Immediate extubation after aortic valve surgery using high thoracic epidural analgesia or opioid-based analgesia

OBJECTIVE: Fast-track anesthesia has gained widespread use in cardiac centers around the world. No study has been published focusing on immediate extubation after aortic valve surgery. This study examines the feasibility and hemodynamic stability of immediate extubation after simple or combined aortic valve surgery using either thoracic epidural analgesia or opioid-based analgesia. DESIGN: Prospective audit, pilot study. SETTING: Single-institution university medical center. PARTICIPANTS: Adult patients undergoing aortic valve replacement (N = 45). INTERVENTIONS: Forty-five patients undergoing aortic valve surgery with an ejection fraction of more than 30% were included in this prospective audit. Induction of anesthesia was done using fentanyl, 2 to 4 mug/kg, propofol, 1 to 2 mg/kg, and endotracheal intubation facilitated by rocuronium; anesthesia was maintained using sevoflurane titrated according to bispectral index (BIS [BIS target: 50]). Perioperative analgesia was provided by high thoracic epidural analgesia (TEA group, bupivacaine 0.125%, 6 to 14 mL/h) or fentanyl, up to 10 microg/kg, followed by patient-controlled analgesia with morphine (OPIOID group). MEASUREMENTS AND MAIN RESULTS: Success of extubation within 30 minutes after surgery was recorded. Hemodynamic data during surgery were compared by using an analysis of variance test; p < 0.05 was considered as showing a significant difference. Data presented as median (25th-75th percentile). In the TEA group, patients underwent simple aortic valve replacement (N = 21) or combined aortic valve surgery (N = 14), with additional coronary artery bypass grafting (N = 10) and replacement of the ascending aorta (Bentall, N = 4). In the OPIOID group, patients underwent simple aortic valve replacement (N = 5) or combined aortic valve surgery (N = 5), with additional aortocoronary bypass grafting (N = 2), replacement of the ascending aorta (Bentall, N = 2), and reconstruction of the mitral valve (N = 1). All 45 patients were extubated within 15 minutes after surgery. There was no need for reintubation; pain scores were lower in the TEA group than in the OPIOID group immediately after surgery and at 6 hours, 24 hours, and 48 hours after surgery. For the TEA group and OPIOID group, the pain scores were 0 (0-2), 0 (0-2), 0 (0-1.5), and 0 (0-0) and 5 (4-5.75), 4 (3-4.5), 4 (3.25-4), and 1 (0-2.5), respectively. During and up to 6 hours after surgery, there was no significant hemodynamic difference between the TEA and OPIOID groups. Eighteen of 45 patients needed temporary pacemaker activation. There were no epidural hematoma or neurologic complications related to TEA. CONCLUSION: Immediate extubation is feasible after aortic valve surgery using either high thoracic epidural analgesia or opioid-based analgesia; both techniques maintain hemodynamic stability throughout surgery. TEA provides superior pain control.     

Immediate Extubation after Aortic Valve Surgery Using High Thoracic Epidural Anesthesia

