Thoracic epidural analgesia improves pulmonary function in patients undergoing cardiac surgery

Practice Advisory for Postoperative Pain Management of Cardiac Surgical Patients: Executive Summary. A Report From the Society of Cardiovascular Anesthesiologists

Cardiac surgery is associated with significant postoperative pain that can affect patients' recovery and quality of life. Optimal analgesia after cardiac surgery can be challenging due to patients' coexisting morbidities and frequently observed adverse effects when opioids are used to treat postoperative pain. In this current era of enhanced recovery and fast track extubation, multimodal analgesia is increasingly being utilized for pain management after cardiac surgery. Regional analgesia is an integral part of multimodal analgesia and has garnered more attention since the development of fascial plane blocks. There is considerable variability among individuals, institutions, and practices in the analgesic approaches used to treat postoperative pain in cardiac surgical patients because of lack of consensus or guidelines. This practice advisory was developed with the overall goal of identifying opportunities for improving postoperative pain relief and pain-related outcomes after cardiac surgery and guiding perioperative providers through the provision of clinically relevant evidence-based recommendations.

Effect of ultrasound-guided transversus abdominis plane block in reducing atelectasis after laparoscopic surgery in children: A randomized clinical trial

Background

Atelectasis is a commonly observed postoperative complication of general anesthesia in children. Pulmonary protective ventilation strategies have been reported to have a beneficial effect on postoperative atelectasis in children. Therefore, the present study aimed to evaluate the efficacy of the ultrasound-guided transversus abdominis plane (TAP) block technique in preventing the incidence of postoperative atelectasis in children.

Materials and methods

This study enrolled 100 consecutive children undergoing elective laparoscopic bilateral hernia repair and randomly divided them into the control and TAP groups. Conventional lung-protective ventilation was initiated in both groups after the induction of general anesthesia. The children in the TAP group received an ultrasound-guided TAP block with 0.3 mL/kg of 0.5% ropivacaine after the induction of anesthesia.

Results

Anesthesia-induced atelectasis was observed in 24% and 84% of patients in the TAP (n = 50) and control (n = 50) groups, respectively, before discharge from the post-anesthetic care unit (T3; PACU) (odds ratio [OR], 0.062; 95% confidence interval [CI], 0.019-0.179; P < 0.001). No significant difference was observed between the control and TAP groups in terms of the lung ultrasonography (LUS) scores 5 min after endotracheal intubation (T1). However, the LUS scores were lower in the TAP group than those in the control group at the end of surgery (T2, P < 0.01) and before discharge from the PACU (T3, P < 0.001). Moreover, the ace, legs, activity, cry and consolability (FLACC) pain scores in the TAP group were lower than those in the control group at each postoperative time point.

Conclusion

Ultrasound-guided TAP block effectively reduced the incidence of postoperative atelectasis and alleviated pain in children undergoing laparoscopic surgery.

Pain management after cardiac surgery via median sternotomy: A systematic review with procedure-specific postoperative pain management (PROSPECT) recommendations

BACKGROUND

Pain after cardiac surgery via median sternotomy can be difficult to treat, and if inadequately managed can lead to respiratory complications, prolonged hospital stays and chronic pain.

OBJECTIVES

To evaluate available literature and develop recommendations for optimal pain management after cardiac surgery via median sternotomy.

DESIGN

A systematic review using PROcedure-SPECific Pain Management (PROSPECT) methodology.

ELIGIBILITY CRITERIA

Randomised controlled trials and systematic reviews published in the English language until November 2020 assessing postoperative pain after cardiac surgery via median sternotomy using analgesic, anaesthetic or surgical interventions.

DATA SOURCES

PubMed, Embase and Cochrane Databases.

RESULTS

Of 319 eligible studies, 209 randomised controlled trials and three systematic reviews were included in the final analysis. Pre-operative, intra-operative and postoperative interventions that reduced postoperative pain included paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs), intravenous magnesium, intravenous dexmedetomidine and parasternal block/infiltration.

