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ORIGINAL ARTICLE Table of Contents   
Year : 2010  |  Volume : 13  |  Issue : 3  |  Page : 224-230
Thoracic epidural analgesia for off-pump coronary artery bypass surgery in patients with chronic obstructive pulmonary disease


Department of Anesthesiology, Critical Care and Cardiothoracic Surgery, Indraprastha Apollo Hospital, New Delhi, India

Click here for correspondence address and email

Date of Submission22-Oct-2010
Date of Acceptance12-Feb-2010
Date of Web Publication6-Sep-2010
 

   Abstract 

The benefits of thoracic epidural analgesia in patients undergoing coronary artery bypass grafting are well documented. However, the literature available on the role of high thoracic epidural analgesia (HTEA) in patients with chronic obstructive pulmonary disease undergoing off-pump coronary artery bypass graft (OPCAB) surgery is scarce. We conducted a randomized clinical trial to establish whether HTEA is beneficial in patients with chronic obstructive pulmonary disease undergoing elective OPCAB surgery. After institutional ethics board approval and informed consent, 62 chronic obstructive pulmonary disease patients undergoing elective OPCAB were randomly grouped into two (n = 31 each). Both groups received general anesthesia (GA), but in the HTEA group patients, TEA was also administered. Standardized surgical and anesthetic techniques were used for both the groups. Pulmonary function tests were performed pre-operatively, 6 h and 24 h post-extubation and on days 2, 3, 4 and 5 along with arterial blood gas analysis (ABG) analysis. Time for extubation (h) and time for oxygen withdrawal (h) were recorded. Pain score was assessed by the 10-cm visual analogue scale. All hemodynamic/oxygenation parameters were noted. Any complications related to the TEA were also recorded. Patients in the HTEA group were extubated earlier (10.8 h vs. 13.5 h, P < 0.01) and their oxygen withdrawal time was also significantly lower (26.26 h vs. 29.87 h, P < 0.01). The VAS score, both at rest and on coughing, was significantly lower in the HTEA group at all times, post-operatively (P < 0.01). The forced vital capacity improved significantly at 6 h post-operatively in the HTEA group (P = 0.026) and remained significantly higher thereafter. A similar trend was observed in forced expiratory volume in the first second on day 2 in the HTEA group (P = 0.024). We did not observe any significant side-effects/mortality in either group. In chronic obstructive pulmonary disease patients undergoing elective OPCAB surgery, HTEA is a good adjunct to GA for early extubation, faster recovery of pulmonary function and better analgesia.

Keywords: Chronic obstructive pulmonary disease, off-pump coronary artery bypass surgery, thoracic epidural analgesia

How to cite this article:
Mehta Y, Vats M, Sharma M, Arora R, Trehan N. Thoracic epidural analgesia for off-pump coronary artery bypass surgery in patients with chronic obstructive pulmonary disease. Ann Card Anaesth 2010;13:224-30

How to cite this URL:
Mehta Y, Vats M, Sharma M, Arora R, Trehan N. Thoracic epidural analgesia for off-pump coronary artery bypass surgery in patients with chronic obstructive pulmonary disease. Ann Card Anaesth [serial online] 2010 [cited 2018 Nov 20];13:224-30. Available from: http://www.annals.in/text.asp?2010/13/3/224/69062



   Introduction Top


The potential benefits of high thoracic epidural anesthesia (HTEA) in patients undergoing coronary artery bypass graft surgery (CABG) are well documented. However, only scarce literature is available about the role of HTEA in patients with chronic obstructive pulmonary disease (COPD) undergoing off-pump coronary artery bypass (OPCAB) graft surgery.

