High thoracic epidural anesthesia, but not clonidine, attenuates the perioperative stress response via sympatholysis and reduces the release of troponin T in patients undergoing coronary artery bypass grafting

In this prospective study, we evaluated whether high thoracic epidural anesthesia (TEA) or i.v. clonidine, in addition to general anesthesia, affects the cardiopulmonary bypass- and surgery-associated stress response and incidence of myocardial ischemia by their sympatholytic properties. Seventy patients scheduled for elective coronary artery bypass graft (CABG) received general anesthesia with sufentanil and propofol. TEA was randomly induced before general anesthesia and continued during the study period in 25 (anesthetized dermatomes C6-T10). Another 24 patients received i.v. clonidine as a bolus of 4 microg/kg before the induction of general anesthesia. Clonidine was then infused at a rate of 1 microg x kg(-1) x h(-1) during surgery and at 0.2-0.5 microg x kg(-1) x h(-1) postoperatively. The remaining 21 patients underwent general anesthesia as performed routinely (control). Hemodynamics, plasma epinephrine and norepinephrine, cortisol, the myocardial-specific contractile protein troponin T, and other cardiac enzymes were measured pre- and postoperatively. During the preoperative night and a follow-up of 48 h after surgery, five-lead electrocardiogram monitoring was used for ischemia detection. Both TEA and clonidine reduced the postoperative heart rate compared with the control group without jeopardizing cardiac output or perfusion pressure. Plasma epinephrine increased perioperatively in all groups but was significantly lower in the TEA group. Neither TEA nor clonidine affected the increase in plasma cortisol. The release of troponin T was attenuated by TEA. New ST elevations > or = 0.2 mV or new ST depression > or = 0.1 mV occurred in > 70% of the control patients but only in 40% of the clonidine group and in 50% of the TEA group. We conclude that TEA (but not i.v. clonidine) combined with general anesthesia for CABG demonstrates a beneficial effect on the perioperative stress response and postoperative myocardial ischemia. Implications: Thoracic epidural anesthesia combined with general anesthesia attenuates the myocardial sympathetic response to cardiopulmonary bypass and cardiac surgery. This is associated with decreased myocardial ischemia as determined by less release of troponin T. These findings may have an impact on the anesthetic management for coronary artery bypass grafting.     

Epidural anesthesia improves outcome and resource use in cardiac surgery: a single-center study of a 1293-patient cohort

Thoracic epidural anesthesia (TEA) combined with general anesthesia in cardiac surgery has the potential to initiate earlier spontaneous ventilation and extubation, improved hemodynamics, less arrhythmia or myocardial ischemia, and an attenuated neurohormonal response. The aim of the current study was to characterize the correlation between TEA and postoperative resource use or outcome in a consecutive-patient cohort. The study was performed in a tertiary care, 3-surgeon, university-affiliated hospital that performs 350 to 400 cardiac surgeries per year. All 1293 adult patients who underwent cardiac surgery between July 1, 2002, and February 1, 2006, were included. Patients were assigned to anesthesiologists practicing TEA (TEA group, n = 506) or not (control group, n = 787) for cardiac surgery. The preoperative parameter values and Parsonnet scores for the 2 groups were similar. The 2 groups had the same distribution of surgery types. The TEA group presented with fewer intensive care unit (ICU) complications, such as delirium, pneumonia, and acute renal failure, and presented with better myocardial protection. The TEA group presented with a higher proportion of immediately postoperative extubations and with shorter ventilation times and ICU stays. Total ICU costs decreased from US $18,700 to $9900 per patient. Combining TEA and general anesthesia for cardiac surgery allows a significant change in anesthesia strategy. This change improves immediate postoperative outcomes and reduces the use and costs of ICU resources.     