CONCLUSIONS

The analgesic regimen for cardiac surgery via sternotomy should include paracetamol and NSAIDs, unless contraindicated, administered intra-operatively and continued postoperatively. Intra-operative magnesium and dexmedetomidine infusions may be considered as adjuncts particularly when basic analgesics are not administered. It is not clear if combining dexmedetomidine and magnesium would provide superior pain relief compared with either drug alone. Parasternal block/surgical site infiltration is also recommended. However, no basic analgesics were used in the studies assessing these interventions. Opioids should be reserved for rescue analgesia. Other interventions, including cyclo-oxygenase-2 specific inhibitors, are not recommended because there was insufficient, inconsistent or no evidence to support their use and/or due to safety concerns.

Thoracic Epidural Anesthesia in Cardiac Surgery: A Systematic Review, Meta-Analysis, and Trial Sequential Analysis of Randomized Controlled Trials

BACKGROUND

Research on fast-track recovery protocols postulates that thoracic epidural anesthesia (TEA) in cardiac surgery contributes to improved postoperative outcomes. However, concerns about TEA's safety hinder its widespread usage. We conducted a systematic review and meta-analysis to assess the benefits and risks of TEA in cardiac surgery.

METHODS

We searched 4 databases for randomized controlled trials (RCTs) assessing the use of TEA against only general anesthesia (GA) in adults undergoing cardiac surgery, up till June 4, 2022. We conducted random-effects meta-analyses, evaluated risk of bias using the Cochrane Risk-of-Bias 2 tool, and rated certainty of evidence via the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach. Primary outcomes were intensive care unit (ICU), hospital length of stay, extubation time (ET), and mortality. Other outcomes included postoperative complications. Trial sequential analysis (TSA) was conducted on all outcomes to elicit statistical and clinical benefit.

RESULTS

Our meta-analysis included 51 RCTs (2112 TEA patients and 2220 GA patients). TEA significantly reduced ICU length of stay (-6.9 hours; 95% confidence interval [CI], -12.5 to -1.2; P = .018), hospital length of stay (-0.8 days; 95% CI, -1.1 to -0.4; P < .0001), and ET (-2.9 hours; 95% CI, -3.7 to -2.0; P < .0001). However, we found no significant change in mortality. TSA found that the cumulative Z-curve passed the TSA-adjusted boundary for ICU length of stay, hospital length of stay, and ET, suggesting a clinical benefit. TEA also significantly reduced pain scores, pooled pulmonary complications, transfusion requirements, delirium, and arrhythmia, without additional complications such as epidural hematomas, of which the risk was estimated to be <0.14%.

CONCLUSIONS

TEA reduces ICU and hospital length of stay, and postoperative complications in patients undergoing cardiac surgery with minimal reported complications such as epidural hematomas. These findings favor the use of TEA in cardiac surgery and warrant consideration for use in cardiac surgeries worldwide.

Practice Advisory for Preoperative and Intraoperative Pain Management of Cardiac Surgical Patients: Part 2

Pain after cardiac surgery is of moderate to severe intensity, which increases postoperative distress and health care costs, and affects functional recovery. Opioids have been central agents in treating pain after cardiac surgery for decades. The use of multimodal analgesic strategies can promote effective postoperative pain control and help mitigate opioid exposure. This Practice Advisory is part of a series developed by the Society of Cardiovascular Anesthesiologists (SCA) Quality, Safety, and Leadership (QSL) Committee's Opioid Working Group. It is a systematic review of existing literature for various interventions related to the preoperative and intraoperative pain management of cardiac surgical patients. This Practice Advisory provides recommendations for providers caring for patients undergoing cardiac surgery. This entails developing customized pain management strategies for patients, including preoperative patient evaluation, pain management, and opioid use-focused education as well as perioperative use of multimodal analgesics and regional techniques for various cardiac surgical procedures. The literature related to this field is emerging, and future studies will provide additional guidance on ways to improve clinically meaningful patient outcomes.

Comparison of regional anesthetic techniques for postoperative analgesia after adult cardiac surgery: bayesian network meta-analysis

Background

Patients usually suffer acute pain after cardiac surgery. Numerous regional anesthetic techniques have been used for those patients under general anesthesia. The most effective regional anesthetic technique was still unclear.

