Clinical outcome of the off-pump coronary artery bypass surgery- a comparison between combined high thoracic epidural anaesthesia with GA and GA alone

Background: The common challenges for the cardiac anaesthesiologist during off pump coronary artery surgery (OPCAB) include haemodynamic stability during the different stressful surgical events and multiple cardiac manipulations, providing adequate myocardial protection, and obtaining effective postoperative analgesia leading to early discharge from the intensive care unit. Objective: This study has been undertaken with a view to find out whether a combined high thoracic epidural anaesthesia (HTEA) with general anaesthesia (GA) is safe and more efficient in providing overall cardiovascular stability as well as improving the parameters leading to a better outcome in terms of a shorter and more predictable road maps to recovery. Methods: Sixty patients aged within 40-70 years, without having any coagulopathy disorder, any emergency surgery or left main disease scheduled for CABG on beating heart were enrolled in prospective, randomized observational comparative study. Patients were divided in two groups. In group A patients received GA alone and in group B patients received high thoracic epidural anaesthesia with GA. The parameters including heart rate, SPO2, CVP, arterial blood pressure, ECG, and ABG analysis were recorded before induction, during induction, intubation and during different events of the surgery. Post operative pain score, sedation score, ventilator hour, duration in the ICU stay, rescue analgesic need and post operative complications was assessed and recorded. Results: significant per-operative mean heart rate changes were observed all the events except at wound closure and during anastomosis with D1/D2 and the mean difference of mean arterial pressure at intubations, skin incision, sternotomy, pericardiotomy, during anastomosis of distal end of the graft with RCA, PDA, LCX and D1/D2 were observed statistically significant (p<0.05). No incidence of different arrhythmia occurred in group B, premature ventricular complex (PVC) was statistically significant (p<0.05) between two groups. No significant change was found in per-operative pH of arterial blood, PaCO2 and PaO2 changes at different times. Post operative pain score (VAS 0-100) in different time interval was found significant (p<0.05) change between two groups in all follow-up times. Status of rescue analgesics were observed statistically significant (p<0.05). The mean ventilator hours were 7.4±1.09 hours in group A and 5.3±0.81 hours in group B. The mean ICU stay was 72.9±9.2 hours in group A and 57.1±12.0 hours in group B. No post-operative complication was observed in both groups. The data were compiled and analyzed by using statistical software SPSS (ver. 12.0) and significance test performed by unpaired t test and Chi square test. P value <0.05 was considered as statistically significant. Conclusion: Both anaesthetic techniques are equally safe but better clinical outcome of the OPCAB surgery with the high thoracic epidural anaesthesia with GA. DOI: http://dx.doi.org/10.3329/jbsa.v22i2.18142 Journal of BSA, 2009; 22(2): 54-60

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Cardiac Drugs Requirement during Off-Pump Coronary Artery Bypass (OPCAB) Surgery- A Comparison between Combined High Thoracic Epidural Anaesthesia (HTEA) with GA and GA Alone

Cardiovascular Journal ◽

10.3329/cardio.v3i1.6420 ◽

1970 ◽

Vol 3 (1) ◽

pp. 7-10

Author(s):

SI Azad ◽

AK Beg ◽

AYFE Chowdhury

Keyword(s):