Preincisional dextromethorphan combined with thoracic epidural anesthesia and analgesia improves postoperative pain and bowel function in patients undergoing colonic surgery

Colonic surgery is associated with severe postoperative pain and postoperative ileus, which contribute to delayed hospital discharge. In previous studies, we demonstrated that IM dextromethorphan (DM) provided preemptive analgesia and improved postoperative pain. The benefit of thoracic epidural anesthesia (TEA) and postoperative epidural analgesia on postoperative pain was well demonstrated. The goal of this study was to investigate the effect of preincisional IM DM combined with intraoperative TEA and postoperative patient-controlled epidural analgesia (PCEA) on pain and bowel function after colonic surgery. Patients were randomized into 3 equal groups to receive: 1) chlorpheniramine maleate (CPM) 20 mg and general anesthesia (CPM-GA); 2) CPM 20 mg and GA combined with TEA (CPM-TEA); or 3) DM 40 mg (containing 20 mg of CPM) and GA combined with TEA (DM-TEA). The CPM, DM, and TEA with lidocaine were administered after GA induction via an IM injection and 30 min before the skin incision. All patients received postoperative PCEA for pain control. Analgesic effects were evaluated for 72 h after surgery using visual analog scale pain scores at rest and moving, time to first PCEA request for pain relief, total PCEA consumption, and the time to first passage of flatus. Statistically significant improvement of postoperative pain and bowel function was observed in the following order: DM-TEA > CPM-TEA > CPM-GA. Compared with the CPM-TEA group, the DM-TEA group averaged 1.6 points lower on first-hour pain scores, 40 min longer to first PCEA request, 15.8 mL less PCEA drug over 72 h, and 14.7 h earlier bowel function (all P < 0.01). We conclude that the combination of preincisional DM (40 mg IM), intraoperative TEA, and postoperative PCEA enhances analgesia and facilitates recovery of bowel function, suggesting possible synergistic interaction with local anesthetics and opioids.     

Einfluss der thorakalen Epiduralanalgesie auf die frühe postoperative Phase nach Eingriffen am Gastrointestinaltrakt

INTRODUCTION: Thoracic epidural anesthesia is increasingly being used in visceral surgery as an adjuvant to general anesthesia and, in addition, as a postoperative method of thoracic epidural analgesia (TEA). This method interrupts specifically nociceptive reflexes, increases the blood supply by blocking sympathetic activation, improves pulmonary function, and has a beneficial effect on gastrointestinal (GI) motility. METHODS: A retrospective study was conducted on 175 patients with a primary GI carcinoma operated between January 1, 1999 and December 31, 1999; 78 operations were performed on the upper GI tract (UGI, gastrectomy), and 97 on the lower GI tract (LGI, anterior rectum resection). The postoperative course in patients with and without TEA was compared. For intraoperative and postoperative catheter analgesia, bupivacaine (intraoperative: 0.25%; postoperative: 0.125%) and fentanyl were used. General anesthesia was administered as balanced anesthesia. RESULTS: A total of 102 patients received combined anesthesia with TEA (UGI n = 61/LGI n = 41) and 73 patients were given general anesthesia with continuous postoperative, intravenous pain therapy or a patient-controlled analgesia (PCA) pump (UGI n = 17/LGI n = 56). There was no difference between the groups with and without TEA in terms of initial demographic details, such as age distribution, tumor stage or ASA classification. Under TEA, the length of stay in the intensive care unit (P < 0.01), the administration of antibiotics (P < 0.001), days without oral nutrition (p < 0.05) and the rate of anastomosis insufficiencies (P < 0.001) was significantly reduced after operations on the upper GI tract. After surgery on the lower GI tract, the use of TEA led to less frequent vomiting and earlier resumption of GI motility (P < 0.01). However, these positive effects did not have a significant beneficial impact on overall hospitalization. CONCLUSION: The combination of TEA and general anesthesia has been shown to offer advantages after operations on both the upper and the lower GI tract. The positive effects of the TEA in the postoperative period should be used for the early enteric nutrition and mobilization of patients.     

