypass Surgery

Kirn??, Klaus; Friberg, Peter; A, Grzegorczyk; Milocco, I; Ricksten, Sven-Erik; Lundin, S.

doi:10.1213/00000539-199412000-00009

Cited by 12 publications

(9 citation statements)

References 8 publications

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“…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.…”

Section: Resultsmentioning

confidence: 99%

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

Chiew

Low

Zeng

et al. 2023

Anesthesia &Amp; Analgesia

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BACKGROUND: Research on fast-track recovery protocols postulates that thoracic epidural anesthesia (TEA) in cardiac surgery contributes to improved postoperative outcomes. However, concerns about TEA’s safety hinder its widespread usage. We conducted a systematic review and meta-analysis to assess the benefits and risks of TEA in cardiac surgery. METHODS: We searched 4 databases for randomized controlled trials (RCTs) assessing the use of TEA against only general anesthesia (GA) in adults undergoing cardiac surgery, up till June 4, 2022. We conducted random-effects meta-analyses, evaluated risk of bias using the Cochrane Risk-of-Bias 2 tool, and rated certainty of evidence via the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach. Primary outcomes were intensive care unit (ICU), hospital length of stay, extubation time (ET), and mortality. Other outcomes included postoperative complications. Trial sequential analysis (TSA) was conducted on all outcomes to elicit statistical and clinical benefit. RESULTS: Our meta-analysis included 51 RCTs (2112 TEA patients and 2220 GA patients). TEA significantly reduced ICU length of stay (−6.9 hours; 95% confidence interval [CI], −12.5 to −1.2; P = .018), hospital length of stay (−0.8 days; 95% CI, −1.1 to −0.4; P < .0001), and ET (−2.9 hours; 95% CI, −3.7 to −2.0; P < .0001). However, we found no significant change in mortality. TSA found that the cumulative Z-curve passed the TSA-adjusted boundary for ICU length of stay, hospital length of stay, and ET, suggesting a clinical benefit. TEA also significantly reduced pain scores, pooled pulmonary complications, transfusion requirements, delirium, and arrhythmia, without additional complications such as epidural hematomas, of which the risk was estimated to be <0.14%. CONCLUSIONS: TEA reduces ICU and hospital length of stay, and postoperative complications in patients undergoing cardiac surgery with minimal reported complications such as epidural hematomas. These findings favor the use of TEA in cardiac surgery and warrant consideration for use in cardiac surgeries worldwide.

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Section: Resultsmentioning

confidence: 99%

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

Chiew

Low

Zeng

et al. 2023

Anesthesia &Amp; Analgesia

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“…The use of thoracic epidural analgesia for cardiac surgery is welldocumented, which suppresses surgical-mediated hormonal and metabolic responses, 24 improves subendocardial blood flow, myocardial oxygen supply secondary to sympathetic blockage, early awakening and extubation and improved pulmonary function leading to earlier ambulation and reduced narcotic requirement. 25 At the same time hypotension due to extensive sympathetic blockage and chances of epidural hematoma, which is particularly detrimental with use of heparinare a major concern in cardiac surgery. 26 Paravertebral block and interpleural analgesia (IPA) are both well-established techniques for post-thoracotomy pain relief and are safer and easier to perform.…”

Section: Discussionmentioning

confidence: 99%

Thoracic paravertebral versus interpleural catheter for post-thoracotomy pain control in minimally invasive cardiac surgery