Abstract Purpose: Fast-track anesthesia has gained widespread use in cardiac centers around the world. No study has focused on immediate extubation after aortic valve surgery. This study examines the feasibility and hemodynamic stability of immediate extubation after simple or combined aortic valve surgery using thoracic epidural anesthesia. Methods: Thirty patients undergoing aortic valve surgery with an ejection fraction of more than 30% were included in this prospective audit. After insertion of a high thoracic epidural catheter, induction with fentanyl 2 to 4 microg/kg, administration of propofol 1 to 2 mg/kg, and endotracheal intubation facilitated by rocuronium, anesthesia was maintained with sevoflurane titrated according to bispectral index (target, 50). Perioperative analgesia was provided by high thoracic epidural analgesia (TEA) (bupivacaine 0.125% 6-14 mL/h). Hemodynamic data were compared by Friedman test. P <.05 was considered to show a significant difference. Data are presented as median (25th-75th percentile). Results: Patients underwent simple aortic valve surgery (n = 17) or combined aortic valve surgery (n = 13) with additional coronary artery bypass grafting (n = 8), replacement of the ascending aorta (Bentall procedure) (n = 4), and repair of open foramen ovale (n = 1). All 30 patients were extubated within 15 minutes after surgery at 36.5 degrees C (36.4 degrees C-36.6 degrees C). There was no need for reintubation. Pain scores were low immediately after surgery and 6, 24, and 48 hours after surgery at 0 (0-3.5), 0 (0-2), 0 (0-2), and 0 (0-2), respectively. During and up to 6 hours after surgery, there was no significant hemodynamic change due to TEA. Fifteen of 30 patients needed temporary pacemaker activation. There were no complications related to TEA. Conclusions: Immediate extubation is feasible after aortic valve surgery with high thoracic epidural analgesia and maintenance of hemodynamic stability throughout surgery. Immediate extubation after aortic valve surgery is a promising new path in cardiac anesthesia.     

Ultra-fast-track anesthesia in off-pump coronary artery bypass grafting: a prospective audit comparing opioid-based anesthesia vs thoracic epiduralbased anesthesia

PURPOSE: To examine the feasibility of immediate extubation after off-pump coronary artery bypass grafting (OPCAB) using opioid based analgesia or high thoracic epidural analgesia (TEA) and compare postoperative analgesia with continuous TEA vs patient-controlled analgesia (PCA). METHODS: One hundred consecutive patients undergoing OPCAB were included in this prospective audit. After induction of anesthesia using fentanyl 2 to 5 microg.kg(-1), propofol 1 to 2 mg.kg(-1) and endotracheal intubation facilitated by rocuronium, anesthesia was maintained using sevoflurane titrated according to bispectral index monitoring. Perioperative analgesia was provided by TEA (n = 63) at the T3/T4 interspace or T4/T5 interspace using bupivacaine 0.125% 8 to 14 mL.hr(-1) and repetitive boluses of bupivacaine 0.25% during surgery. In patients who were fully anticoagulated or refused TEA, perioperative analgesia was achieved by i.v. fentanyl boluses (up to 15 microg.kg(-1)) and remifentanil 0.1 to 0.2 microg.kg(-1).min(-1), followed by morphine PCA after surgery (n = 37). Maintenance of body temperature was achieved by a heated operating room and forced-air warming blankets. RESULTS: Ninety-five patients were extubated within 25 min after surgery (PCA, n = 33; TEA, n = 62). Five patients were not extubated immediately because their core temperature was lower than 35 degrees C. One patient was re-intubated because of agitation (TEA group); one was re-intubated because of severe pain and morphine-induced respiratory depression (PCA group). Pain scores were low after surgery, with pain scores in the TEA group being significantly lower immediately, at six hours, 24 hr and 48 hr after surgery (P < 0.05). CONCLUSION: Immediate extubation is possible after OPCAB using either opioid-based analgesia or TEA. TEA provides significantly lower pain scores after surgery in comparison to morphine PCA.     

Coronary artery bypass grafting using two different anesthetic techniques: Part 2: Postoperative outcome.