全麻复合硬膜外阻滞对换瓣手术病人术后血浆皮质醇、血糖及术后恢复的影响

目的观察全麻复合硬膜外阻滞对心脏瓣膜置换手术病人血浆皮质醇(Cor)、血糖(Glu)及术后恢复的影响。方法将20例换瓣手术病人随机分为全麻复合硬膜外阻滞(GEA)和单纯全麻(GA)两组。于术前、术后4 h、术后第1、3、7天取血浆测Cor、Glu浓度,并记录术后清醒时间和拔管时间。结果与术前比较,GA组病人术后4 h,术后第1天血浆Cor水平均显著升高(P<0.05),GEA组血浆Cor水平仅在术后4 h显著增高(P<0.05),但其术后4 h,术后第1天的血浆Cor水平明显低于GA组(P<0.05)。术后第1天,GEA组血浆Cor水平即恢复致术前水平,GA组至术后第3天才恢复致术前水平。两组病人Glu从术后4 h至第7天均高于麻醉前水平,GEA组升高的幅度小于GA组,在术后各时点两组之间差异有显著意义(P<0.05)。GEA组病人术后清醒时间、术后拔管时间早于GA组(P<0.05),术后VAS显著低于GA组(P<0.05)。结论全麻复合硬膜外阻滞可减轻心脏换瓣手术病人应激反应和术后疼痛,有利于病人术后早清醒与早拔管。     

High-dose remifentanil suppresses stress response associated with pneumoperitoneum during laparoscopic colectomy

Purpose

Although laparoscopic surgery is minimally invasive, it produces stress responses to an extent similar to that of conventional laparotomy. Both epidural anesthesia and remifentanil intravenously (i.v.), combined with general anesthesia, provide stable hemodynamics during laparoscopic surgery. However, it has not been elucidated whether epidural anesthesia and remifentanil are associated with suppression of autonomic and neuroendocrine stress responses. This study aimed to clarify whether thoracic epidural anesthesia (TEA) or remifentanil suppresses stress responses during laparoscopic surgery.

Methods

We assigned 60 patients undergoing laparoscopic colectomy to three groups anesthetized with 40 % oxygen–air–sevoflurane plus either TEA (TEA group), continuous infusion of remifentanil 0.25 μg/kg/min [low-dose (LD) group], or 1.0 μg/kg/min [high-dose (HD) group] (n = 20 each group). Plasma concentrations of adrenocorticotropic hormone (ACTH), cortisol, antidiuretic hormone (ADH), and catecholamines were measured immediately before anesthesia induction, and 30 and 90 min after the start of pneumoperitoneum.

Results

All groups showed no significant changes in hemodynamics during the course of anesthesia. Compared with TEA, both high-dose and low-dose remifentanil significantly suppressed increases in ACTH, ADH, and cortisol during pneumoperitoneum. Plasma adrenaline showed no significant changes during pneumoperitoneum in any group. Compared with TEA, low-dose remifentanil produced significantly higher plasma concentrations of noradrenaline and dopamine during pneumoperitoneum.

Conclusion

Notwithstanding similar hemodynamic responses in all groups, only high-dose remifentanil suppressed both sympathetic responses and the hypothalamus–pituitary–adrenal axis. This result indicates that of these three anesthesia regimens, high-dose remifentanil seems most suited for laparoscopic surgery.     

Vigilance of hemodynamic changes immediately after transferring patients is crucial

Purpose

A decrease in blood pressure is sometimes observed when a postsurgical patient is transferred to another bed after recovering from anesthesia. However, the mechanism behind this hypotension has not been completely elucidated. The purpose of this study was to investigate and compare changes in hemodynamic properties for possible causes of hypotension before and after transfer to another bed of postsurgical patients receiving general anesthesia, combined epidural and general anesthesia, or combined spinal and general anesthesia.

Methods

We studied 69 patients undergoing elective surgery who were randomized to receive anesthesia by one of the three methods. After surgery, the tracheal tube was removed, and each patient was transferred to another bed. Hemodynamic data recorded immediately before and after transfer of the patient to another bed were compared.

Results

After transfer of patients receiving general anesthesia or combined epidural and general anesthesia, systolic arterial pressure (SAP), diastolic arterial pressure (DAP), and cardiac output (CO) decreased; heart rate (HR) and systemic vascular resistance (SVR) did not change. However, after transfer of patients receiving combined spinal and general anesthesia, SAP, DAP, HR, and CO decreased, but SVR did not change.

