Thoracic Epidural Anesthesia for Cardiac Surgery: A Randomized Trial

Background The addition of thoracic epidural anesthesia (TEA) to general anesthesia (GA) during cardiac surgery may have a beneficial effect on clinical outcomes. TEA in cardiac surgery, however, is controversial because the insertion of an epidural catheter in patients requiring full heparinization for cardiopulmonary bypass may lead to an epidural hematoma. The clinical effects of fast-track GA plus TEA were compared with those of with fast-track GA alone. Methods A randomized controlled trial was conducted in 654 elective cardiac surgical patients who were randomly assigned to combined GA and TEA versus GA alone. Follow-up was at 30 days and 1 yr after surgery. The primary endpoint was 30-day survival free from myocardial infarction, pulmonary complications, renal failure, and stroke. Results Thirty-day survival free from myocardial infarction, pulmonary complications, renal failure, and stroke was 85.2% in the TEA group and 89.7% in the GA group (P = 0.23). At 1 yr follow-up, survival free from myocardial infarction, pulmonary complications, renal failure, and stroke was 84.6% in the TEA group and 87.2% in the GA group (P = 0.42). Postoperative pain scores were low in both groups. Conclusions This study was unable to demonstrate a clinically relevant benefit of TEA on the frequency of major complications after elective cardiac surgery, compared with fast-track cardiac anesthesia without epidural anesthesia. Given the potentially devastating complications of an epidural hematoma after insertion of an epidural catheter, it is questionable whether this procedure should be applied routinely in cardiac surgical patients who require full heparinization.

Download Full-text

Meta-analysis of Thoracic Epidural Anesthesia versus General Anesthesia for Cardiac Surgery

Anesthesiology ◽

10.1097/aln.0b013e318201d300 ◽

2011 ◽

Vol 114 (2) ◽

pp. 271-282 ◽

Cited By ~ 93

Author(s):

Vesna Svircevic ◽

Diederik van Dijk ◽

Arno P. Nierich ◽

Martijn P. Passier ◽

Cor J. Kalkman ◽

...

Keyword(s):

Myocardial Infarction ◽

Cardiac Surgery ◽

General Anesthesia ◽

Epidural Anesthesia ◽

Controlled Trial ◽

Meta Analysis ◽

Thoracic Epidural Anesthesia ◽

Supraventricular Arrhythmias ◽

Respiratory Complications ◽

Thoracic Epidural

Background A combination of general anesthesia (GA) with thoracic epidural anesthesia (TEA) may have a beneficial effect on clinical outcomes after cardiac surgery. We have performed a meta-analysis to compare mortality and cardiac, respiratory, and neurologic complications in patients undergoing cardiac surgery with GA alone or a combination of GA with TEA. Methods Randomized studies comparing outcomes in patients undergoing cardiac surgery with either GA alone or GA in combination with TEA were retrieved from PubMed, Science Citation index, EMBASE, CINHAL, and Central Cochrane Controlled Trial Register databases. Results The search strategy yielded 1,390 studies; 28 studies that included 2,731 patients met the selection criteria. Compared with GA alone, the combined risk ratio for patients receiving GA with TEA was 0.81 (95% CI: 0.40-1.64) for mortality, 0.80 (95% CI: 0.52-1.24) for myocardial infarction, and 0.59 (95% CI: 0.24-1.46) for stroke. The risk ratios for the respiratory complications and supraventricular arrhythmias were 0.53 (95% CI: 0.40-0.69) and 0.68 (95% CI: 0.50-0.93), respectively. Conclusions This meta-analysis showed that the use of TEA in patients undergoing cardiac surgery reduces the risk of postoperative supraventricular arrhythmias and respiratory complications. The sparsity of events precludes conclusions about mortality, myocardial infarction, and stroke, but the estimates suggest a reduced risk after TEA. The risk of side effects of TEA, including epidural hematoma, could not be assessed with the current dataset, and therefore TEA should be used with caution until its benefit-harm profile is further elucidated.

Download Full-text

Early axtubation in cardiac surgery

Medicinski pregled ◽

10.2298/mpns1004183n ◽

2010 ◽

Vol 63 (3-4) ◽

pp. 183-187

Author(s):

Vojislava Neskovic ◽

Predrag Milojevic ◽

Dragana Unic ◽

Ivan Ilic ◽

Nada Popovic

Keyword(s):

