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| Year : 2009
| Volume
: 12 | Issue : 1 | Page
: 1-3 |
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| Thoracic epidural anaesthesia in cardiac surgery- the current standing |
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Mark A Chaney
Director of Cardiac Anesthesia, Department of Anesthesia and Critical Care, University of Chicago, 5841 South Maryland Avenue, MC 4028 Chicago, Illinois 60637, USA
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How to cite this article:
Chaney MA. Thoracic epidural anaesthesia in cardiac surgery- the current standing. Ann Card Anaesth 2009;12:1-3 |
Adequate postoperative analgesia prevents unnecessary patient discomfort, may decrease morbidity, may decrease ICU/hospital length of stay, and may thus potentially decrease cost. In the current era of early tracheal extubation, achieving optimal pain relief after cardiac surgery can be challenging. Adequate postoperative analgesia after cardiac surgery may be attained via a wide variety of techniques [Table 1]. Traditionally, analgesia after cardiac surgery has been obtained with intravenous opioids (specifically morphine). No single technique is clearly superior; each possesses distinct advantages and disadvantages.
Utilization of epidural techniques in patients undergoing cardiac surgery has increased over the past decade or so. [1] Potential benefits include improved postoperative analgesia, attenuation of the stress response to surgery and induction of thoracic cardiac sympathectomy. In summary, the many clinical investigations involving the use of epidural techniques in patients undergoing cardiac surgery indicate that administration of thoracic epidural opioids or local anaesthetics to patients before and after cardiopulmonary bypass produce reliable postoperative analgesia after cardiac surgery. However, no additional clinical benefits beyond analgesia have been reliably obtained. Administration of thoracic epidural local anaesthetics can both reliably attenuate the perioperative stress response associated with cardiac surgery and induce thoracic sympathectomy; yet it remains controversial whether or not they truly affect outcome.
Since first reported in 1954, numerous clinical studies have been published regarding the use of epidural techniques in cardiac patients. Unfortunately, most are all small, poorly-controlled (none prospective, randomized, blinded) investigations. Prior to the year 2000, such studies focused on the ability of these techniques to attenuate stress response (as assessed via a wide variety of mediators in the blood) and/or induce thoracic cardiac sympathectomy (as assessed via various haemodynamic changes). However, since the year 2000, such studies have more appropriately focused on the ability of these techniques to truly affect clinical outcome (morbidity and mortality). Four of these studies deserve mention.
In 2001, Scott and associates in a fairly large (420 patients) prospective randomized study revealed that the use of epidural techniques may facilitate earlier tracheal extubation, decrease risk of lower respiratory tract infection, and decrease risk of supraventricular arrhythmias following cardiac surgery. [2] However, this study has been criticized for a number of reasons. The two study groups were not equivalent (epidural patients were 'healthier') despite randomization, perioperative beta-blockade was discontinued/forbidden, and key outcome data (haemodynamics, length-of-stay) was not presented. In 2002, Priestley and associates in a fairly large (100 patients) prospective randomized study revealed that the use of epidural techniques enhanced postoperative analgesia yet had no effect on pulmonary (spirometry, saturations, radiography) nor cardiac (ischemia, enzymes, atrial fibrillation) function. [3] Patients receiving epidurals were extubated sooner yet length-of-stay data was not altered. Similarly, in 2003, Royse and associates in a fairly large (80 patients) prospective randomized study revealed once again that the use of epidural techniques enhance postoperative analgesia and facilitate earlier tracheal extubation yet nothing else. [4] No effects were observed regarding pulmonary function (spirometry, saturations), cardiac function (ischemia, atrial fibrillation), renal function (creatinine levels) nor length-of-stay. Lastly, in 2006, Hansdottir and associates (via the best-designed study to date) provide additional evidence that thoracic epidural techniques offer no real clinical benefits to patients undergoing cardiac surgery. [5] This relatively large (113 patients) prospective trial randomized patients undergoing elective cardiac surgery to receive either patient-controlled thoracic epidural analgesia (catheter inserted the day prior to surgery: using bupivacaine, fentanyl and adrenalin) or patient-controlled intravenous morphine analgesia during the immediate postoperative period. Perioperative care was standardized (all patients underwent general anaesthesia and received a median sternotomy). When the two groups were compared, the only difference was a shorter time to postoperative tracheal extubation in patients receiving thoracic epidural analgesia (2.3 h versus 7.3 h). Absolutely no differences were observed regarding postoperative analgesia (at rest and during cough), degree of sedation, lung volumes (forced vital capacity, forced vital capacity at one second, peak expiratory flow), degree of ambulation, global quality of recovery score (including all five domains studied), cardiac morbidity (myocardial infarction, atrial fibrillation, etc.), renal morbidity (peak serum creatinine), neurologic outcome (stroke, confusion), intensive care unit stay, nor hospital length-of-stay. Furthermore, this group of experienced investigators reported a very high (17%) 'failure' rate for the use of thoracic epidural catheters in these patients.