Conclusion

The decrease in blood pressure observed after transfer of a postsurgical patient to another bed after general, combined epidural and general, and combined spinal and general anesthesia was associated with a decrease in CO and no change in SVR, but HR decreased after combined spinal and general anesthesia, whereas it was unchanged after general and combined epidural and general anesthesia. The decrease in blood pressure is assumed to be caused by a decrease in venous return, and several reflexes might participate in this decrease of blood pressure, especially after combined spinal and general anesthesia.     

Effect of combined erector-spinae plane blocks on the immediate postoperative neuronal and stress biomarkers after thoracoscopic radical resection for lung cancers

BackgroundThis study evaluates the impact of general anesthesia combined with erector spinae plane blocks (ESPB) on patients who underwent thoracoscopic radical resection (TRR) for lung cancer.MethodsThere involved a total of 108 patients undergoing TRR for lung cancers. Patients enrolled were equally allocated into experimental group (general anesthesia combined with ESPB) and control group (general anesthesia). The following parameters, including baseline characteristics, serum markers of neurological disorders, postoperative pain degree, dosage of narcotic, adverse events and early postoperative rehabilitation quality, were compared between the two groups.ResultsBased on Visual Analogue Scale, the postoperative pain degree was significantly lower in experimental group on 6h postoperative (P<0.001). And markedly lower results were observed in the levels of serum markers of neurological disorders in the experimental group one day after surgery (all P<0.05). Moreover, the dosage of narcotic and early postoperative rehabilitation quality based on QoR-40 scale were significantly lower in experimental group (all P<0.05).ConclusionAdding ESPB with general anesthesia reduce the postoperative pain up to 6 h, reduce the requirement of postoperative narcotic and help early postoperative rehabilitation quality.     

A prospective randomized study of intraoperative thoracic epidural analgesia in off-pump coronary artery bypass surgery

Objective

The purpose of this study was to test the hypothesis that general anesthesia (GA) plus thoracic epidural anesthesia (TEA) has no impact on the outcomes of off-pump coronary artery bypass surgery (OPCABs) compared to GA followed by patient-controlled TEA (PCTEA), while GA plus TEA leads to a higher requirement for vasoactive drug use.

Methods

Sixty-four patients, American Society of Anesthesiologists physical status II and III, who were scheduled for elective OPCABs, were offered an epidural catheter inserted at the T2?C3 interspace and then randomized into 1 of 2 groups according to whether TEA was applied intraoperatively. The TEA_perio group received GA plus TEA, while the TEA_post group received GA alone. All groups had postoperative PCTEA. The number of requirements for vasoactive drugs and the extubation times were recorded. The analgesic effect was monitored by visual analog scale (VAS) pain scores. Heart rate, blood pressure, and blood gases were also monitored. The data are presented as mean values?±?standard deviation, or medians with quartiles.

Results

The proportion of vasoactive drug use was significantly higher in the TEA_perio group intraoperatively (before or during completion of anastomoses: 59.4 vs. 20.7%, p?=?0.004; after completion of anastomoses: 53.1 vs. 17.2%, p?=?0.007). There was no statistically significant difference in extubation times or VAS scores between the 2 groups.

Conclusions

We conclude that GA plus TEA has no impact on the outcomes of OPCABs, while its use leads to a higher requirement for vasoactive drug use. GA followed by PCTEA facilitates the anesthesia administration, while it does not affect the extubation time and the postoperative analgesic effect.     

Combined spinal and general anesthesia vs general anesthesia for robotic sacrocervicopexy: a randomized controlled trial

Introduction and hypothesis

Gynecologic laparoscopic surgery is frequently accompanied by early postoperative pain. This study assessed the effect of combined general and spinal anesthesia on postoperative pain score, analgesic use, and patient satisfaction following robotic surgeries.