Pujara

Singh

Prajapati

et al. 2023

Asian Cardiovasc Thorac Ann

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Objective The aim of this study was to compare efficacy and safety of paravertebral block (PVB) and interpleural analgesia (IPA) after minimally invasive cardiac surgery through thoracotomy in terms of quality of analgesia, post-operative mechanical ventilation time, intensive care unit (ICU) and hospital length of stay (LOS) and complications. Design A randomized, prospective study. Participants A total of 50 adult patients (18–50 years old) undergoing minimally invasive cardiac surgery via thoracotomy. Intervention Patients were randomized for group A: paravertebral epidural catheter ( n = 25), group B: interpleural catheter ( n = 25). All patients were given Inj. Bupivacaine 0.125%, 8 ml and Inj. Tramadol 100 mg as an adjuvant, total volume 10 ml. Results After obtaining institutional review board approval, data collected and analysed – visual analogue score (VAS) at rest and on coughing, haemodynamic and respiratory parameters, time to extubation, supplementary analgesia requirement, LOS and complications. VAS was recorded at 0, 2, 3, 4, 8, 12 and 24 h post-extubation, while blood gases at-after shifting, 4, 8, 12 and 24 h. There were no significant differences in haemodynamic or respiratory parameters, VAS at rest and on coughing, ventilation duration, ICU and hospital LOS between two groups. The requirement of rescue analgesia was in one patient of mini coronary artery bypass in group B, while one patient in group A required reintubation due to respiratory acidosis and got successfully extubated on next day morning. Conclusion PVB and IPA both are safe and effective techniques for minimally invasive cardiac surgery with thoracotomy. It allows optimal pain control and safe ICU fast-track post-operative course.

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“…Heart rate is reduced (10), cardiac arrhythmia is less frequent, and intraoperative hemodynamic stability can be significantly improved [10,15,16]. In addition, TEA lowers the incidence of intraoperative myocardial ischemia [9,10] and reduces endogenous stress response to surgical manipulations [9,11]. Reduction in both tachycardia and ischemic events has demonstrated the benefits of TEA in the postoperative period.…”

Section: Commentmentioning

confidence: 99%

“…Advantages of TEA include sympatholysis with subsequent reduction of endogenous stress response and enhancement of coronary artery perfusion [8][9][10][11][12]. Karagoz and co-workers were the first who reported coronary artery bypass grafting (CABG) via small lateral thoracotomy with the sole use of TEA in 5 conscious patients with single-vessel CAD [13].…”

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confidence: 99%

Coronary Artery Bypass Grafting via Sternotomy in Conscious Patients

et al. 2003

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The application of high thoracic epidural anesthesia (TEA) as an adjunct to general anesthesia is increasingly being used for coronary artery bypass grafting (CABG) with extracorporeal circulation. Recent developments in beating heart techniques rendered the sole use of TEA in conscious patients possible, and have been reported for single-vessel beating heart CABG via lateral thoracotomy. For multi-vessel revascularization, the heart is usually approached via sternotomy; therefore, the sole use of TEA was applied in awake patients who underwent CABG via sternotomy. A total of 7 patients scheduled for awake coronary artery bypass grafting (ACAB) received TEA via an epidural catheter placed at the levels of T1-2 or T2-3, respectively. Total arterial myocardial revascularization was performed after partial lower sternotomy. Besides standard monitoring, anesthetic levels were determined using an epidural scoring scale for arm movements (ESSAM). While 6 patients were awake and spontaneously breathing during the entire procedure, one patient had to be intubated intraoperatively because of respiratory distress caused by phrenic nerve palsy. Hemodynamics were stable throughout the operation. No significant arterial hypercarbia occurred. All patients rated TEA as "good" or "excellent." We could demonstrate that the single use of TEA for CABG via sternotomy was feasible and that the patients felt well, were painfree, and remained hemodynamically stable. High patient satisfaction in our small and highly selected cohort can be reported. Because beating heart surgery in a conscious patient still carries a significant risk, further randomized controlled trials are mandatory to definitively evaluate the role of sole TEA in cardiac surgery.

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Thoracic Epidural Anesthesia During Coronary Artery Bypass Surgery

Cited by 12 publications

References 8 publications

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

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

Thoracic paravertebral versus interpleural catheter for post-thoracotomy pain control in minimally invasive cardiac surgery

Coronary Artery Bypass Grafting via Sternotomy in Conscious Patients

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