Methods

Five databases were searched, including PubMed, MEDLINE, Embase, ClinicalTrials.gov, and Cochrane Library. The efficiency outcomes were pain scores, cumulative morphine consumption, and the need for rescue analgesia in this Bayesian analysis. Postoperative nausea, vomiting and pruritus were safety outcomes. Functional outcomes included the time to tracheal extubation, ICU stay, hospital stay, and mortality.

Results

This meta-analysis included 65 randomized controlled trials involving 5,013 patients. Eight regional anesthetic techniques were involved, including thoracic epidural analgesia (TEA), erector spinae plane block, and transversus thoracic muscle plane block. Compared to controls (who have not received regional anesthetic techniques), TEA reduced the pain scores at 6, 12, 24 and 48 h both at rest and cough, decreased the rate of need for rescue analgesia (OR = 0.10, 95% CI: 0.016-0.55), shortened the time to tracheal extubation (MD = -181.55, 95% CI: -243.05 to -121.33) and the duration of hospital stay (MD = -0.73, 95% CI: -1.22 to -0.24). Erector spinae plane block reduced the pain score 6 h at rest and the risk of pruritus, shortened the duration of ICU stay compared to controls. Transversus thoracic muscle plane block reduced the pain scores 6 and 12 h at rest compared to controls. The cumulative morphine consumption of each technique was similar at 24, 48 h. Other outcomes were also similar among these regional anesthetic techniques.

Conclusions

TEA seems the most effective regional postoperative anesthesia for patients after cardiac surgery by reducing the pain scores and decreasing the rate of need for rescue analgesia.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/, ID: CRD42021276645.

New insight into the analgesic recipe: A cohort study based on smart patient-controlled analgesia pumps records

Purpose: Intravenous patient-controlled analgesia (IV-PCA) has been widely used; however, regimen criteria have not yet been established. In China, the most often used opioid is sufentanil, for which repeated doses are a concern, and empirical flurbiprofen axetil (FBP) as an adjuvant. We hypothesized that hydromorphone would be a better choice and also evaluated the effectiveness of FBP as an adjuvant.

Methods: This historical cohort study was conducted in two tertiary hospitals in China and included 12,674 patients using hydromorphone or sufentanil for IV-PCA between April 1, 2017, and January 30, 2021. The primary outcome was analgesic insufficiency at static (AIS). The secondary outcomes included analgesic insufficiency with movement (AIM) and common opioid-related adverse effects such as postoperative nausea and vomiting (PONV) and dizziness.

Results: Sufentanil, but not the sufentanil-FBP combination, was associated with higher risks of AIS and AIM compared to those for hydromorphone (OR 1.64 [1.23, 2.19], p < 0.001 and OR 1.42 [1.16, 1.73], p < 0.001). Hydromorphone combined with FBP also decreased the risk of both AIS and AIM compared to those for pure hydromorphone (OR 0.74 [0.61, 0.90], p = 0.003 and OR 0.80 [0.71, 0.91], p < 0.001). However, the risk of PONV was higher in patients aged ≤35 years using FBP (hydromorphone-FBP vs. hydromorphone and sufentanil-FBP vs. hydromorphone, OR 1.69 [1.22, 2.33], p = 0.001 and 1.79 [1.12, 2.86], p = 0.015).

Conclusion: Hydromorphone was superior to sufentanil for IV-PCA in postoperative analgesia. Adding FBP may improve the analgesic effects of both hydromorphone and sufentanil but was associated with an increased risk of PONV in patients <35 years of age.

Fast-tracking with continuous thoracic epidural analgesia in paediatric congenital heart surgeries: an institutional experience

Objective

To assess the success of fast-tracking in infants and small children undergoing paediatric cardiac surgery under general anaesthesia with continuous thoracic epidural analgesia (TEA).

Methodology

It is a retrospective study at a tertiary care hospital. A total of 461 children, aged 12 years or younger, were operated for congenital heart disease over a 2-year period from January 2018 to December 2019. After the exclusion of 71 patients, data from the remaining 390 patients were analysed.