Methods

This was a randomized controlled trial. Thirty-eight consecutive women who underwent robotic surgeries for pelvic organ prolapse (sacrocolpopexy with or without subtotal hysterectomy) were randomly assigned to receive general anesthesia (control group, n?=?20) or combined general with spinal anesthesia (study group, n?=?18). Pain scores were assessed at rest and while coughing using a visual analog scale (VAS) 0–10. Dosage of analgesic medication consumption was retrieved from patients’ charts.

Results

There were no statistically significant differences between the two groups with respect to demographic data and intraoperative hemodynamic parameters. In the postanesthesia care unit (PACU) mean total IV morphine and meperidine dosages were significantly lower for the study than the control group (0.33 vs 7.59 mg, 1.39 vs 27.89 mg, respectively, P?<?0.003, <0.001, respectively). In addition, a significantly lower percentage of patients belonging to the study group demanded analgesic medications while in the PACU (33 vs 53 %, P?=?0.042). Pain scores in the PACU and during postoperative day 1 were significantly lower in the study group than in the control group (delta VAS 1.9 vs 3.0, P?=?0.04). Satisfaction with pain treatment among both patients and nurses was significantly higher in the study group.

Conclusions

Reported levels of pain and analgesic use during the first 24 h following robotic gynecologic surgery were significantly lower following general and spinal anesthesia compared to general anesthesia alone.     

Thoracic epidurals in heart valve surgery: neurologic risk evaluation

OBJECTIVE: To evaluate the risk of neurologic complications resulting from epidural hematoma in a series of patients who had surgery for repair or replacement of heart valves under combined general and thoracic epidural anesthesia (TEA). DESIGN: Prospective observational study. SETTING: General reference hospital associated with a university. PARTICIPANTS: Patients (n = 305) who had surgery for replacement or repair of heart valves. INTERVENTIONS: An epidural catheter was inserted at T1-3 as soon as the patient was in the operating room, and local anesthetic was administered as a bolus, then as a continuous infusion throughout the operation and postoperatively. A protocol for postoperative neurologic evaluation was used to rule out clinical signs of spinal lesions. A set of safety guidelines was routinely followed. MEASUREMENTS AND MAIN RESULTS: Preoperatively a battery of coagulation tests was systematically carried out: activated partial thromboplastin time, platelet count, and prothrombin time. Oral anticoagulants (warfarin) were stopped >60 hours before surgery, and antiplatelet drugs (aspirin) were stopped 7 days before. No patient required parenteral opiates postoperatively. Of the patients, 65% were extubated in the operating room. There were no neurologic complications resulting from epidural hematoma. CONCLUSION: TEA can provide effective postoperative analgesia and assist in early tracheal extubation in cardiac valve surgery. In this series, there were no neurologic deficits detected. When certain safety measures are taken, routine TEA is feasible and helpful in cardiac valve surgery.     

Outcome after valve surgery in octogenarians and efficacy of early mobilization with early cardiac rehabilitation

Purpose  

This study aimed to compare postoperative complications and the surgical outcome in patients aged <80 years versus octogenarian patients. Another aim was to evaluate the safety and efficacy of early mobilization with early cardiac rehabilitation in octogenarians.     

Factors Associated with Postoperative Nausea and Vomiting in Patients Undergoing an Ambulatory Hand Surgery

Background

Patients undergoing ambulatory surgery under general anesthesia experience considerable levels of postoperative nausea and vomiting (N/V) after their discharge. However, those complications have not been thoroughly investigated in hand surgery patients yet. We investigated factors associated with postoperative N/V in patients undergoing an ambulatory hand surgery under general anesthesia and determined whether patients'' satisfaction with this setting is associated with postoperative N/V levels.

Methods

We prospectively evaluated 200 consecutive patients who underwent ambulatory hand surgeries under general anesthesia to assess their postoperative N/V visual analogue scale (VAS) levels during the first 24 hours after surgery and their satisfaction with an ambulatory surgery setting. Potential predictors of postoperative N/V were; age, sex, body mass index, smoking behavior, a history of postoperative N/V after previous anesthesia or motion sickness, preoperative anxiety level and the duration time of anesthesia. We conducted multivariate analyses to identify factors associated with postoperative N/V levels. We also conducted multivariate logistic regression analyses to determine whether the N/V levels are associated with the patients'' satisfaction with this setting. Here, potential predictors for satisfaction were sex, age, postoperative pain and N/V.