Patients with underlying respiratory disorders are at increased risk of post-operative complications. [1],[2] Hyper-reactive airways, severe post-operative pain, effects of residual anesthesia, immobilization following surgery and use of sedatives and analgesics further compound the problem. The end result is atelectasis and consequent ventilation-perfusion mismatching thus increasing the risk of hypoxia and other pulmonary and systemic complications. HTEA for these patients may offer a distinct advantage beyond its beneficial effects on hemodynamics, like pain control without sedation, reduction in stress response, faster extubation and mobilization, decreased incidence of deep vein thrombosis (DVT) and good patient acceptance. OPCAB has been associated with less inflammatory response and better morbidity and mortality outcome. [3]

This randomized study was undertaken to determine the beneficial effects of HTEA on the hemodyanmic/oxygenation parameters, length of intensive care unit (ICU)/hospital stay and outcome benefits in patients with COPD undergoing elective OPCAB surgery.


   Materials and Methods Top


Approval of the institutional ethics board and written informed consent were obtained from all patients. Diagnosis of COPD was made as per the Global Strategy for Obstructive Lung Diseases (GOLD) guidelines (i.e., forced expiratory volume in 1 s/forced vital capacity [FEV 1 /FVC] < 70%, FEV 1 <80% of predicted but ≥30% of predicted). [4] Sixty-two COPD patients in the 45-70 years age group with physical status of ASA II and III scheduled for elective OPCAB surgery were randomized by computer-generated numbers into two groups:

  • HTEA group (n = 31) - patients received TEA in addition to general anesthesia (GA).
  • GA group (n = 31) - patients received GA only
  • Exclusion criteria were:
  • Emergency surgery
  • Combined procedures (e.g. CABG with valve replacement)
  • CABG on cardiopulmonary bypass (CPB)
  • Very severe COPD (FEV1/FVC <70% and FEV1 <30% of predicted) or cor-pulmonale.


Pulmonary function tests (PFT) were performed by a hand-held Spirometer (Vitalograph 2120; Vitalograph Limited, Buckingham, U.) during pre-operative assessment, at 6 h and 24 h post-extubation and on the post-extubation days 2, 3, 4 and 5 along with arterial blood gas analysis (ABG) by a respiratory therapist. The best of the three consecutive PFT values were taken into consideration. Classification of the COPD was based on their pre-operative PFT values (i.e., FEV 1 /FVC < 70%) plus FEV 1 ≥80% of the predicted - Mild COPD; FEV 1 ≤80% of predicted but ≥50% of predicted - Moderate COPD; FEV 1 ≤50% of predicted but ≥30% of predicted - Severe COPD; FEV 1 ≤30% of predicted - Very Severe COPD). Emphasis was given on the proper performance of PFT as judged by flow volume loops and clinical assessment.

Patients in both the groups received pre-medication as per the hospital protocol (i.e., tab. lorazepam 2 mg and tab pantaprozole 40 mg on the night before surgery). In addition, they also received their cardiac medications along with optimum treatment for COPD (inhaled levo-salbutamol sulphate 1.25 mg and ipratropium bromide 500 ΅g eight-hourly).

Prior to induction of anesthesia, in the HTEA group patients, an epidural catheter was placed in the C7-T1 or T1-T2 interspace in a sitting position using a 18 G Tuohy's needle (Epidural mini pack, system 1; Smith Med. ASD Inc., Keene, NH, USA) using the hanging drop technique by the chief anesthesiologist. Intrathecal placement was ruled out using 3 ml of 2% lidocaine without epinephrine as test dose. Adequacy and level of the block were established by confirming loss of pin prick sensation and warm/cold discrimination.

The epidural catheter was inserted at least 2 h before heparinization with a clear understanding that in case of a bloody tap, the surgery would be postponed. Patients were administered a bolus dose of 8-10 ml of 0.25% bupivacaine to induce the sensory block till at least the T4 level. Bupivacaine infusion (0.125%) with fetanyl citrate (1 ΅g/ml) at the rate of 5 ml/h was commenced and continued till post-operative day 3 to provide intra- and post-operative analgesia.