These techniques are not without risk. The most troubling and undesirable drug effect of epidural local anaesthetics is hypotension and the four clinically relevant undesirable drug effects of epidural opioids (pruritus, nausea and vomiting, urinary retention, respiratory depression) are well known. Epidural anaesthesia and analgesia may either mask postoperative myocardial ischemia or initiate postoperative myocardial ischemia (through alterations in sympathetic-parasympathetic balance). Most importantly, risk of potentially catastrophic haematoma is increased when epidural instrumentation is performed in a patient prior to systemic heparinization required for cardiac surgery. In 2004, the first case report of a postoperative epidural haematoma associated with a thoracic epidural catheter inserted in a patient before cardiac surgery was published. [6] Since then, numerous such reports (with catastrophic consequences: permanent paralysis) have appeared in the literature. [1],[7] Additionally, thromboembolic complications (neurologic, stroke) may occur during the postoperative period when normalization of coagulation parameters (in a patient requiring anticoagulation) is achieved to safely remove the epidural catheter. [8] Thus, bleeding and/or thromboembolic complications associated with these techniques in this setting are very real and potentially catastrophic.
Cardiac surgery is unique, and because of this, involves unique risks not routinely associated with non-cardiac surgery. Furthermore, as all are aware, for a wide variety of reasons, patients presenting for cardiac surgery continue to get older and 'sicker' (more comorbidities: neurologic dysfunction, myocardial dysfunction, renal dysfunction, etc.). Multiple factors interact in a complicated manner during the perioperative period that affect outcome and quality of life after cardiac surgery [Table 2]. Although others may disagree, the list of factors in [Table 2] is arranged in descending order of importance as viewed by this author. Obviously, depending on specific clinical situations, certain factors will be more important than others. It is extremely difficult (if not impossible) to determine exactly how important attaining adequate or 'high-quality' postoperative analgesia truly is in relation to all these important clinical factors surrounding a patient undergoing cardiac surgery. [9] For example, how important is it to obtain 'high-quality' postoperative analgesia in an 80-year-old patient with preoperative myocardial dysfunction, renal dysfunction, and a heavily calcified aorta after double-valve replacement? It could be argued that factors other than quality of postoperative analgesia will determine clinical outcome in this patient. On the other hand, how important is it to obtain 'high-quality' postoperative analgesia in an otherwise healthy 50-year-old patient after routine coronary artery bypass grafting? It is likely that this patient's clinical outcome will be satisfactory even if postoperative analgesia is suboptimal.