The aim of the present investigation was to study the effects of intraoperative and postoperative epidural pain management during and after coronary artery bypass grafting (CABG) on the recovery time, postoperative pulmonary and cardiac parameters, visual analog scale (VAS) scores, and sedation scores (SS) compared with patients anesthetized with general anesthesia (GA) whose postoperative pain was relieved with intermittent intravenous (IV) administration of nicomorphine. Fifty-four patients were studied postoperatively after uncomplicated CABG. In the thoracic epidural analgesia (TEA) group (n = 27), intraoperative analgesia was based on high TEA in combination with GA. In the GA group (n = 27), IV anesthesia with high-dose sufentanil and midazolam was used. Postoperative pain management in the GA group consisted of intermittent IV administration of nicomorphine, 0.1 mg/kg every 6 hours, whereas for the TEA group continuous high TEA with 0.125% bupivacaine plus sufentanil, 1:1,000,000 (0.05 mL/cm body length/hr) was used. Patients in the TEA group awakened earlier (148 [34] minutes vs 335 [51] minutes), resumed spontaneous respiration earlier (326 [79] minutes vs 982 [52] minutes), and were extubated earlier (463 [79] minutes vs 1140 [58] minutes). VAS score, SS, and postoperative PaO2 were significantly (P less than or equal to 0.01) better in the TEA group. The incidence of tachycardia (15 vs 2 patients) and postoperative myocardial ischemia (12 vs 4 patients) was higher in the GA group. It is concluded that intraoperative and postoperative pain treatment with epidurally administered bupivacaine plus sufentanil improved the recovery time, as well as pulmonary and cardiac outcome after CABG, when compared with IV postoperative pain treatment after intraoperative GA with sufentanil and midazolam.     

Comparison of continuous thoracic epidural and paravertebral blocks for postoperative analgesia after minimally invasive direct coronary artery bypass surgery

OBJECTIVE: To compare continuous thoracic epidural analgesia (TEA) and paravertebral block (PVB) for postoperative analgesia in patients undergoing minimally invasive direct coronary artery bypass (MIDCAB) surgery for quality of analgesia, complications, compliance to chest physiotherapy, hemodynamics, and respiratory effects. DESIGN: Prospective, randomized study. SETTING: Specialty research hospital. PARTICIPANTS: Forty-one consenting patients undergoing MIDCAB surgery. INTERVENTIONS: Patients in the TEA group had an epidural catheter inserted at the T4-5 interspace, whereas patients in the PVB group had a catheter inserted in the paravertebral space on the left side at the T4-5 level. MEASUREMENTS AND MAIN RESULTS: Parameters evaluated included visual analog scale pain scores at rest and while coughing, supplemental analgesic requirement, complications, hemodynamics, and respiratory parameters. Measurements were made at 2-hour intervals for 12 hours beginning at 10 minutes after endotracheal extubation. There was no statistically significant difference in visual analog scale scores and requirement of supplemental analgesia between the 2 groups. Cardiac index at 4 hours and 6 hours was significantly higher in the TEA group. Patients in the PVB group had significantly lower respiratory rates at 8, 10, and 12 hours. All other parameters were comparable. In 1 patient, the epidural space could not be catheterized. One patient in the TEA group had transient hypotension, and 1 patient complained of backache at the site of the epidural catheter insertion. CONCLUSION: PVB is as effective as TEA for postoperative analgesia after MIDCAB surgery. PVB is technically easier than TEA and may be safer than TEA because no complications were seen in the PVB group.     

Lumbar versus thoracic epidural buprenorphine for postoperative analgesia following coronary artery bypass graft surgery

BACKGROUND: Thoracic epidural analgesia (TEA) is reported to provide effective analgesia following cardiac surgery. We compared the effect of buprenorphine (BN) through the lumbar and thoracic epidural routes for postoperative analgesia following coronary artery bypass graft surgery (CABG). METHODS: Forty patients with normal left ventricular ejection fraction scheduled for CABG were randomly divided into two groups, the TEA group (n = 19) and the lumbar epidural analgesia (LEA) group (n = 20). For postoperative pain relief they received epidural BN 0.15 mg at the first demand for pain relief following extubation. A top-up dose of BN 0.15 mg was administered in cases where visual analogue scale (VAS) score was > 3 at 1 h after first dose. Subsequent breakthrough pain was treated with 30 mg intramuscular ketorolac tromethamine (ketorolac). Pain assessed by VAS score on a 0-10 scale, respiratory rate, FEV1, FVC, mean arterial blood pressure, cardiac index, PaO2 and PaCO2 were measured at frequent intervals. Side effects of epidural opioids were noted. RESULTS: Both groups were comparable in demographic characteristics, had similar VAS scores from 1 to 24 h postoperatively, required similar amounts of intramuscular ketorolac for break-through pain and had comparable pulmonary functions and side effects. CONCLUSION: This study shows that BN by the lumbar epidural route for analgesia after CABG compares favourably with the same drug through the thoracic route in terms of quality of analgesia and incidence of side effects.     