Measurements and main results

The median time for extubation after intensive care unit admission was 2 h and 25 min (0-20 h). Extubation within 6 h was achieved in 215 patients (~ 55%). Patients in the early extubation group had significantly shorter hospital stay (4.1 ± 2.3 vs 6.9 ± 3.9 days, p = 0.004) than patients in the ventilated group. Reintubation was required in 27 (6.9%) patients. Thirteen patients died postoperatively on ventilator. Patients with low nadir temperature intraoperatively and cardiopulmonary bypass time > 90 min significantly predicted failure in fast-tracking with an odds ratio (OR) = 1.27; CI: 1.18-1.38 and OR = 2.3; CI: 1.8-2.96 respectively. The Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery Congenital Heart Surgery mortality score, younger age, Down syndrome and high vasopressor inotropic score did not adversely affect early extubation, contrary to contemporary concerns.

Conclusions

A multimodal approach for perioperative pain relief and sedation consisting of propofol and dexmedetomidine infusion along with TEA ensures early extubation in 59% of the cases undergoing paediatric cardiac surgery. Our data suggests that fast-tracking is feasible with safe and superior outcomes in a subset of appropriate patients undergoing paediatric cardiac surgery.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12055-022-01373-8.

Perioperative Pulmonary Atelectasis: Part II. Clinical Implications

The development of pulmonary atelectasis is common in the surgical patient. Pulmonary atelectasis can cause various degrees of gas exchange and respiratory mechanics impairment during and after surgery. In its most serious presentations, lung collapse could contribute to postoperative respiratory insufficiency, pneumonia, and worse overall clinical outcomes. A specific risk assessment is critical to allow clinicians to optimally choose the anesthetic technique, prepare appropriate monitoring, adapt the perioperative plan, and ensure the patient's safety. Bedside diagnosis and management have benefited from recent imaging advancements such as lung ultrasound and electrical impedance tomography, and monitoring such as esophageal manometry. Therapeutic management includes a broad range of interventions aimed at promoting lung recruitment. During general anesthesia, these strategies have consistently demonstrated their effectiveness in improving intraoperative oxygenation and respiratory compliance. Yet these same intraoperative strategies may fail to affect additional postoperative pulmonary outcomes. Specific attention to the postoperative period may be key for such outcome impact of lung expansion. Interventions such as noninvasive positive pressure ventilatory support may be beneficial in specific patients at high risk for pulmonary atelectasis (e.g., obese) or those with clinical presentations consistent with lung collapse (e.g., postoperative hypoxemia after abdominal and cardiothoracic surgeries). Preoperative interventions may open new opportunities to minimize perioperative lung collapse and prevent pulmonary complications. Knowledge of pathophysiologic mechanisms of atelectasis and their consequences in the healthy and diseased lung should provide the basis for current practice and help to stratify and match the intensity of selected interventions to clinical conditions.

Effect of Deep versus Moderate Neuromuscular Blockade on Quantitatively Assessed Postoperative Atelectasis Using Computed Tomography in Thoracic Surgery; a Randomized Double-Blind Controlled Trial

Background: postoperative atelectasis is a significant clinical problem during thoracic surgery with one-lung ventilation. Intraoperative deep neuromuscular blockade can improve surgical conditions, but an increased risk of residual paralysis may aggravate postoperative atelectasis. Every patient was verified to have full reversal before extubation. We compared the effect of deep versus moderate neuromuscular blockade on postoperative atelectasis quantitatively using chest computed tomography. Methods: patients undergoing thoracic surgery were randomly allocated to two groups: moderate neuromuscular blockade during surgery (group M) and deep neuromuscular blockade during surgery (group D). The primary outcome was the proportion and the volume of postoperative atelectasis measured by chest computed tomography on postoperative day 2. The mean values of the repeatedly measured intraoperative dynamic lung compliance during surgery were also compared. Result: the proportion of postoperative atelectasis did not differ between the groups (1.32 [0.47–3.20]% in group M and 1.41 [0.24–3.07]% in group D, p = 0.690). The actual atelectasis volume was 38.2 (12.8–61.4) mL in group M and 31.9 (7.84–75.0) mL in group D (p = 0.954). Some factors described in the lung protective ventilation were not taken into account and might explain the atelectasis in both groups. The mean lung compliance during one-lung ventilation was higher in group D (26.6% in group D vs. 24.1% in group M, p = 0.026). Conclusions: intraoperative deep neuromuscular blockade did not affect postoperative atelectasis when compared with moderate neuromuscular blockade if full reversal was verified.

