Requirement of Postoperative Ventilation and analgesics during Off-Pump Coronary Artery Bypass (OPCAB) surgery – A Comparison between Combined High Thoracic Epidural Anaesthesia (HTEA) with GA and GA Alone

Beckground: This is often difficult to achieve optimal pain relief after coronary artery bypass surgery and also great challenge to choice appropriate analgesics with minimize the duration of mechanical ventilation. In the postoperative period inadequate analgesia may increase morbidity by causing adverse haemodynamic, metabolic, immunologic and haemostatic attentions and prolong mechanical ventilation with more ICU stay. High Thoracic Epidural Anaesthesia (HTEA) as an adjunct to general anaesthesia has been shown to be potentially beneficial in postoperative pain relief and the requirement of mechanical ventilationin patients with off-pump coronary artery bypass surgery (OPCAB). HTEA provides good protection from stress response, ensures hemodynamic stability, improves distribution of coronary blood flow with reducing demand of oxygen, less requirement of postoperative analgesia , mechanical ventilation and ICU stay. Objective: This study has been undertaken with a view to compare requirement of postoperative mechanical ventilation and analgesics in OPCAB surgery between HTEA with GA and GA alone. Methods: This prospective, randomized case control comparative study was carried out in sixty patients without having left main coronary artery disease, left ventricular ejection fraction <30% or contraindication of regional anaesthesia scheduled for OPCAB. They were divided into two groups, thirty in each group. Group A received GA alone and group B received high thoracic epidural anaesthesia with GA. Requirement of postoperative analgesics, pain score, consciousness score, sedation score, satisfection level and duration of ventilation with length of stay in intensive care unit were recorded in the post-operative period. Results: Rescue analgesics received and found 16(53.3%) and 6(20.0%) needed analgesia in group A and group B respectively and the difference was statistically significant (p<0.05). Regarding the pain score (VAS) during maintenance with ventilator with awareness at first fourth hour significant (p<0.05) change between two groups. After extubation at rest in different time interval and found significant (p<0.05) change between two groups in all follow-up times. Post-operative pain score (VAS) after extubation at movement in different time interval and found significant (p<0.05) change between two groups. Post-operative pain score (VAS) after extubation at during coughing in different time interval and found significant (p<0.05) change between two groups. Post-operative sedation score at first six hour (hourly) and found significant (p<0.05) change between two groups except 1st hour, which was not significant (p>0.05). The mean extubation 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 and the difference was statistically significant (p<0.05) in unpaired t-test. No postoperative complication was observed in both groups. Conclusion: HTEA with GA appeared to be most reliable postoperative pain relief, shorter mechanical ventilation, ICU stay in OPCAB surgery Bangladesh Heart Journal 2021; 36(2): 74-81

Early Outcomes Following off-Pump Coronary Artery Bypass Surgery under General Anaesthesia with and without High Thoracic Epidural Analgesia: A Comparative Study

Introduction: Reduction of postoperative morbidity by providing optimal pain relief and improving overall quality of care is an important goal of modern anaesthesia practice. The aim of this prospective, randomized, open, controlled study is to investigate the impact of high thoracic epidural analgesia on early clinical outcomes in patients undergoing off-pump coronary artery bypass (OPCAB) surgery. Methodology: After obtaining the institutional ethics committee approval and written informed consent from all patients, 80 patients of either sex, aged 40 – 70 years, scheduled for elective primary OPCAB surgery were randomized into two groups. Group I received 4 mL of an epidural bolus of 1% ropivacaine and fentanyl 100 µg followed by ropivacaine 1% and fentanyl 5 µg/mL infusion for 72 h at 3–5 mL/h postoperatively. Analgesia in the Group II was provided with a continuous IV fentanyl infusion. Patients were given rescue analgesic (inj Tramadol intravenous) when VAS score is >40 in the postoperative period. Results: VAS score, need for rescue analgesics and incidence of postoperative arrythmia were significantly lower in Group I specially for first twenty four hours postoperatively. Time for extubation and length of postoperative ICU stay were found similar in both the groups. Incidence of other outcomes found to be not significant. Conclusion: The pain scores, analgesic requirements and incidence perioperative arryrhmias were significantly less in Group I compared to Group II, but we could not be able to find any significant difference in time for extubation and length of ICU stay, neither in incidence of postoperative MI, CVA, renal failure, blood transfusion and death.

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

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.

High Thoracic Epidural Analgesia as an Adjunct to General Anesthesia in Patients Undergoing Off-Pump Coronary Artery Bypass Grafting

Aim: To investigate the effect of high thoracic epidural analgesia combined with general anesthesia on pain management and postoperative outcomes in patients undergoing off-pump Coronary Artery Bypass Grafting (CABG). Materials and Methods: Patients were divided into two groups; Group 1 received general anesthesia and high thoracic epidural anesthesia whereas Group 2 received general anesthesia alone during off-pump coronary artery bypass grafting. Epidural catheters were placed at least 6 hours before transfer to the operating room. An epidural analgesic solution of 0.25% bupivacaine and 10 µg/ml fentanyl was started as continuous infusion at 5 ml/hour and maintained for at least 12 hours after completion of surgery. A 10-cm visual analog scale was used to measure pain at 4th, 6th, 9th and 12th postoperative hours. Results: Mean time to extubation was similar between two groups (2.45±0.88 vs. 2.59±1.31 for Groups 1 and 2, respectively, p=0.90). In all measurements, mean Visual Analogue Scale VAS scores were significantly lower in Group 1 compared to Group 2 (6.50±1.53 vs. 4.09±1.83 at 4th hour, 6.62±1.55 vs. 3.71±1.85 at 6th hour, 5.83±1.40 vs. 2.93±1.54 at 9th hour and 4.41±1.97 vs. 2.50±1.19 at 12th hour, p<0.001 in each comparison). Conclusion: Continuous high thoracic epidural analgesia seems to be a good adjunct to general anesthesia, as its pain relief effect becomes obvious at 4th postoperative hour and lasts at least 12th postoperative hour.

High Thoracic Epidural Anesthesia in Cardiac Surgery as a Sole Anesthetic Technique. Series of 12 Interventions.

Epidural anesthesia has been used widely as a combination to general anesthesia in cardiac surgery since early seventies. The addition of this technique to general anesthesia may have beneficial effects on clinical outcome. Several clinical trials and experiments have shown that there may be significant benefits using epidural anesthesia in cardiac surgery. Somehow neuroaxial blockade manages to attenuate the response to surgical stress and improve perioperative analgesia. Between august 2014 and September 2018, high thoracic epidural anesthesia was applied to 12 patients as a sole anesthetic technique. Epidural anesthesia was chosen because the patients had relative contraindications to general anesthesia and mechanical ventilation. This paper gives an overview of epidural anesthesia usage and our experience.