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.     

The effects of remifentanil and thoracic epidural on oxygenation and pulmonary shunt fraction during one-lung ventilation

OBJECTIVE: To compare the effects of remifentanil and thoracic epidural analgesia on the hemodynamic changes and pulmonary shunt fraction during one-lung ventilation (OLV) for thoracotomy. DESIGN: Prospective, single crossover design. SETTING: Tertiary care hospital. PARTICIPANTS: Thirty-four patients undergoing OLV for thoracic surgery. INTERVENTIONS: During general anesthesia with 2-lung ventilation, one-lung ventilation with remifentanil infusion, and one-lung ventilation with thoracic epidural anesthesia (TEA), hemodynamic parameters and arterial and mixed venous blood gases were taken from the radial and pulmonary artery catheters. During these 3 study periods, cardiac index (CI) was measured using thermodilution technique while shunt fraction (Qs/Qt), alveolar arterial oxygen gradient (A-a O(2)), and systemic (SVRI) and pulmonary vascular resistances indices (PVRI) were calculated. A p value <0.05 was taken to be statistically significant. MEASUREMENTS AND MAIN RESULTS: When OLV was instituted, there was a significant decrease in mean arterial blood pressure. Arterial oxygenation decreased, whereas CI and Qs/Qt increased during OLV, but there was no significant difference between remifentanil infusion and thoracic epidural analgesia. CONCLUSIONS: Both remifentanil infusion and TEA are suitable for analgesia during thoracic surgery when OLV is used. There was no significant difference in PaO(2) and Qs/Qt during each administration.     

Effects of preemptive epidural analgesia on post-thoracotomy pain

OBJECTIVE: The purpose of this study was to determine whether preemptive thoracic epidural analgesia (TEA) initiated before surgical incision would reduce the severity of acute post-thoracotomy pain and the incidence of chronic post-thoracotomy pain. METHOD: Meta-analysis of randomized controlled trials (RCTs). SEARCH STRATEGY: MEDLINE, the Cochrane Central Register of Controlled Trials (CENTRAL) and EMBASE were searched from 1966 to December 2004 for prospective RCTs published in all languages using the following MeSH terms: post-thoracotomy pain, epidural analgesia, chronic pain, and preemptive analgesia. SELECTION CRITERIA: All RCTs that compared thoracic epidural analgesia initiated before surgical incision (preemptive group) versus thoracic epidural analgesia initiated after completion of surgery (control group) in adult patients undergoing unilateral thoracotomy. MEASUREMENTS AND MAIN RESULTS: Three authors reviewed all citations and simultaneously extracted data on sample size, patient characteristics, surgical and analgesic interventions, methods of pain assessment, and pain scores at 24 hours, 48 hours, and 6 months postoperatively. Six studies were included with a total of 458 patients. Pooled analyses indicated that preemptive TEA was associated with a statistically significant reduction in the severity of acute pain on coughing at 24 and 48 hours (weighted mean difference -1.17 [95% confidence interval (CI) -1.50 to -0.83] and -1.08 [95% CI -1.17 to -0.99]), respectively. Acute pain was a good predictor of chronic pain. However, there was no statistically significant difference in the overall incidence of chronic pain at 6 months between the preemptive TEA group (39.6%) and the control group (48.6%). CONCLUSION: Preemptive TEA appeared to reduce the severity of acute pain but had no effect on the incidence of chronic pain.     

Cardiopulmonary complications after major surgery: a role for epidural analgesia?