Current Status of Neuraxial and Paravertebral Blocks for Adult Cardiac Surgery

Cardiac surgeries are known to produce moderate to severe pain. Pain management has traditionally been based on intravenous opioids. Poorly controlled pain can result in increased incidence of respiratory complications such as atelectasis and pneumonia leading to prolonged intubation and intensive care unit length of stay and subsequent prolonged hospital stay. Adequate perioperative analgesia improves hemodynamics and immunologic responses, which would result in better outcomes after cardiac surgery. Opioid sparing "Enhanced Recovery After Surgery" protocols are increasingly being incorporated into cardiac surgeries. This will reduce opioid requirements and opioid-related side effects and facilitate fast-tracking of patients. Regional analgesia can be provided by neuraxial blocks, fascial plane blocks, peripheral nerve blocks, or simply by the infiltration of the wound with local anesthetics for cardiac surgery. Neuraxial analgesia is provided through epidural, spinal, and paravertebral routes. Though they are being replaced by peripheral fascial plane blocks, epidural and spinal analgesia are still being used in some centers. In this article, neuraxial forms of analgesia are focused. We sought to review epidural analgesia and its impact in suppressing hemodynamic stress response, reducing pulmonary complications, and development of chronic pain. The relationship between intraoperative heparinization and potential neuraxial hematoma is discussed. Other neuraxial options such as spinal and paravertebral analgesia and their usefulness, benefits, and limitations are also reviewed.

Risk of Postoperative Hyperalgesia in Adult Patients with Preoperative Poor Sleep Quality Undergoing Open-heart Valve Surgery

Purpose

Studies have reported that preoperative poor sleep quality could decrease the pain threshold in patients undergoing noncardiac surgery. However, the risk of postoperative hyperalgesia (HA) in cardiac surgery patients with preoperative poor sleep quality remains unclear.

Patients and Methods

We retrospectively collected clinical data from patients undergoing open-heart valve surgery between May 1 and October 31, 2019, in Fuwai Hospital (Beijing). We assessed preoperative sleep quality and postoperative pain severity using the Pittsburgh sleep quality index (PSQI) and numerical pain rating scale (NPRS), respectively. A PSQI of six or greater was considered to indicate poor sleep quality, and a NPRS of four or greater was considered to indicate HA. Multivariable logistic regression analysis was used to study the risk of postoperative HA in patients with preoperative poor sleep quality.

Results

We divided 214 eligible patients into two groups based on postoperative HA; HA group: n=61 (28.5%) and nonHA group: n=153 (71.5%). Compared with nonHA patients, patients with postoperative HA showed a higher percentage of history of smoking, 17 (11.1%) vs 15 (24.6%) and alcohol abuse, 5 (3.3%) vs 6 (9.8%), higher intraoperative dose of sufentanil (median, 1.02 vs 1.12 μg/kg/h), and longer duration of ventilation with tracheal catheter (median, 760 vs 934 min). Preoperative poor sleep quality was associated independently with an increased risk of postoperative HA (adjusted odds ratio [AOR]: 2.66; 95%CI: 1.31–5.39, P=0.007). Stratification by history of smoking revealed a stronger risk of postoperative HA in nonsmoking patients with preoperative poor sleep quality (AOR: 3.40; 95%CI: 1.51–7.66, P=0.003). No risk was found in patients who had history of smoking (AOR: 0.83; 95%CI: 0.14–4.75, P=0.832).

Conclusion

Preoperative poor sleep quality is an independent risk factor for postoperative HA in adult patients undergoing open-heart valve surgery who had no history of smoking.

Comparison of Thoracic Epidural Analgesia and Traditional Intravenous Analgesia With Respect to Postoperative Respiratory Effects in Cardiac Surgery

OBJECTIVES

Surgical stress and pain affect the respiratory condition of patients and can cause complications that affect morbidity and mortality in cardiac surgeries. The authors studied the effect of thoracic epidural analgesia (TEA) versus traditional intravenous analgesia on postoperative respiratory mechanics in cardiac surgery.

DESIGN

Retrospective, observational study.

SETTING

Single, university hospital.

PARTICIPANTS

Patients undergoing cardiac surgery.

INTERVENTIONS

Comparing the postoperative respiratory effects of TEA with bupivacaine or intravenous analgesia with tramadol or paracetamol or dexmedetomidine.