GA was induced using intravenous midazolam 0.04 mg/kg, fentanyl citrate 2-3 ΅g/kg and steep dose of thiopentone sodium and pancuronium bromide 0.1 mg/kg body weight was used to facilitate orotracheal intubation. Anesthesia was maintained with oxygen in air and isoflurane (1-2 MAC end-tidal concentration). The patients also received continuous infusion of bupivacaine 0.125% at 5 ml/h through epidural catheter. Patients in the GA group received GA only. Intra-operatively, additional doses of analgesics (intravenous fentanyl 2 ΅g/kg bolus), neuromuscular blockers (pancuronium 0.03 mg/kg) and intravenous midazolam 0.04 mg/kg were administered at the discretion of the anesthesiologists who attended the case. Mechanical ventilation was performed using the Aestiva anesthesia machine (Datex Ohmeda, WI, USA). Intraoperative monitoring included pulse oximetry, capnography, electrocardiogram, invasive arterial blood pressure through femoral artery and thermodilution pulmonary artery catheter-derived data, which was inserted through a sheath into the internal jugular vein. ABG analysis on room air (FiO 2 - 0.21) was obtained before induction of anesthesia.

OPCAB was performed in all patients via standard sternotomy after 2 mg/kg of heparin sulfate (administered at least 2 h after epidural insertion in Group-1 patients). Activated clotting time (ACT) was measured by Hemotec (Actalyke Mini II; Helena Lab, Texas, USA) and maintained >300 s by incremental doses of heparin (1 mg/kg). Pericardiotomy was performed to gain access to the heart and CABG was performed using the left internal mammary artery and/or reversed venous grafts from the superficial saphenous system with the help of the stabilizing devices, "Octopus" and/or "Starfish" (Medtronic Inc., Minneapolis, MN, USA). Intraoperative management of anesthesia and hemodynamics was at the discretion of the anesthetist and a dedicated anesthetists was assigned for the data collection. Intraoperative intravenous fluids used were 6% hydroxyl ethyl starch and lactated ringer solution, and the amounts used were recorded. Autologous blood transfusion was accomplished in all the patients using the cell saver (Dideco, Mirandola Modena, Italy). Normothermia was maintained by Bair Hugger 505 ((Bair Hugger, Minnesota, USA) and warming of fluids.

After surgery, all patients were transferred to the ICU and were electively mechanically ventilated. Patients in the HTEA group received continuous infusion of bupivacaine 0.125% + Fentanyl 1 ΅g/ml at the rate of 5 ml/h till the third post-operative day (to avoid potential side-effects of opoids). Patients in the GA group received injection Tramadol 1-2 mg/kg IV, eight-hourly, for analgesia. Pain assessment was performed using 10 cm visual analogue scale (VAS) (10 cm -maximum pain and 0 - no pain). Rescue analgesia (injection Tramadol 1 mg/kg) was administered whenever the VAS score was ≥5. All hemodynamic and oxygenation parameters along with inotropic and/or vasopressor requirements were recorded. Any untoward complications of HTEA, like paresis, hypotension, urinary retention (after removal of urinary catheter), respiratory depression, pruritis etc. were noted every four hourly by an independent, dedicated observer.

Observations recorded

Time to extubation (in h)

The extubation criteria included hemodynamic stability with systolic blood pressure ≥100 mmHg (without inotropes and/or vasopressors), core temperature ≥36 0 C, spontaneous ventilation with PaO 2 ≥100 mmHg on FiO 2 = 0.4 and PaCO 2 ≤ 40 mmHg, blood loss from chest drains <50 ml/h and urine output >1 ml/kg/h. Oxygen withdrawl time was recoreded (When the pt was not requiring oxygen inhalation to maintain a SpO 2 > 90%)

Other parameters recorded were arterial blood pressure (ABP), heart rate (HR), cardiac index (CI) and systemic vascular resistance (SVR), inotropic and vasopressor requirement, PFT 6 h and 24 h after extubation and on post-extubation days 2, 3, 4 and 5. ABG was performed every 3 h (and whenever required) during the post-operative period. Pain score (10 cm VAS) at rest and on coughing and post-operative complications, if any, attributable to epidural catheter and rescue analgesia (i.e. total dose of tramadol), were also recorded.