Results

Postoperative N/V were associated with a non-smoking history, a history of motion sickness and a high level of preoperative anxiety. Twenty-two patients (11%) were dissatisfied with the ambulatory setting and this dissatisfaction was independently associated with moderate (VAS 4-7) and high (VAS 8-10) levels of postoperative N/V and with a high level (VAS 8-10) of postoperative pain.

Conclusions

Although most of the patients were satisfied with the ambulatory surgery setting, moderate to high levels of N/V were associated with dissatisfaction of patients with this setting, suggesting a need for better identifying and managing those patients at risk. The information regarding risk factors for N/V could help in preoperative patient consultation regarding an ambulatory hand surgery under general anesthesia.     

Thoracic epidural anesthesia preserves myocardial function during intraoperative and postoperative period in coronary artery bypass grafting operation

AIM: The purpose of this study was to investigate the effect of thoracic epidural anesthesia (TEA) in patients with poor ventricular function undergoing conventional coronary artery bypass graft surgery (CABG) during the intraoperative and the postoperative period. METHODS: Eighty patients (n = 80) undergoing elective CABG surgery with cardiopulmobary bypass (CPB) were divided into 4 groups: 1) General anesthesia (GA) plus poor ventricular (PV) function patients (Group GA plus PV) (n = 20), ejection fraction (EF) = or <40%; 2) GA plus good ventricular (GV) function patients (Group GA plus GV) (n = 20), EF >40%; 3) Thoracic epidural anaesthesia (TEA)+GA, poor ventricular function patients (Group TEA+GA plus PV) (n = 20), EF = or <40%; 4) TEA+GA, good ventricular function patients (Group TEA+GA plus GV) (n = 20), EF >40%. RESULTS: Within groups, at 4 h after the end of CPB, in the Group TEA+GA plus PV and Group TEA+GA plus GV, the cardiac index values were significantly higher than baseline values; P < 0.05, whereas no difference was found in the Group GA plus PV and Group GA plus GV. According to Tukey test, using repeated measures, between trend of groups, the cardiac index values were significantly different P < 0.05. In the Group TEA+GA plus PV, cardiac index values were significantly higher than the Group GA plus PV, P < 0.05. But in the Group GA plus GV, cardiac index values were not significantly different than the Group TEA+GA plus GV. The incidence of reperfusion ventricular fibrillation (VF) after release of aortic cross-clamp, in the Group TEA+GA plus PV (4 of 20 patients: 20%) was significantly lower than in the Group GA plus PV (11 of 20 patients: 55%); P < 0.05. The incidence of reperfusion VF after release of aortic cross-clamp, in the Group TEA+GA plus GV (5 of 20 patients: 25%) was not significantly different than in the Group GA plus GV (10 of 20 patients: 50%); NS. CONCLUSIONS: TEA seems to be effective in patients with poor left ventricular function. Our results (improved cardiac index, reduced arrhythmias after release of aortic clamp and decreased inotropic requirement) are better with TEA, particularly in patients with poor left ventricular function.     

Thoracic epidural anesthesia combined with general anesthesia: the preferred anesthetic technique for thoracic surgery