MEASUREMENTS AND MAIN RESULTS

A total of 1,369 patients were screened, and 1,280 patients were enrolled in the study. Postoperative sedation and analgesia level, extubation times, respiratory complications, lengths of intensive care and hospital stay, morbidity, and mortality were compared. Additional sedative and analgesic drug requirement in the TEA group (25.3% and 60.1% respectively) were significantly lower than the intravenous group (41.4% and 71.8%, respectively; p < 0.001 and p < 0.05, respectively). Extubation time in the TEA group also was significantly lower than the intravenous group (p < 0.01). Respiratory complication and hospital stay in the TEA group were lower than intravenous group (p < 0.05).

CONCLUSIONS

TEA provided better postoperative respiratory condition via better sedative analgesia in cardiac surgery.

Fast tracking after repair of congenital heart defects

Fast tracking after repair of congenital heart defects (CHD) is a process involving the reduction of perioperative period by timely admission, early extubation after surgery, short intensive care unit (ICU) stay, early mobilisation, and faster hospital discharge. It requires a coordinated multidisciplinary team involvement. In the last 2 decades, many centres have adopted the fast tracking strategy in paediatric cardiac population, safely and successfully extubating patients in the OR with reported benefits in terms of reduced morbidity and ICU/hospital stay. In this manuscript, we will review the literature available on early extubation after repair of CHD and share our experience with this approach.

Implementation of On-table Extubation After Pediatric Cardiac Surgery in the Developing World

In the recent years there has been increasing trend towards the practice of on-table extubation after pediatric cardiac surgery among practitioner in European and non-European countries. In this article we share our experience with on-table extubation among children after cardiac surgery in the developing world supported with the currently available literature.

Epidural analgesia for adults undergoing cardiac surgery with or without cardiopulmonary bypass

BACKGROUND

General anaesthesia combined with epidural analgesia may have a beneficial effect on clinical outcomes. However, use of epidural analgesia for cardiac surgery is controversial due to a theoretical increased risk of epidural haematoma associated with systemic heparinization. This review was published in 2013, and it was updated in 2019.

OBJECTIVES

To determine the impact of perioperative epidural analgesia in adults undergoing cardiac surgery, with or without cardiopulmonary bypass, on perioperative mortality and cardiac, pulmonary, or neurological morbidity.

SEARCH METHODS

We searched CENTRAL, MEDLINE, and Embase in November 2018, and two trial registers up to February 2019, together with references and relevant conference abstracts.

SELECTION CRITERIA

We included all randomized controlled trials (RCTs) including adults undergoing any type of cardiac surgery under general anaesthesia and comparing epidural analgesia versus another modality of postoperative pain treatment. The primary outcome was mortality.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures as expected by Cochrane.