Improvement in postoperative pulmonary mechanics with epidural analgesia has been described. Data on the hemodynamic effects of this technique are absent from the surgical literature. To provide such data we have evaluated two groups of patients undergoing aortic reconstruction: group I (n = 25), general anesthesia and group II (n = 6), general anesthesia with adjunctive epidural analgesia. The groups were comparable preoperatively as judged by the incidence of cardiac history, preoperative ejection fraction, and measured hemodynamic parameters. Postoperatively there were no significant differences in the pressure-related parameters; however, rate-related factors including heart rate and double product were significantly decreased in group II with no reduction in cardiac index. Postoperative increases in total body oxygen consumption were also markedly attenuated by epidural analgesia. Epidural analgesia reduces the hemodynamic demands on the heart after major surgery and is a useful adjunct, especially in patients with coronary artery disease.     

The use of continuous positive airway pressure by face mask and thoracic epidural analgesia after lung transplantation. Gothenburg Lung Transplant Group.

OBJECTIVE: To evaluate the clinical use of continuous positive airway pressure (CPAP) and thoracic epidural analgesia (TEA) after lung transplantation (LTx). DESIGN: Retrospective case series. SETTING: Cardiothoracic intensive care unit (ICU) at a university hospital. PARTICIPANTS: All heart-lung, bilateral, and single-lung transplant recipients between 1990 and 1996 at this institution (n = 102). INTERVENTIONS: Postoperative pain was controlled by a thoracic epidural infusion of bupivacaine, 1 mg/mL, and sufentanil, 1 microg/mL. After extubation, CPAP, 5 to 10 cm H2O by face mask, was used to prevent reperfusion edema. MEASUREMENTS AND MAIN RESULTS: In 99 patients, the length of ventilation (LOV) was a median of 4.3 hours (range, 1.0 to 312.0 hours). The median LOV was 8.0 hours (range, 1.5 to 41.0 hours) in the heart-lung recipients, 4.5 hours (range, 2.0 to 47.0 hours) in the bilateral-lung recipients, and 3.5 hours (range, 1.0 to 312.0 hours) in the single-lung recipients. Three transplant recipients, all with primary pulmonary hypertension, were prematurely extubated and reintubated because of pulmonary edema. Twelve hours after extubation, the median oxygenation index (PaO2/F(I)O2, PaO2 in kilopascal units) was greater than 35. The median ICU length of stay for all transplant recipients was 4 days (range, 2 to 270 days). CONCLUSION: The postoperative use of CPAP and TEA is associated with early and safe tracheal extubation after LTx and may shorten ICU stay.     

Interpleural versus epidural analgesia with ropivacaine for postthoracotomy pain and respiratory function

STUDY OBJECTIVE: To evaluate the impact of interpleural analgesia (IP) on postthoracotomy pain and respiratory function as an alternative to thoracic epidural analgesia (TEA). DESIGN: Prospective, randomized study. SETTING: Tertiary-care military hospital. PATIENTS: Sixty young patients scheduled for elective thoracic surgery (correction of aorta coarctation and patent ductus arteriosus). INTERVENTIONS: Patients were randomized into two groups to receive either IP or TEA for postthoracotomy pain management. MEASUREMENTS: Patients in the IP group (n = 30) had a catheter inserted between the parietal and visceral pleura by a surgeon, and 0.2% ropivacaine was given through this catheter. In the TEA group, ropivacaine was administered through a thoracic epidural catheter. The impact of both methods on pain control, respiratory function, and pulmonary complications was analyzed and compared. MAIN RESULTS: The frequency of atelectasis and pleural effusion was also significantly high in the IP group (P < 0.01). Respiratory function and postoperative pain scores were better in the TEA group (P < 0.01). Arterial blood gas analysis on the fifth postoperative day was significantly better in the TEA group. CONCLUSION: Thoracic epidural analgesia has more beneficial effects on respiratory function and postoperative pain after thoracotomy than does IP.     