Thoracic epidural anesthesia (TEA) combined with general anesthesia (GA) as well as total-IV anesthesia (TIVA) are both established anesthetic managements for thoracic surgery. We compared them with respect to hypoxic pulmonary vasoconstriction, shunt fraction and oxygenation during one-lung ventilation. Fifty patients, ASA physical status II-III undergoing pulmonary resection were randomly allocated to two groups. In the TIVA group, anesthesia was maintained with propofol and fentanyl. In the TEA group, anesthesia was maintained with TEA (bupivacaine 0.5%) combined with low-dose concentration 0.3-0.5 vol% of isoflurane (end-tidal). Changing from two-lung ventilation to one-lung ventilation caused a significant increase in cardiac output (CO) in the TIVA group, whereas no change was observed in the TEA group. One-lung ventilation caused significant increases in shunt fraction in both groups which was associated per definition with a significant decrease in PaO(2) in both groups but PaO(2) remained significantly increased in the TEA group (P < 0.05). We conclude that both anesthetic regimens are safe intraoperatively. However, TEA in combination with GA did not impair arterial oxygenation to the same extent as TIVA, which might be a result of the changes in CO. Therefore, patients with preexisting cardiopulmonary disease and impaired oxygenation before one-lung ventilation might benefit from TEA combined with GA. IMPLICATIONS: Fifty patients underwent lung surgery through the opened chest wall requiring ventilation of only one lung. Patients were randomly assigned to receive either general anesthesia alone or in combination with regional anesthesia via a catheter in the back. Oxygen content in the blood and blood pressure was better maintained in the group receiving the combination of general with regional anesthesia.     

Efficacy and safety of transversus abdominis plane blocks versus thoracic epidural anesthesia in patients undergoing major abdominal oncologic resections: A prospective,randomized controlled trial

Background

The purpose of this study was to compare patient outcomes for thoracic epidural anesthesia (TEA) with transversus abdominis plane (TAP) blocks.

Effects of thoracic epidural anesthesia on systemic hemodynamic function and systemic oxygen supply-demand relationship

The effects of thoracic epidural anesthesia (TEA) on total body oxygen supply-demand ratio are complex due to potential influences on both O2 delivery (QO2) and consumption (VO2). One hundred and five patients undergoing abdominal aortic surgery were randomly assigned to one of three groups to compare the cardiovascular and metabolic responses associated with (1) thoracic epidural anesthesia plus light general anesthesia (group TEA); (2) general anesthesia with halothane (group H); and (3) neuroleptanalgesia (group NLA). Values of cardiac index (CI) and QO2 were less intraoperatively in the TEA group than in the H or NLA groups, while VO2 values were similar. VO2 during recovery was greater in both the TEA and NLA groups than in the H group. Consequently the oxygen supply-demand ratio (QO2/VO2) was less in the TEA group throughout the perioperative period and about 30% below baseline values during early recovery. At comparable VO2, CI and mixed venous O2 saturation were always less in the TEA group than in the NLA group. Heart rate was slowest intraoperatively during TEA, and stroke work was less with TEA than with NLA. As cardiac filling pressure and systemic vascular resistance did not differ among the three groups, reduced adaptation of CI to tissue O2 needs during TEA was attributed to negative inotropic and chronotropic effects of the sympathetic blockade. We conclude that in patients undergoing abdominal aortic surgery, TEA has no apparent advantage over general anesthesia.     

Effect of Anesthetic Methods on Cerebral Oxygen Saturation in Elderly Surgical Patients: Prospective, Randomized, Observational Study

Background

Intraoperative cerebral oxygen desaturation was reported to be associated with postoperative cognitive dysfunction in elderly patients. The effect of the anesthesia method on regional cerebral oxygen saturation (rSO₂) is still a question under debate. The purpose of this study was to compare the effects of three common anesthesia methods on intraoperative rSO₂ changes in elderly patients.

Methods

In this prospective randomized clinical trial, 87 patients scheduled for elective transurethral prostatectomy were allocated to receive general inhalational anesthesia (GA group, n?=?30), spinal anesthesia (SA group, n?=?28), or spinal anesthesia plus sedation with midazolam (SA+S group, n?=?29).

Results

The numbers of patients showing a decrease in rSO₂ below the baseline value were higher in the SA (92.9?%) and SA+S (100?%) groups than in the GA group (33.3?%). The number of patients with a ≥50?% decrease in rSO₂ below baseline was greater in the SA+S (31.0?%) group than in the GA (0?%) or SA (3.6?%) group. During surgery, patients subjected to general anesthesia had higher rSO₂ than those with spinal anesthesia. Blood pressures and heart rates were similar in three groups except 5 and 10?min after anesthesia. Intraoperative SpO₂ was higher in the GA group than in the two spinal anesthesia groups.