MAIN RESULTS

We included 69 trials with 4860 participants: 2404 given epidural analgesia and 2456 receiving comparators (systemic analgesia, peripheral nerve block, intrapleural analgesia, or wound infiltration). The mean (or median) age of participants varied between 43.5 years and 74.6 years. Surgeries performed were coronary artery bypass grafting or valvular procedures and surgeries for congenital heart disease. We judged that no trials were at low risk of bias for all domains, and that all trials were at unclear/high risk of bias for blinding of participants and personnel taking care of study participants.Epidural analgesia versus systemic analgesiaTrials show there may be no difference in mortality at 0 to 30 days (risk difference (RD) 0.00, 95% confidence interval (CI) -0.01 to 0.01; 38 trials with 3418 participants; low-quality evidence), and there may be a reduction in myocardial infarction at 0 to 30 days (RD -0.01, 95% CI -0.02 to 0.00; 26 trials with 2713 participants; low-quality evidence). Epidural analgesia may reduce the risk of 0 to 30 days respiratory depression (RD -0.03, 95% CI -0.05 to -0.01; 21 trials with 1736 participants; low-quality evidence). There is probably little or no difference in risk of pneumonia at 0 to 30 days (RD -0.03, 95% CI -0.07 to 0.01; 10 trials with 1107 participants; moderate-quality evidence), and epidural analgesia probably reduces the risk of atrial fibrillation or atrial flutter at 0 to 2 weeks (RD -0.06, 95% CI -0.10 to -0.01; 18 trials with 2431 participants; moderate-quality evidence). There may be no difference in cerebrovascular accidents at 0 to 30 days (RD -0.00, 95% CI -0.01 to 0.01; 18 trials with 2232 participants; very low-quality evidence), and none of the included trials reported any epidural haematoma events at 0 to 30 days (53 trials with 3982 participants; low-quality evidence). Epidural analgesia probably reduces the duration of tracheal intubation by the equivalent of 2.4 hours (standardized mean difference (SMD) -0.78, 95% CI -1.01 to -0.55; 40 trials with 3353 participants; moderate-quality evidence). Epidural analgesia reduces pain at rest and on movement up to 72 hours after surgery. At six to eight hours, researchers noted a reduction in pain, equivalent to a reduction of 1 point on a 0 to 10 pain scale (SMD -1.35, 95% CI -1.98 to -0.72; 10 trials with 502 participants; moderate-quality evidence). Epidural analgesia may increase risk of hypotension (RD 0.21, 95% CI 0.09 to 0.33; 17 trials with 870 participants; low-quality evidence) but may make little or no difference in the need for infusion of inotropics or vasopressors (RD 0.00, 95% CI -0.06 to 0.07; 23 trials with 1821 participants; low-quality evidence).Epidural analgesia versus other comparatorsFewer studies compared epidural analgesia versus peripheral nerve blocks (four studies), intrapleural analgesia (one study), and wound infiltration (one study). Investigators provided no data for pulmonary complications, atrial fibrillation or flutter, or for any of the comparisons. When reported, other outcomes for these comparisons (mortality, myocardial infarction, neurological complications, duration of tracheal intubation, pain, and haemodynamic support) were uncertain due to the small numbers of trials and participants.

AUTHORS' CONCLUSIONS

Compared with systemic analgesia, epidural analgesia may reduce the risk of myocardial infarction, respiratory depression, and atrial fibrillation/atrial flutter, as well as the duration of tracheal intubation and pain, in adults undergoing cardiac surgery. There may be little or no difference in mortality, pneumonia, and epidural haematoma, and effects on cerebrovascular accident are uncertain. Evidence is insufficient to show the effects of epidural analgesia compared with peripheral nerve blocks, intrapleural analgesia, or wound infiltration.

Advantages of Epidural Analgesia on Pulmonary Functions in Liver Transplant Donors

OBJECTIVE

Epidural analgesia (EA) has positive effects on anesthetic requirement, blood loss, postoperative analgesia, and pulmonary function tests (PFTs). The purpose of the present study was to investigate the effect of EA on postoperative PFTs in liver transplant donors (LTDs).

METHODS

In the present study, 66 LTDs were classified as total intravenous anesthesia (TIVA) and TIVA+EA groups. Patient's age, sex, body mass index, induction and maintenance dose of propofol (IDP and MDP), operation duration, forced expiratory volume in 1 second (FEV₁), forced vital capacity (FVC), FEV₁/FVC ratio, visual analog scale (VAS), atelectasis scores, and lengths of intensive care unit (ICU) and hospital stays were recorded.

RESULTS

In the TIVA+EA group, IPD, MPD, delta-FEV₁ delta-FVC, VAS for all time, atelectasis score and length of hospital stay were significantly lower than in the TIVA group (P < .001 for all). Whereas VAS at the end of the operation was negatively correlated with delta-FEV₁ and delta-FVC (r² = 0.26 P < .001; r² = 0.41 P < .001; respectively), it was positively correlated with atelectasis score and length of ICU stay (r² = 0.49, P < .001; and r² = 0.41, P < .001; respectively). Atelectasis score was positively correlated with length of ICU stay (r² = 0.86, P < .001).

CONCLUSIONS

Reduced anesthetic requirement, better postoperative analgesia, reduced atelectasis score, and preserved PFTs can be provided with the use of EA in LTDs. Positive effects of EA on anesthesia requirement, pain management and pulmonary function are associated with outcomes.