Respiratory and hemodynamic effects of thoracic or lumbar epidural alfentanyl after thoracic surgery

OBJECTIVES: The aim of this study was to evaluate the effects on pulmonary function and hemodynamics of three different types of analgesia after thoracotomy. MATERIAL AND METHODS: Forty-five ASA II-IV patients undergoing thoracotomy (for lobectomy or pneumonectomy) were randomized to three groups (n = 15 each) for double-blind study. After a test dose into the epidural space at T5-7 (groups T-A and T-AL) or L2-3 (group L-A) interspace, 10 micrograms/Kg of alfentanil was administered in all groups, followed by epidural infusion of 400 micrograms/h of alfentanil (group T-A and L-A) or 400 micrograms/h of alfentanil with 50 mg/h of lidocaine (group T-AL) during surgery and 24 hours postoperatively. The patients also used a patient-controlled analgesia device to administer intravenous morphine postoperatively. During the study period the following variables were recorded: hemodynamic parameters, lung function, quality of analgesia and respiratory complications. ANOVA was performed and Scheffé and Chi-square tests were applied with 0.05 as the level of statistical significance. RESULTS: No differences were found between groups with respect to patient characteristics or type of surgery. Rescue analgesia requirements were higher in group L-A than in the other groups. PaO2 (6 and 18 hours) and spirometric parameters (12 and 18 hours) were significantly higher in group T-AL than in the other groups (p < or = 0.05). No other statistically significant differences were found. CONCLUSIONS: Respiratory parameters were better after thoracic epidural analgesia with alfentanil and lidocaine than after the other analgesic techniques studied. Group L-A patients had greater need for rescue analgesia than did patients in the other groups.     

Addition of 0.1% bupivacaine to buprenorphine and droperidol in patient-controlled epidural analgesia improved postoperative pain scores on coughing after gynecological surgery

STUDY OBJECTIVE: To compare the analgesic efficacy of additional 0.1% bupivacaine to patient-controlled epidural analgesia (PCEA) using buprenorphine and droperidol after gynecological surgery. DESIGN: Randomized, double-blinded study. SETTING: Operating theater and general ward at Jichi Medical School Hospital. PATIENTS: Thirty patients with American Society of Anesthesiologists physical status I and II scheduled for gynecological surgery. INTERVENTIONS: Patients received combined general and epidural anesthesia for surgery and epidural analgesia for postoperative analgesia. Patients were assigned to receive PCEA with or without 0.1% bupivacaine. Group 1 (n = 15) received buprenorphine 20 microg and droperidol 0.1 mg diluted with saline, and group 2 (n = 15) received bupivacaine 2 mg, buprenorphine 20 microg, and droperidol 0.1 mg diluted with saline (0.1% bupivacaine solution) in a bolus dose of the PCEA, respectively. No background epidural infusion was used. MEASUREMENTS: Visual analog pain scale (VAPS) scores at rest and on coughing, and cumulative frequency of self-administrated analgesic solution in PCEA were recorded at 24 and 48 hours postoperatively. MAIN RESULTS: There were no significant differences noted between the groups in VAPS scores at rest or in cumulative volumes of PCEA solution in 24 or 48 hours postoperatively. Median VAPS scores on coughing in group 2 were significantly lower than those values in group 1 at 24 hours (36 vs 65 mm, P < .001) and 48 hours (32 vs 54 mm, P = .036) postoperatively. CONCLUSIONS: Addition of 0.1% bupivacaine to PCEA using buprenorphine and droperidol provides better analgesia on coughing after gynecological surgery.     