General Anaesthesia ◽

Epidural Anaesthesia ◽

Artery Bypass ◽

Off Pump ◽

Thoracic Epidural ◽

Thoracic Epidural Anaesthesia ◽

Group A ◽

High Thoracic Epidural ◽

Pump Coronary Artery Bypass ◽

Group B

Background: During off pump coronary artery bypass surgery (OPCAB) to provide adequate myocardial protection cardiac anaesthesiologist frequently needs to use various pharmacological intervention rather than physiological manipulation. This is challenging to overcome the adverse effects of the various drugs. During the past few years, high thoracic epidural anaesthesia (HTEA) as an adjunct to general anaesthesia has become more popular and has been shown to be potentially beneficial in patients with coronary diseases. It provides good protection from stress response, ensures hemodynamic stability, improves distribution of coronary blood flow and reduce demand for oxygen and perioperative arrhythmia. Objective: This study has been undertaken with a view to compare the requirement of intraoperative cardiac drugs between HTEA with General Anaesthesia(GA) and GA alone. Methods: Prospective, randomized case control study was undertaken in sixty patients, without having left main coronary disease, left ventreicular ejection fraction <35% or contraindication of regional anaesthesia scheduled for OPCAB. They were divided into two groups, thirty in each group. Group A patients received GA alone and group B patients received high thoracic epidural anaesthesia with GA. Requirement of drugs (antiarrhythmic, inotropes, vasoconstrictor, vasodilators,Esmolol e.g.) during operation were recorded. Results: Dopamine was needed in 27(90.0%)patients in group A and 11(36.7%) patients in group B, adrenaline was used in 15(50.0%)patients in group A and 4(13.3%) in group B; Dobutamine was used only in 5(15.0%) patients in group A and ephedrine was required only in 2(5.0%) in group B. Regarding the Antiarrhythmic drugs, Lignocanie, Amiodarone and DC Shock was required only in 17(55.0%), 12(40.0%) and 5(15.0%) patients respectively only in group A. In vasodilators group, Nitropruside was used in 5(15.0%) and 1(3.3%) patients in group A and group B respectively. Esmolol was used in 17(55.0%) patients in group A and 1(3.3%) in group B. Significant (p<0.05) difference were found in use of all drugs between two groups except Ephedrine and Nitropruside. Conclusion: The anaesthetic technique HTEA with GA required minimum intra operative cardiac drugs than GA only. Key words: Cardiac drug; HTEA; General Anaesthesia; OPCAB. DOI: 10.3329/cardio.v3i1.6420Cardiovasc. j. 2010; 3(1): 7-10

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A comparison of high thoracic epidural anaesthesia versus conventional intravenous opioids in pediatric patients undergoing corrective open heart surgery for ventricular septal defect

International Journal of Advances in Medicine ◽

10.18203/2349-3933.ijam20212858 ◽

2021 ◽

Vol 8 (8) ◽

pp. 1142

Author(s):

Kshetrimayum Sandeep Kumar Singh ◽

Vipul K. Sharma ◽

Sachin Shouche ◽

Shibu Sasidharan ◽

Harpreet Dhillon

Keyword(s):

Epidural Anaesthesia ◽

Postoperative Bleeding ◽

Open Heart Surgery ◽

Skin Incision ◽

Lower Amount ◽

Intravenous Fentanyl ◽

Thoracic Epidural ◽

Thoracic Epidural Anaesthesia ◽

The Mean ◽

High Thoracic Epidural

Background: We compared high thoracic epidural anaesthesia with a combination of morphine and bupivacaine versus IV fentanyl as an alternative for perioperative pain management.Methods: Group-E: Injection Morphine 75-100 mcg/kg and Injection 0.25 % Bupivacaine 0.5 ml/kg was given via epidural catheter at insertion, Injection 0.25% Bupivacaine 0.5 ml/kg just before skin incision, and continuous infusion of Injection 0.125% Bupivacaine at 0.2 ml/kg/hr intra-operatively. Post-operative 0.1 ml/kg/hr infusion. Group F- intravenous fentanyl 2-3 mcg/Kg IV bolus given just before skin incision, followed by 1-2 mcg/Kg/hr IV fentanyl started after weaning from cardiopulmonary bypass.Results: The mean ScvO2 was comparable between the two groups during induction period but became higher in group E during bypass and post bypass period intraoperatively, and the difference in rise in ScvO2 is statistically significant with a p<0.05. The mean rSo2- C was comparable between the two groups in the first postoperative hour but group F shows higher rSo2-C postoperatively which was statistically significant. The postoperative pain was significantly lower in group E in the postoperative period (except for 4,5,6 and 40 and 48th hour).Conclusions: HTEA to paediatric patients prior to sternotomy for cardiac surgeries resulted in a much better control of haemodynamic parameters. Produces better central venous and regional tissue oxygenation during bypass and post bypass intraoperatively as compared to the patients that received only intravenous fentanyl. There was lower amount of postoperative bleeding in the HTEA group with significant reduction in requirement of post-operative ventilation and time to extubation after surgery, better post-operative pain control and overall outcome.