Conclusions

Spinal anesthesia is associated with more frequent cerebral desaturation than general anesthesia; and it was aggravated when combined with midazolam sedation. The cerebral effects of anesthesia should be considered when managing high-risk elderly patients.     

Comparison of three anesthetic techniques for off-pump coronary artery bypass grafting: general anesthesia, combined general and high thoracic epidural anesthesia, or high thoracic epidural anesthesia alone

OBJECTIVE: This study compared general anesthesia (GA), combined GA plus thoracic epidural anesthesia (TEA), and TEA alone in patients scheduled for off-pump coronary artery bypass grafting. DESIGN: Prospective, nonrandomized clinical study SETTING: University hospital. PARTICIPANTS: Ninety consenting patients undergoing beating-heart coronary artery revascularization with comparable coronary status and left ventricular function. INTERVENTIONS: GA (n=30) was conducted with propofol, remifentanil, and cisatracurium or combined with TEA (GA+TEA, n=30) or TEA as the sole anesthetic with ropivacaine plus sufentanil (TEA, n=30). MEASUREMENTS AND MAIN RESULTS: Groups were comparable regarding the surgical approaches and the number of anastomoses. Four patients (GA, n=2; GA+TEA, n=2) who required unplanned cardiopulmonary bypass, and 4 patients in the TEA group who underwent unexpected intubation because of pneumothorax (n=2), phrenic nerve palsy, or incomplete analgesia were excluded from further analysis. Intraoperative heart rate decreased significantly with both GA+TEA and TEA. None of the patients with TEA alone was admitted to the intensive care unit, they all were monitored on average for 6 hours postoperatively in the intermediate care unit and allowed to eat and drink as desired on admission. Postoperative pain scores were lower in both groups with TEA. There were no differences among groups in patients overall satisfaction. CONCLUSION: Based on the authors data, all anesthetic techniques were equally safe from the clinicians standpoint. However, GA+TEA appeared to be most comprehensive, allowing for revascularization of any coronary artery, providing good hemodynamic stability and reliable postoperative pain relief. Nonetheless, the actual and potential risks of TEA during cardiac surgery should not be underestimated.     

Thoracic epidural anesthesia for cardiac surgery: the effects on tracheal intubation time and length of hospital stay.

Improvements in analgesia after major surgery may allow a more rapid recovery and shorter hospital stay. We performed a prospective randomized trial to study the effects of epidural analgesia on the length of hospital stay after coronary artery surgery. The anesthetic technique and postoperative mobilization were altered to facilitate early intensive care discharge and hospital discharge. Fifty patients received high (T1 to T4) thoracic epidural anesthesia (TEA) with ropivacaine 1% (4-mL bolus, 3-5 mL/h infusion), with fentanyl (100-microg bolus, 15-25 microg/h infusion) and a propofol infusion (6 mg x kg(-1) x h(-1)). Another 50 patients (the General Anesthesia group) received fentanyl 15 microg/kg and propofol (5 mg x kg(-1) x h(-1)), followed by IV morphine patient-controlled analgesia. The TEA group had lower visual analog scores with coughing postextubation (median, 0 vs 26 mm; P < 0.0001) and were extubated earlier (median hours [interquartile range], 3.2 [2.1-4.6] vs 6.7 [3.3-13.2]; P < 0.0001). More than half of all patients were discharged home on Postoperative Day 4 (24%) or 5 (33%), but there was no difference in the length of stay between the TEA group (median [interquartile range], Day 5 [5-6]) and the General Anesthesia group (median [interquartile range], Day 5 [4-7]). There were no differences in postoperative spirometry or chest radiograph changes or in markers for postoperative myocardial ischemia or infarction. No significant TEA-related complications occurred. In summary, TEA provided better analgesia and allowed earlier tracheal extubation but did not reduce the length of hospital stay after coronary artery surgery. IMPLICATIONS: We found that epidural analgesia was more effective than IV morphine for cardiac surgery. Epidural anesthesia also allowed earlier weaning from mechanical ventilation, but it did not affect hospital discharge time.