When one thoughtfully reads the existing literature, the only clear benefit of using thoracic epidural catheters in patients undergoing cardiac surgery is 'enhanced' postoperative analgesia. [1],[10] Yet these techniques are labour intensive, associated with real clinical risks (local anaesthetic/opioid issues, complicates postoperative assessment, haematoma/thromboembolic issues), and have a high failure rate. Furthermore, a clear link between 'enhanced' or 'high-quality' postoperative analgesia and outcome in patients after cardiac surgery has yet to be established. Thus, it is not surprising that this technique remains extremely controversial, with numerous Editorials being written on the subject. [11],[12],[13],[14],[15],[16] Until there is clear evidence linking the use of thoracic epidural catheters in patients undergoing cardiac surgery to improved postoperative outcome (cardiac, pulmonary, renal, etc.), the potential benefits and potential risks should be seriously considered in each individual patient prior to applying the technique in this scenario.
 References | |  |
| 1. | Chaney MA. Intrathecal and epidural anesthesia and analgesia for cardiac surgery. Anesth Analg 2006;102:45-64.  [PUBMED] [FULLTEXT] |
| 2. | 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. [PUBMED] [FULLTEXT] |
| 3. | 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. [PUBMED] [FULLTEXT] |
| 4. | 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. [PUBMED] |
| 5. | Hansdottir V, Philip J, Olsen MF, Eduard C, Houltz E, Ricksten SE. Thoracic epidural versus intravenous patient-controlled analgesia after cardiac surgery. Anesthesiology 2006;104:142-51. [PUBMED] [FULLTEXT] |
| 6. | Rosen DA, Hawkinberry DW 2nd, Rosen KR, Gustafson RA, Hogg JP, Broadman LM. An epidural hematoma in an adolescent patient after cardiac surgery. Anesth Analg 2004;98:966-9. [PUBMED] [FULLTEXT] |
| 7. | Ho AM, Li PT, Karmakar MK. Risk of hematoma after epidural anesthesia and analgesia for cardiac surgery. Anesth Analg 2006;103:1327. [PUBMED] [FULLTEXT] |
| 8. | Chaney MA, Labovsky JK. Case report of thoracic epidural anesthesia and cardiac surgery: Balancing postoperative risks associated with hematoma formation and thromboembolic phenomenon. J Cardiothorac Vasc Anesth 2005;19:768-71. [PUBMED] [FULLTEXT] |
| 9. | Chaney MA. How important is postoperative pain after cardiac surgery? J Cardiothorac Vasc Anesth 2005;19:705-7. [PUBMED] [FULLTEXT] |
| 10. | Aybek T, Kessler P, Dogan S, Neidhart G, Khan MF, Wimmer-Greinecker G, et al . Awake coronary artery bypass grafting: Utopia or reality? Ann Thorac Surg 2003;75:1165-70. [PUBMED] |
| 11. | Chaney MA. Cardiac surgery and intrathecal/epidural techniques: At the crossroads? Can J Anesth 2005;52:783-8. [PUBMED] [FULLTEXT] |
| 12. | Mora Mangano CT. Risky business. J Thorac Cardiovasc Surg 2003;125:1204-7. |
| 13. | Castellano JM, Durbin CG. Epidural analgesia and cardiac surgery: Worth the risk? Chest 2003;117:305-7. |
| 14. | Schwann NM, Chaney MA. No pain, much gain? J Thorac Cardiovasc Surg 2003;126:1261-4. [PUBMED] [FULLTEXT] |
| 15. | Gravlee GP. Epidural analgesia and coronary artery bypass grafting: The controversy continues. J Cardiothorac Vasc Anesth 2003;17:151-3. [PUBMED] [FULLTEXT] |
| 16. | O'Connor CJ, Tuman KJ. Epidural anesthesia and analgesia for coronary artery bypass graft surgery: Still forbidden territory? Anesth Analg 2001;93:523-5. [PUBMED] [FULLTEXT] |
Correspondence Address:
Mark A Chaney
Director of Cardiac Anesthesia, Department of Anesthesia and Critical Care, University of Chicago, 5841 South Maryland Avenue, MC 4028 Chicago, Illinois 60637
USA
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0971-9784.45005
Clinical trial registration None
[Table 1], [Table 2] |
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