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Cardiovascular Stability during Off-Pump Coronary Artery Bypass (OPCAB) Surgery- A Comparison between Combined High Thoracic Epidural Anaesthesia (HTEA) with TIVA and TIVA alone

Cardiovascular Journal ◽

10.3329/cardio.v2i2.6633 ◽

1970 ◽

Vol 2 (2) ◽

pp. 163-167 ◽

Cited By ~ 2

Author(s):

SI Azad ◽

AK Beg ◽

AYFE Chowdhury ◽

UHS Khatun

Keyword(s):

Heart Rate ◽

Coronary Artery ◽

Skin Incision ◽

Off Pump ◽

Thoracic Epidural ◽

Thoracic Epidural Anaesthesia ◽

Opcab Surgery ◽

High Thoracic Epidural ◽

Group B ◽

Cardiovascular Stability

Background: In Bangladesh, although OPCAB surgery are done, the number of centers are limited and as a result, studies on this subject are also few. Consequently, there are no exclusive data regarding the best anaesthetic technique in the context of superior haemodynamic stability. This study has been undertaken with a view to find out whether a combined HTEA with GA (TIVA) is safe and more efficient in providing overall cardiovascular stability. The common challenges for the cardiac anaesthesiologist during off pump coronary artery surgery (OPCAB) to maintain optimal cardiovascular parameters such as heart rate, blood pressure, CVP and arrhythmias during the different stressful surgical events and multiple cardiac manipulations, providing adequate myocardial protection, are sometimes difficult. This study has been undertaken with a view to find out whether a combined HTEA with TIVA is safe and more efficient in providing overall cardiovascular stability. Method: Sixty patients aged between 40-70 years, without having any coagulopathy disorder , any emergency surgery or left main disease scheduled for CABG on beating heart were enrolled in prospective, randomized observational comparative study. Patients were divided in two groups. In group A patients received TIVA alone and in group B patients received high thoracic epidural anaesthesia with TIVA. The parameters including heart rate , SPO2 , CVP , arterial blood pressure , rate pressure product , arrhythmia in ECG, were recorded before induction, during induction , intubation and during different events of the surgery ( skin incision, sternotomy, pericardiotomy, coronary artery anastomosis with graft , sternum closure and wound closure) was recorded. Result: Significant per-operative mean heart rate changes were observed all the events except at wound closure and during anastomosis with D1/D2 and the mean difference of mean of mean arterial pressure at intubations, skin incision, sternotomy, pericardiotomy, during anastomosis of distal end of the graft with RCA, PDA, LCX and D1/D2 were observed statistically significant (p<0.05) . No incidence of different arrhythmia occurred in group B, premature ventricular complex (PVC) was statistically significant (p<0.05) between two groups. Conclusion: HTEA with TIVA appeared to be most comprehensive, allowing for revascularization of any coronary artery, providing good cardiovascular stability during OPCAB.Key Words: CABG; OPCAB; HTEA; TIVA DOI: 10.3329/cardio.v2i2.6633Cardiovasc. j. 2010; 2(2) : 163-167

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Early Post operative Pain Management and Early Extubation after Off-pump Coronary Artery Bypass Graft Surgery is better managed with Thoracic Epidural Analgesia

Cardiovascular Journal ◽

10.3329/cardio.v9i2.32427 ◽

2017 ◽

Vol 9 (2) ◽

pp. 142-146

Author(s):

Naresh Chandra Mandal ◽

Md Fidah Hossain ◽

Nirmal Kanti Dey ◽

Md Motiur Rahman Sarkar ◽

Abdullah Al Mamun ◽

...

Keyword(s):

Coronary Artery ◽

Epidural Analgesia ◽

Artery Bypass ◽

Thoracic Epidural Analgesia ◽

Off Pump ◽

Thoracic Epidural ◽

Post Operative Pain ◽

Group A ◽

Pump Coronary Artery Bypass ◽

Group B

Background: Off-pump coronary artery bypass (OPCAB) graft surgery is the commonest operation worldwide. Sternotomy, pleurotomy with opening of the pleural space, harvesting of internal mammary artery may lead to severe post-operative pain. Thoracic epidural analgesia (TEA) may reduced significant post-operative pain & allow the patient early extubation.Methods: A total of 60 patients with ischaemic heart disease (IHD) were included in the study who were admitted in the Department of Cardiac Surgery in NICVD, Dhaka from July 2006 to June 2008 & underwent off-pump coronary artery bypass (OPCAB) graft surgery. Out of the total 60 patients, 30 were in the group-A receiving thoracic epidural analgesia along with general anaesthesia and the rest 30 were in the group-B receiving general anaesthesia alone.Results: Patients in the epidural group had significantly less pain on the operative day and for the next 2 days. Total ventilation time in hours in Group-A was 6.4 + 1.0 and in Group-B was 10.1 +1.8 hours respectively. Postoperative X-ray chest revealed significant pulmonary complication in Group- B than Group-A. There were no complications related to epidural haematoma and no permanent neurological squeal.Conclusion: Thoracic epidural analgesia reduced significant post-operative pain and improvement in pulmonary function and early extubation.Cardiovasc. j. 2017; 9(2): 142-146