Comparison of 4 techniques for general anesthesia for carotid endarterectomy: inflammatory response, cardiocirculatory complications, and postoperative analgesia

OBJETIVE: To study the analgesia, hemodynamic stability and inflammatory response in patients undergoing carotid endarterectomy under different types of general anesthesia. MATERIALS AND METHODS: A comparison of 80 patients randomized to 4 groups: group 1, maintenance with sevoflurane at a minimum alveolar concentration (MAC) of 1; group 2, sevoflurane at MAC 1.5; group 3, remifentanil; group 4, propofol. Variables studied were hemodynamic alterations during and after surgery, level of postoperative analgesia, differential white cell counts, levels of interleukin-6 (IL-6), and clinical signs and symptoms of systemic inflammatory response syndrome in the first 24 hours after surgery. RESULTS: The incidences of episodes of intraoperative hypertension were 60% in group 1, 65% in group 2, 50% in group 3, and 60% in group 4. The incidences of episodes of intraoperative hypotension were 85% in group 1, 80% in group 2, 80% in group 3, and 75% in group 4. Patients in groups 3 and 4 had higher incidences of systemic inflammatory response syndrome (p<0.05) in the first 24 hours after surgery and higher levels of IL-6 (p<0.05). Postoperative analgesia was similar in all 4 groups. CONCLUSIONS: Increased levels of IL-6 in peripheral blood and of systemic inflammatory response syndrome were found in the early postoperative period in groups that did not receive halogenated gases. Hemodynamic stability and analgesia were similar in all groups, however.     

Coronary artery bypass grafting using two different anesthetic techniques: Part I: Hemodynamic results.

Hemodynamic changes were studied during two different anesthetic techniques in 54 patients undergoing coronary artery bypass grafting (CABG). All patients had normal to moderately impaired left ventricular function and were randomly assigned to two groups. In 27 patients, high thoracic epidural analgesia (TEA) with bupivacaine 0.375% plus sufentanil 1:200,000 (ie, 5 micrograms/mL) was used in combination with general anesthesia with midazolam/N2O; in the other 27 patients, general anesthesia (GA) with midazolam and sufentanil was used. After induction of epidural analgesia, heart rate and mean arterial pressure (MAP) decreased. Changes in cardiac index, systemic vascular resistance, and pulmonary capillary wedge pressure were not observed, whereas the stroke volume index increased significantly. After induction of intravenous anesthesia MAP decreased (20%) in both groups. During the pre-bypass period, metaraminol was used in 7 of 27 patients in the GA group and in 5 of 27 patients in the TEA group to treat hypotension. Inotopic drugs were used in 5 patients in the GA group and in none in the TEA group to treat a low CO. Ten GA patients and 4 TEA patients developed hypertension after sternal spread and the GA patients required more nitroprusside. Four GA patients developed electrocardiographic evidence of prebypass ischemia and, therefore, more nitroglycerin was needed for treating myocardial ischemia. More sodium nitroprusside was needed in the GA group during cardiopulmonary bypass (CPB) and the post-bypass period to treat hypertension with a high SVR. In conclusion, hemodynamic stability was more pronounced in the TEA than the GA group before and after CPB.     

Effects of thoracic vs. lumbar epidural anaesthesia on systemic haemodynamics and coronary circulation in sevoflurane anaesthetized dogs

Background : Although many investigators reported changes in coronary circulation during thoracic epidural anaesthesia (TEA), no previous studies have attempted to compare it with lumbar epidural anaesthesia (LEA) concerning coronary circulation. Our aim was to compare effects of TEA on systemic haemodynamics and coronary circulation with those of LEA in anaesthetized dogs. Methods : In dogs receiving 1.5% sevoflurane, 2% lidocaine (0.1 ml kg^?1)was injected into the epidural space via an epidural catheter inserted at either the T7-T8 (TEA group, n=8) or L5-L6 (LEA group, n=8) interspace, and the same dose was repeated again 30 min later. Results : Heart rate and maximum left ventricular dP/dt decreased in the TEA group but were unchanged in the LEA group. Decreases in mean arterial pressure were found for both groups, and they were more substantial in the TEA than in the LEA group. Decreases in left ventricular minute work index were found for both groups, and they tended to be more substantial in the TEA than in the LEA group. Coronary perfusion pressure and blood flow decreased in both groups. Calculated coronary vascular resistance increased in the TEA group but was unchanged in the LEA group. Conclusion : The most significant difference between TEA and LEA concerning coronary circulation was characterized by an increase in coronary vascular resistance in the TEA group, which was not present in the LEA group. The increase in coronary vascular resistance caused by TEA may be explained by a coronary vasoconstriction caused by a lower myocardial oxygen demand.     