Mechanical Ventilation ◽

Cardiac Surgery ◽

General Anesthesia ◽

Epidural Anesthesia ◽

Fast Track ◽

Tracheal Extubation ◽

Early Extubation ◽

Cardiac Anesthesia ◽

Thoracic Epidural ◽

High Thoracic Epidural

Introduction An early extubation in cardiac surgery (fast track cardiac anesthesia) refers to mechanical ventilation during 1-6 hours after the intervention, the extubation criteria being the same as for any other surgery. Different protocols have been established for managing patients undergoing fast track anesthesia, with high-thoracic epidural anesthesia being increasingly used in the last few years. Material and methods Thirty-five consecutive patients scheduled for OPCAB surgery, who were planned for very fast track cardiac anesthesia (planned extubation within one hour after the end of the operation), were included in the study. Combined high-thoracic epidural and general anesthesia was performed in all patients, with bupivacain as a local anesthetic and inhalational or intravenous anesthetic used for general anesthesia. Results Thirty three of 35 patients (94.3%) were extubated early, with the mean duration of the mechanical ventilation of 56?92 minutes. Very fast track cardiac anesthesia was performed successfully in 24/35 (68,8%) patients; these patients had higher ejection fraction, lower Euroscore, shorter duration of the surgery, and fewer numbers of grafts, as compared to the patients extubated early. Euroscore was the only independent predictor of the early extubation (higher score - longer mechanical ventilation time). Discussion and conclusion Our results suggest that high-toracic epidural anesthesia enables successful early tracheal extubation in the population of patients scheduled for OPCAB cardiac surgery. We had no complications related to this type of anesthesia and very good perioperative results.

Download Full-text

Faculty Opinions recommendation of Meta-analysis of thoracic epidural anesthesia versus general anesthesia for cardiac surgery.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.13293969.14653077 ◽

2011 ◽

Author(s):

Yukio Hayashi

Keyword(s):

Cardiac Surgery ◽

General Anesthesia ◽

Epidural Anesthesia ◽

Meta Analysis ◽

Thoracic Epidural Anesthesia ◽

Thoracic Epidural

Download Full-text

Faculty Opinions recommendation of Thoracic epidural anesthesia for cardiac surgery: a randomized trial.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.8803957.9334055 ◽

2011 ◽

Author(s):

Glenn Murphy

Keyword(s):

Cardiac Surgery ◽

Randomized Trial ◽

Epidural Anesthesia ◽

Thoracic Epidural Anesthesia ◽

Thoracic Epidural

Download Full-text

Faculty Opinions recommendation of Thoracic epidural anesthesia for cardiac surgery: a randomized trial.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.8803957.12478056 ◽

2011 ◽

Author(s):

Yukio Hayashi

Keyword(s):

Cardiac Surgery ◽

Randomized Trial ◽

Epidural Anesthesia ◽

Thoracic Epidural Anesthesia ◽

Thoracic Epidural

Download Full-text

Preoperative cigarette smoking and short-term morbidity and mortality after cardiac surgery: a meta-analysis

Heart Asia ◽

10.1136/heartasia-2018-011069 ◽

2018 ◽

Vol 10 (2) ◽

pp. e011069 ◽

Cited By ~ 1

Author(s):

Nicholas Gregory Ross Bayfield ◽

Adrian Pannekoek ◽

David Hao Tian

Keyword(s):

Cardiac Surgery ◽

Smoking Status ◽

Meta Analysis ◽

Surgical Site Infections ◽

Neurological Complications ◽

Pulmonary Complications ◽

Morbidity And Mortality ◽

Surgical Patients ◽

Short Term ◽

Increased Risk

Currently, the choice of whether or not to electively operate on current smokers is varied among cardiothoracic surgeons. This meta-analysis aims to determine whether preoperative current versus ex-smoking status is related to short-term postoperative morbidity and mortality in cardiac surgical patients. Systematic literature searches of the PubMed, MEDLINE and Cochrane databases were carried out to identify all studies in cardiac surgery that investigated the relationship between smoking status and postoperative outcomes. Extracted data were analysed by random effects models. Primary outcomes included 30-day or in-hospital all-cause mortality and pulmonary morbidity. Overall, 13 relevant studies were identified, with 34 230 patients in current or ex-smoking subgroups. There was no difference in mortality (p=0.93). Current smokers had significantly higher risk of overall pulmonary complications (OR 1.44; 95% CI 1.27 to 1.64; p<0.001) and postoperative pneumonia (OR 1.62; 95% CI 1.27 to 2.06; p<0.001) as well as lower risk of postoperative renal complications (OR 0.82; 95% CI 0.70 to 0.96; p=0.01) compared with ex-smokers. There was a trend towards an increased risk of postoperative MI (OR 1.29; 95% CI 0.95 to 1.75; p=0.10). No difference in postoperative neurological complications (p=0.15), postoperative sternal surgical site infections (p=0.20) or postoperative length of intensive care unit stay (p=0.86) was seen. Cardiac surgical patients who are current smokers at the time of operation do not have an increased 30-day mortality risk compared with ex-smokers, although they are at significantly increased risk of postoperative pulmonary complications.

Download Full-text