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Comparative Study of Haemodynamic Status and Arrhythmia between Combined Epidural with General Anaesthesia and General Anaesthesia alone in Off-pump Coronary Artery Bypass (OPCAB) Surgery

Journal of Bangladesh College of Physicians and Surgeons ◽

10.3329/jbcps.v26i3.4193 ◽

1970 ◽

Vol 26 (3) ◽

pp. 116-120 ◽

Cited By ~ 1

Author(s):

Ranadhir Kumar Kundu ◽

Abdul Khaleque Beg ◽

Shahadat Hossain ◽

Naimul Haque ◽

M Mahafuddoza ◽

...

Keyword(s):

Blood Pressure ◽

General Anaesthesia ◽

Artery Bypass ◽

Venous Pressure ◽

Control Group ◽

Off Pump ◽

Thoracic Epidural ◽

Arterial Blood ◽

Group A ◽

Group B

Objectives: To find out if combined general anaesthesia (GA) with high thoracic epidural anaesthesia (HTEA) was better in controlling haemodynamic condition and reducing incidences of arrhythmia during induction of GA and during positioning and handling of the heart itself by the surgeons. Materials and Method: Forty (40) patients of 40-65 yrs age were randomly selected and divided in two groups (group A, n= 20: combined HTEA and GA- study group, group B, n= 20: GA alone- control group). Group A received HTEA introduced through an indwelling epidural catheter at C7-T1 or T1-T2 interspace. Lignocaine (1%) 5 ml and Bupivacain (0.25%) 5ml with Fentanyl 10 mg was given through the catheter as bolus followed by Bupivacain (0.25%) 5ml with Fentanyl 10 mg was given at 2 hours interval. General anaesthesia was induced and maintained in a standardized manner for all patients of both the groups. The parameters monitored were Heart Rate (HR), Arterial Blood Pressure (ABP), and Electrocardiogram (ECG - arrhythmia and ST changes), Oxygen saturation (SpO2) and Central Venous Pressure (CVP) during the procedure Results: Induction of GA was smoother and with fewer blood pressure peaks in all patients of group A. They demonstrated a stable haemodynamic status throughout operation in general and during positioning of the heart and bypass grafting in particular. Incidences and severity of cardiac arrhythmias were also less during these periods. Conclusion: Combined HTEA-GA technique for OPCAB procedure is safe and affords to achieve stable haemodynamic status during induction of GA. It also allows reducing incidence of arrhythmias during cardiac position and grafting. Regarding the above qualities, group A appeared superior to group B. DOI: 10.3329/jbcps.v26i3.4193 J Bangladesh Coll Phys Surg 2008; 26: 116-120

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High Thoracic Epidural anaesthesia for Off-pump CABG in a spontaneously breathing (conscious) patient (ACAB)

Journal of the Bangladesh Society of Anaesthesiologists ◽

10.3329/jbsa.v17i1.4052 ◽

2009 ◽

pp. 48-51

Author(s):

Naimul Haque ◽

Shahadat Hossain ◽

Shahnaz Ferdous ◽

NA Kamrul Ahsan ◽

Nazmul Hossain

Keyword(s):