Ropivacaine 0.1% with fentanyl 2 microg mL(-1) by epidural infusion for labour analgesia

BACKGROUND AND OBJECTIVE: To evaluate the efficacy of 0.1% ropivacaine with fentanyl 2 microg mL(-1) via epidural for analgesia in labour. METHODS: In a randomized study, 80 nulliparous parturients in labour had epidural analgesia initiated with 0.2% ropivacaine and fentanyl and were then randomized to receive either 0.1% ropivacaine with fentanyl 2 microg mL(-1) at 10mL h(-1) (Group R1, n = 38) or 0.2% ropivacaine with fentanyl 2 microg mL(-1) at 8 ml h(-1) (Group R2, n = 39) as epidural infusions. Supplementary analgesia was provided on request with ropivacaine 0.2% 5 mL as an epidural bolus. RESULTS: There were no significant differences between the visual analogue pain scores either with respect to motor block or sensory block. The amount of local anaesthetic used was lower in the 0.1% ropivacaine group than in the 0.2% ropivacaine group (P = 0.001). Side-effects, patient satisfaction, labour outcome and neonatal outcomes were similar in both groups. CONCLUSIONS: An epidural infusion of 0.1% ropivacaine with fentanyl 2 microg mL(-1) at 10 mL h(-1) provided adequate analgesia in the first stage of labour. The level of analgesia was similar to that obtained using 0.2% ropivacaine with fentanyl 2 microg mL(-1) and with no differences with regard to motor or sensory block.     

The influence of high thoracic epidural analgesia on the cardiovascular system

The effect of high thoracic epidural analgesia (TEA) on the cardiovascular system was investigated in 10 patients (5 with cardiovascular disease and 5 without known cardiovascular disorder), who were scheduled for a thoracotomy. An epidural catheter was inserted at T1-T2 level. Plain bupivacaine (Marcaine) 0.5%, 4 to 6 ml was used and resulted in a mean analgesic level from C7 to T5. TEA did not significantly affect the following parameters: heart rate, mean arterial pressure, cardiac index, central venous pressure, pulmonary capillary wedge pressure, stroke volume index, systemic vascular resistance, pulmonary vascular resistance, right and left ventricular stroke work index. From this study it is concluded that high TEA with bupivacaine has only minor effects on the cardiovascular system.     

Thoracic epidural anesthesia does not improve the incidence of arrhythmias after transthoracic esophagectomy.

OBJECTIVE: The incidence of arrhythmias related to an esophagectomy is high, and its clinical significance has been well accepted. Thoracic epidural anesthesia (TEA) can modulate the sympathetic tone and neuroendocrine responses associated with major operation. This study was aimed to evaluate the effects of TEA on the incidence of arrhythmias in transthoracic esophagectomy patients. METHODS: The records of 185 patients who underwent the Ivor-Lewis operation between 2001 and 2004 by the same operator were reviewed. The patients were divided into three groups. Group 1 (n = 58) received post-operative intravenous patient-controlled analgesia without TEA. Group 2 (n = 55) received postoperative epidural patient-controlled analgesia using local anesthetics. The patients of group 3 (n = 72) were anesthetized intra-operatively by the combination technique of thoracic epidural bupivacaine and inhalation agents, and post-operative pain control was done in the same way with group 2. RESULTS: Arrhythmias occurred 29.3, 50 and 29.2% in groups 1, 2 and 3, respectively. There were no statistical differences in the incidences of arrhythmias among the three groups. CONCLUSIONS: This result shows that TEA was not beneficial to reduce the incidence of arrhythmias in the transthoracic esophagectomy patients.