The incidence of post-operative myocardial infarction was recorded, as documented by 12-lead EKG and creatinine phospho kinase (CPK), CPK-MB levels. Pulmonary complications were observed by daily chest X-ray and atelectasis was graded by a radiologist according to the Richter's radiological score (0 - clear lung field; 1 - plate-like atelectasis or slight infiltration; 2 - partial atelectasis; 3 - lobar atelectasis; 4 - bilateral lobar atelectasis).

Statistical method

The values are presented as mean ± standard deviation. Categorical data were compared using the Chi square test. Continuous data were compared using the Student t-test. P-value <0.05 was considered significant. Analysis was performed using SPSS 12.0 statistical software.


   Results Top


Patients from both groups had comparable demographics, baseline characteristics and comorbidities [Table 1]. The total operative time and number of grafts were similar between the groups. The intraoperative requirement of fentanyl was significantly lower in the HTEA group (P<0.001) [Table 2].
Table 1: Demographic data and clinical information

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Table 2: Intraoperative management (anesthetic and surgical data)

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Patients in the HTEA group were extubated significantly earlier (mean, 10.8±3.19 h vs. 13.5±2.88 h) (P < 0.01) and the oxygen withdrawal time was also significantly lower in the HTEA group (vs. GA group) (26.26±5.63 h vs. 29.87±5.24 h) (P < 0.01).

Similar amount of intravenous fluids, inotropic and vasopressor support were administered in both groups. Hemodynamic parameters were comparable in both groups during the pre-extubation period. In the post-extubation period, although the HR and SVR were lower in the HTEA group (vs. GA group), the difference was not significant [Table 3]. The pre-operative and pre-extubation ABG values were statistically similar between the groups but, after extubation, patients in the HTEA group had statistically significantly higher PaO 2, although these were not clinically significant (104.7±8.20 mmHg vs. 93.3±2.85 mmHg, P < 0.01), and lower PaCO2 (34.5±1.81 mmHg vs. 42..9±1.1mmHg, P < 0.01) than in the GA group [Table 4]. ABG was carried out every three hourly and whenever required.
Table 3: Hemodynamic parameters

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Table 4: Arterial blood gas analysis

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VAS, both at rest and on coughing, was statistically significant But clinically nonsignificant because VAS score of ≤ 3 is usually clinically acceptable at all time points post-operatively (in HTEA group vs. GA group) (P-value <0.001) [Table 5]. Rescue analgesia was used in a lower number of patients in the HTEA group as compared to the GA group On all subsequent days [Table 6]. Nausea, vomiting and constipation were lesser in the HTEA group than in the GA group patients (P < 0.05). None in either group had respiratory depression, pruritis, urinary retention or motor paresis [Table 7].
Table 5: Visual analogue score between the groups

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Table 6: Requirement of rescue analgesia in both groups on subsequent post-operative days

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Table 7: Complications observed during HTEA

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Regarding PFT values, Forced vital capacity (FVC) values decreased significantly in both groups in the immediate posto-perative period but improved significantly at 6 h post-operatively in the HTEA group patients (vs. GA group). This improvement in FVC became more significant with the time in the HTEA group.

A similar trend was also observed in FEV 1 , with the difference becoming statistically highly significant from the second post-operative day. Although the pre-operative difference in FVC and FEV 1 between the two groups was also significant, their values improved consistently over a period of time post-operatively, although it remained low as compare to baseline because of the postoperative status [Table 8].
Table 8: Pulmonary function tests in both groups

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The ratio of FEV 1 /FVC remained similar between the groups throughout the study. PEFR values improved very significantly in the HTEA group patients (vs. GA group). Intraoperatively, a significantly lower dose of fentanyl was used in the HTEA group patients. There was no difference between the two groups regarding ICU and hospital length of stay. There was no mortality, reintubation or perioperative myocardial infarction in either group.