Epidural Anaesthesia ◽

Beating Heart ◽

Off Pump ◽

Thoracic Epidural ◽

The Third ◽

Thoracic Epidural Anaesthesia ◽

Pump Cabg ◽

High Thoracic Epidural ◽

Anaesthetic Mixture ◽

Conscious Patient

A 68 yr old man with ischemic heart disease (IHD) affecting triple vessels was admitted in National Institute of Cardiovascular Diseases & Hospital (NICVD), Dhaka for Coronary artery bypass grafting (CABG). He had been suffering from angina with minimal exercise with mild left ventricular systolic dysfunction. He was also suffering from hypertension and mild obstructive airway disease for the last ten years. He underwent off-pump CABG on beating heart using high thoracic epidural anaesthesia (TEA) without intubation. The patient was awake and breathing spontaneously, tolerated each phase of the operation without having any harmful effect. The effect of movement of the chest wall and the heart during spontaneous respiration did not influence the conduction of the operation. Epidurall catheter was placed at TI-2 interspace, in lateral decubitous position. After a test dose of 2% lignocaine 5ml, 0.5% Bupivacaine 14 ml + Fentanyl 2 ?gm/ml was injected epidurally. Central venous catheter was placed under local anaesthesia and inj Morphine 7.5 mg was given intramuscularly. After mid sternotomy left internal mammary artery (LIMA) and venous grafts were anastomozed to coronary arteries on beating heart. Haemodynamically patient was stable throughout the procedure and oxygenation was maintained by assisted facemask ventilation. At the end of operation laryngeal mask airway (LMA) was used for better oxygenation, which was withdrawn one hour later in the postoperative period. After transferring to the ICU, the patient was fully conscious, oriented, responds to commands, capable of coughing and clearing of secretions and pain free. He didn't require any ionotropic support or any systemic analgesic. Postoperative analgesia was maintained by continuous epidural infusionn of local anaesthetic mixture (0.5% Bupivacaine 20 ml + 2% Lignocaine 20 ml + Fentanyl (50?gm) I ml + NS 9 ml= 50 ml) via syringe pump at 1ml /hour. Liquid diet was allowed to the patient from the first POD and epidural analgesia was provided upto the third POD. Patient was shifted to HDU from ICU on the third POD. The patient was highly satisfied about the anaesthetic and operative procedure. DOI: http://dx.doi.org/10.3329/jbsa.v17i1.4052 Journal of BSA, Vol. 17, No. 1 & 2, 2004 p.48-51

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Respiratory effects of high thoracic epidural anaesthesia

Acta Anaesthesiologica Scandinavica ◽

10.1111/j.1399-6576.1986.tb02399.x ◽

1986 ◽

Vol 30 (3) ◽

pp. 215-217 ◽

Cited By ~ 25

Author(s):

A. Sundberg ◽

M. Wattwil ◽

A. Arvill

Keyword(s):

Epidural Anaesthesia ◽

Respiratory Effects ◽

Thoracic Epidural ◽

Thoracic Epidural Anaesthesia ◽

High Thoracic Epidural

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Incidence of post-operative cardiac complications in cardiac patients undergoing urological procedures

International Journal of Advances in Scientific Research ◽

10.7439/ijasr.v1i2.1810 ◽

2015 ◽

Vol 1 (2) ◽

pp. 80

Author(s):

Mastan Saheb Shaik ◽

Venkata Rama Rao M ◽

Sailaja K

Keyword(s):

General Anaesthesia ◽

Regional Anaesthesia ◽

Cardiac Complications ◽

Anesthetic Techniques ◽

Ecg Changes ◽

Arterial Blood ◽

Group A ◽

Urological Procedures ◽

The Mean ◽

Group B

Context: There are limited studies indicating the incideance of post operative morbidity and mortality in high risk patients. Urological procedures constitute a major portion of geriatric surgeries where a cardiac obligation is almost inevitable and selected for this study purpose.Aims: To compare the incidence of post operative cardiovascular complications during regional and general anesthetic techniques in patients with known cardiac risk undergoing urological surgeriesSettings and Design: Prospective randomized double blind study.Methods and Material: 40 patients aged above 50 years posted for elective urological surgeries were enrolled in the study after obtaining approval from hospital ethics committee and written informed consent from the patients. Patients were divided into two groups A& B. Group A (n=20) received general and group B (n=20) received regional anaesthesia (spinal/ Epidural). All the patients received standard premedication and their basal vitals( BP, HR, ECG pattern) were recorded. The same parameters were monitored in the post operative period at regular intervals.Statistical analysis used: Student T test is used to test the significance of stastical difference in the variables between the two groups.Results: The mean heart rate and the mean arterial blood pressure were increased (P<0.01) in the general anaesthesia group. Group A showed 10% incidence of ECG changes and group B showed 35% incidence of ECG changes. But the changes in the hemodynamics were not significant.Conclusions: There is no difference between regional anaesthesia and general anaesthesia regarding the post operative outcome after urological procedures with respective hemodynamic changes.

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