   Discussion Top


Patients with COPD undergoing cardiac surgery are exposed to increased incidence of pulmonary complications, longer ICU stays, increased operative morbidity and mortality. [5] Hence, any technique that reduces this morbidity without significant side-effects is desirable.

HTEA improves the pulmonary dynamics after thoracotomy, thoracic trauma and upper abdominal trauma. Possible mechanisms include direct action on vital capacity, which permits better spontaneous ventilation. Analgesia without sedation helps in rapid mobilization and active pulmonary rehabilitation. These pulmonary benefits of HTEA may be an added advantage in patients with COPD. [6]

Nevertheless, TEA has not gained widespread use, mainly due to the potential risk of epidural hematoma in fully anticoagulated patients and the subsequent occurrence of paraplegia. [7] Risk is increased when epidural instrumentation is performed after systemic heparinization. [8] .However, epidural instrumentation can be performed safely in patients who subsequently receive intravenous heparin by observing certain precautions, such as delaying surgery for 24 h in case of hemorrhagic tap, heparinization 60 min after catheter insertion and maintaining tight perioperative control of anticoagulation. [9] We had no neurological event in either group.

On the other hand, the beneficial effects of TEA in patients undergoing OPCAB have been well documented in the literature. [10] In our trial, we studied the effects of the same in patients with COPD and found the analgesia to be very safe and effective in these patients without causing hemodynamic instability.

Patients from both groups had comparable baseline demographics. Patients in the HTEA group were extubated earlier and the oxygen withdrawal time was also significantly lower, similar to the findings of Hemmerling et al. [11] .Lower VAS score (both at rest and on coughing) and less number of patients who received rescue analgesia in the HTEA group suggest significantly better analgesia in the HTEA group. The inotropic/vasopressor requirements and the hemodynamic parameters were comparable in both groups.

The HR was lower at both times, i.e. pre and post-extubation, in the HTEA group due to sympathetic blockade with HTEA, but this is also attributed to better analgesia, as demonstrated by lower VAS. This would be an advantage in a patient with coronary artery disease because it leads to optimization of oxygen demand/supply ratio in already jeopardized myocardium with resultant enhanced coronary perfusion and improved ventricular functions.

Patients in the HTEA group had statistically significant improvement in the PFT values (FVC, FEV 1 and PEFR) post-operatively as compared to the GA group. We excluded patients with very severe COPD (FEV 1 ≤30% of predicted) because potential motor blockade (paralysis) of respiratory muscles (intercostal and abdominal) by HTEA and may decrease ventilatory reserve (end respiratory volume and vital capacity), peak inspiratory and expiratory flow rates and may negatively affect the ability to cough sufficiently. This may hamper weaning and may give rise to post-operative pulmonary complications, which are unfavorable in COPD patients. [9] We did not find any such case probably because the concentration of Bupivacaine used was quite low. These findings are consistent with those of Gruber et al., who studied the effects of TEA on ventilatory mechanics in patients with severe COPD. [5]

Blomberg et al. first demonstrated the beneficial effects of TEA in cardiac surgery. [12] Scott et al., in a randomized controlled study, reported earlier extubation, fewer supra-ventricular arrhythmias, lower incidence of acute renal failure and less post-operative confusion in the HTEA group. [10] Priestley et al. found a lower VAS on coughing, earlier extubation but similar hospital length of stay with high TEA, [13] .similar to our findings. Royse et al. showed lower pain scores, earlier extubation, improved cooperation with chest physiotherapy, improved post-operative O 2 tension and PEFR with TEA. [14]

The above findings are consistent with those of our study, where patients in the HTEA group were extubated earlier, had better analgesia and earlier withdrawal of oxygen. These findings can be attributed to TEA, as it provides better and sedation-free analgesia and better cooperation during chest physiotherapy. In con­trast, Fillinger et al. reported no differences in the incidence of atrial fibrillation, extubation time and length of ICU stay. [15]

In this study, TEA caused no significant changes in mean arterial pressure, HR, CI or SVR. These findings are consistent with observations made by Salvi et al., [16] who concluded that TEA as an adjunct to general anesthesia did not compromise hemodynamics in patients undergoing OPCAB.

There was no incidence of epidural hematoma in our study. Joachimsson et al. and Liem et al. inserted a TEA catheter 20-24 h before CPB in n = 16 and n = 27 patients, respectively, with no complications. [9],[17] Chakravarthy M et al in a large study involving more than 2000 patients had the similar results. [18] Furthermore, Mathews et al. reported that a single injection of intrathecal morphine as late as 50 min before heparin administration for CPB was safe and was not associated with epidural or subdural hematoma in 40 patients. [19] We also had a similar experience with intrathecal morphine in OPCAB. [20]

To strictly avoid epidural hematoma formation, the following precautions need to be taken: proper selection of patients, normalization of coagulation before instrumentation, midline technique, administration of saline solution through the needle to distend the epidural space before insertion of the catheter, an atraumatic epidural catheter insertion technique, avoidance of repeated attempts, readiness to postpone surgery in case of bloody tap with strict neurological monitoring for 24 h, keeping a minimal interval of 1-2 h between catheter insertion and heparinization, vigilant monitoring of ACT and intraoperative heparin reversal are essential in order to avoid such complications. All these safety measures were strictly followed in our study.

The other well-known complications attributed to epidural opoids include respiratory depression (early and delayed), pruritis, nausea, vomiting, constipation and urinary retention. [21] The side-effects attributed to local anesthetic include hypotension, bradycardia and myocardial depression because of increased systemic concentration of local anesthetics, especially bupivacaine. However, combined use of local anesthetic with opoids reduces the incidence of side-effects. None of our patients had respiratory depression (early or delayed) and motor blockade. The incidence of nausea, vomiting and constipation was far lower in the HTEA group. The higher incidence of nausea and constipation in the GA group could be attributed to frequent use of tramadol hydrochloride as rescue analgesia.

Limitations

This was a small, single-center study and the study subjects were COPD patients with relatively preserved pulmonary and cardiac functions.


   Conclusion Top


In this randomized study, we found earlier extubation and oxygen withdrawal, better analgesia and better recovery of PFT value in the HTEA group with no significant side-effects. Hence, we strongly recommend the use of TEA in patients with COPD undergoing elective OPCAB surgery. We also suggest that similar, large multicenter trials be conducted to establish the role of HTEA in patients with COPD undergoing OPCAB.

 
   References Top

1.Higgins TL, Estafanous FG, Loop FD, Beck GJ, Blum JM, Paranandi L. Stratification of morbidity and mortality by preoperative in coronary artery bypass, patients. A clinical severity score. JAMA 1992;267:2344-8.   Back to cited text no. 1  [PUBMED]    
2.Cohen A, Katz M, Hceuptmanu E, Schachner A. COPD in patients undergoing coronary artery bypass grafting. J Thorac Cardiovasc Surg 1995;109:374-81.  Back to cited text no. 2      
3.Mehta Y, Juneja R. Off pump coronary artery bypass grafting: new developments but a better outcome? Curr Opin Anaesthesiol 2002;15:9-18.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]  
4.Rabe KF, Hurd S, Anzueto A, Barnes PJ, Buist SA, Calverley P, et al. Global strategy for the diagnosis, management, and prevention of chronic obstructive lung disease: GOLD Executive Summary. Am J Respir Crit Care Med 02007;176:532-55.  Back to cited text no. 4      
5.Gruber EM, Tschernko EM, Kritzinger M, Deviatko E, Wisser W, Zurakowski D, et al. The effects of thoracic epidural analgesia with bupivacaine 0.25% on ventilatory mechanics in patients with severe chronic obstructive pulmonary disease. Anesth Analg 2001;92:1015-9.   Back to cited text no. 5  [PUBMED]  [FULLTEXT]  
6.EL Baz NM, Falvas CP, Jeusih RJ. Continuous epidural infusion of morphine for treatment of people after thoracic surgery. Anesth Analg 1981;67:687-94.   Back to cited text no. 6      
7.Chaney MA. Intrathecal and epidural anesthesia and analgesia for cardiac surgery. Anesth Analg 1997;84:1211-21.   Back to cited text no. 7  [PUBMED]  [FULLTEXT]  
8.HorIocker TT, Wedel DJ, Schroeder DR, Rose SH, Elliott BA, McGregor DG, et al. Preoperative antiplatelet therapy does not increase the risk of spinal hematoma associated with regional anesthesia. Anesth Analg 1995;80:303-9.   Back to cited text no. 8      
9.Joachimsson PO, Nystrom SO, Tyden H. Early extubation after coronary artery surgery in efficiently rewarmed patients: a post-­opererative comparison of opioid anesthesia versus inhalational anesthesia and thoracic epidural analgesia. J Cardiothorac Vasc Anesth 1989;3:444-54.   Back to cited text no. 9      
10.Scott NB, Turfrey DJ, Ray DA, Nzewi O, Sutcliffe NP, Lal AB, et al. A prospective randomized study of the potential benefits of thoracic epidural anesthesia and analgesia in patients undergoing coronary artery bypass grafting. Anesth Analg 2001;93:528-35.   Back to cited text no. 10  [PUBMED]  [FULLTEXT]  
11.Hemmerling TM, Prieto I, Choiniere JL, Basile F, Fortier JD, Priestley MC. Thoracic epidural anesthesia for cardiac surgery: the effects on tracheal intubation time and length of hospital stay. Can J Anaesth 2005;52:883.  Back to cited text no. 11      
12.Blomberg S, Emanuelsson H, Ricksten SE. Thoracic epidural anesthesia and central hemodynamics in patients with unstable angina pectoris. Anesth Analg 1989;69:558-62.   Back to cited text no. 12  [PUBMED]  [FULLTEXT]  
13.Priestley MC, Cope L, Halliwell R, Gibson P, Chard RB, Skinner M, et al. Thoracic epidural anesthesia for cardiac surgery: The effects on tracheal intubation time and length of hospital stay. Anesth Analg 2002;94:275-82.   Back to cited text no. 13  [PUBMED]  [FULLTEXT]  
14.Royse C, Royse A, Soeding P, Blake D, Pang J. Prospective randomized trial of high thoracic epidural analgesia for coronary artery bypass surgery. Ann Thorac Surg 2003;75:93-100.   Back to cited text no. 14  [PUBMED]    
15.Fillinger MP, Yeager MP, Dodds TM, Fillinger MF, Whalen PK, Glass DD. Epidural anesthesia and analgesia: Effects on recovery from cardiac surgery. J Cardiothorac Vasc Anesth 2002;16:15-20.  Back to cited text no. 15  [PUBMED]  [FULLTEXT]  
16.Salvi L, Sisillo E, Brambillasca C, Juliano G, Salis S, Marino MR. High thoracic epidural anesthesia for off-pump coronary artery bypass surgery. J Cardiothorac Vasc Anesth 2004;18:256-62.  Back to cited text no. 16  [PUBMED]  [FULLTEXT]  
17.Liem TH, Booij LH Hsenbos MA, Gielen MJ. Coronary artery bypass grafting using two different anesthetic techniques. hemodynamic results. J Cardiothorac Vasc Anesth 1992;6:148-55.  Back to cited text no. 17      
18.Chakravarthy M, Thimmangowda P, Krishnamurthy J, Nadiminti S, Jawali V., Thoracic epidural anesthesia in cardiac surgical patients: a prospective audit of 2,113 cases. J Cardiothorac Vasc Anesth. 2005 Feb;19 (1):44-8.   Back to cited text no. 18      
19.Mathews ET, Abrams LD. Intrathecal morphine in open-heart surgery. Lancet 1980;2:543.   Back to cited text no. 19  [PUBMED]    
20.Mehta Y, Kulkarni V, Juneja R, Sharma KK, Mishra Y, Raizada A, et al. Spinal (subarachnoid) morphine for off-pump coronary artery bypass surgery. Heart Surg Forum 2004;7:E205-10.  Back to cited text no. 20  [PUBMED]  [FULLTEXT]  
21.Chaney MA. Side effects of intrathecal and epidural opiods (review article). Can J Anaesth 1995;42:891-903.  Back to cited text no. 21  [PUBMED]  [FULLTEXT]  

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Correspondence Address:
Yatin Mehta
Department of Cardiac Anesthesia and Critical Care, Indraprastha Apollo Hospital, Sarita Vihar, New Delhi - 110 076
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9784.69062

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]

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Annals of Cardiac Anaesthesia Number of Documents that reference this Document. 2013;
[Pubmed]
8 Benefits and Risks of Epidural Analgesia in Cardiac Surgery
Yatin Mehta,Dheeraj Arora
Journal of Cardiothoracic and Vascular Anesthesia. 2013;
[Pubmed] | [DOI]
9 Guía de práctica clínica basada en la evidencia para el manejo de la sedoanalgesia en el paciente adulto críticamente enfermo
E. Celis-Rodríguez,C. Birchenall,M.Á. de la Cal,G. Castorena Arellano,A. Hernández,D. Ceraso,J.C. Díaz Cortés,C. Dueñas Castell,E.J. Jimenez,J.C. Meza,T. Muñoz Martínez,J.O. Sosa García,C. Pacheco Tovar,F. Pálizas,J.M. Pardo Oviedo,D-I. Pinilla,F. Raffán-Sanabria,N. Raimondi,C. Righy Shinotsuka,M. Suárez,S. Ugarte,S. Rubiano
Medicina Intensiva. 2013; 37(8): 519
[Pubmed] | [DOI]
10 Future of Awake Cardiac Surgery
Murali Chakravarthy
Journal of Cardiothoracic and Vascular Anesthesia. 2013;
[Pubmed] | [DOI]
11 Thoracic epidural anesthesia with bupivacaine attenuates systemic inflammatory response and lung impairment associated with cerulein-induced pancreatitis in rats | [Ratlarda bupivakain ile saǧlanan torakal epidural anestezi seruleinin tetiklediǧi akut pankreatit ile ilişkili sistemik inflamatuar cevabi ve akciǧer hasarini azaltmaktadir]
Bedirli, N., Akyürek, N., Kösem, B., Yaman, M., Çavunt Bayraktar, A., Kurtipek, O., Kavutçu, M.
Turkish Journal of Medical Sciences. 2012; 42(2): 217-227
[Pubmed]
12 The outcome of thoracic epidural anesthesia in elderly patients undergoing coronary artery bypass graft surgery
El-Morsy, G.Z., El-Deeb, A.
Saudi Journal of Anaesthesia. 2012; 6(1): 16-21
[Pubmed]
13 Poststernotomy pain: A clinical review
Mazzeffi, M., Khelemsky, Y.
# # Journal of Cardiothoracic and Vascular Anesthesia. 2011; 25(6): 1163-1178
[Pubmed]
14 Poststernotomy Pain: A Clinical Review
Michael Mazzeffi,Yury Khelemsky
Journal of Cardiothoracic and Vascular Anesthesia. 2011; 25(6): 1163
[Pubmed] | [DOI]
15 Preoperative considerations for patients with chronic obstructive pulmonary disease
Ana Mandras,Dusica Simic,Vesna Stevanovic,Djordje Ugrinovic,Vesna Skodric,Nevena Kalezic
Acta chirurgica iugoslavica. 2011; 58(2): 71
[Pubmed] | [DOI]



 

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