Effectiveness of combined regional-general anesthesia for reducing mortality in coronary artery bypass: meta-analysis

BACKGROUND AND OBJECTIVES

Neuraxial anesthesia (NA) has been used in association with general anesthesia (GA) for coronary artery bypass; however, anticoagulation during surgery makes us question the viability of benefits by the risk of epidural hematoma. The aim of this study was to perform a meta-analyzes examining the efficacy of NA associated with GA compared to GA alone for coronary artery bypass on mortality reduction.

METHODS

Mortality, arrhythmias, cerebrovascular accident (CVA), myocardial infarction (MI), length of hospital stay (LHS), length of ICU stay (ICUS), reoperations, blood transfusion (BT), quality of life, satisfaction degree, and postoperative cognitive dysfunction were analyzed. The weighted mean difference (MD) was estimated for continuous variables, and relative risk (RR) and risk difference (RD) for categorical variables.

RESULTS

17 original articles analyzed. Meta-analysis of mortality (RD=-0.01, 95% CI=-0.03 to 0.01), CVA (RR=0.79, 95% CI=0.32-1.95), MI (RR=0.96, 95% CI=0.52-1.79) and LHS (MD=-1.94, 95% CI=-3.99 to 0.12) were not statistically significant. Arrhythmia was less frequent with NA (RR=0.68, 95% CI=0.50-0.93). ICUS was lower in NA (MD=-2.09, 95% CI=-2.92 to -1.26).

CONCLUSION

There was no significant difference in mortality. Combined NA and GA showed lower incidence of arrhythmias and lower ICUS.

Spirometric values and chest pain intensity three days post-operative coronary artery bypass graft surgery

Aim

Coronary artery bypass graft surgery (CABG) is proved to have ventilatory complications and reduction in spirometric values. This study aimed to examine the hypothesis that reduction of post-operative chest pain intensity would be associated with improvement in the spirometric values for patient underwent CABG.

Materials and method

26 cardiac patients recruited for this study. Their convenience to the study inclusion criteria decided their eligibility. Through 3 days after elective CABG their spirometric values were measured along with their perception to chest pain intensity using 0–10 numeric rating scale. Collected data were recorded and analyzed statistically.

Results

Chest pain intensity showed progressive significant (P = 0.0001) reduction through the 3 days post-operative. On the other hand spirometric values also showed progressive improvement through the 3 days post-operative. This improvement was significant for all measured spirometric values except for the ratio of forced expiratory volume in the 1st second to the forced vital capacity (P = 0.134). There was no significant relationship between the chest pain intensity and spirometric values. This was applied to all measured spirometric values and to the 3 days postoperative.

Conclusion

The current study findings rejected the examined hypothesis that reduction of post-operative chest pain intensity would be associated with improvement in the spirometric values for patient underwent coronary artery bypass graft surgery. There was no significant relationship between the chest pain intensity and any of the spirometric values at any of the 3 post-operative days.

Effect of electro-acupuncture stimulation of Ximen (PC4) and Neiguan (PC6) on remifentanil-induced breakthrough pain following thoracal esophagectomy

The clinical analgesic effect of electro-acupuncture (EA) stimulation (EAS) on breakthrough pain induced by remifentanil in patients undergoing radical thoracic esophagectomy, and the mechanisms were assessed. Sixty patients (ASAIII) scheduled for elective radical esophagectomy were randomized into three groups: group A (control) receiving a general anesthesia only; group B (sham) given EA needles at PC4 (Ximen) and PC6 (Neiguan) but no stimulation; and group C (EAS) electrically given EAS of the ipsilateral PC4 and PC6 throughout the surgery. The EAS consisting of a disperse-dense wave with a low frequency of 2 Hz and a high frequency of 20 Hz, was performed 30 min prior to induction of general anesthesia and continued through the surgery. At the emergence, sufentanil infusion was given for postoperative analgesia with loading dose of 7.5 μg, followed by a continuous infusion of 2.25 μg/h. The patient self-administration of sufentanil was 0.75 μg with a lockout of 15 min as needed. Additional breakthrough pain was treated with dezocine (5 mg) intravenously at the patient's request. Blood samples were collected before (T1), 2 h (T2), 24 h (T3), and 48 h (T4) after operation to measure the plasma β-EP, PGE2, and 5-HT. The operative time, the total dose of sufentanil and the dose of self-administration, and the rescue doses of dezocine were recorded. Visual Analogue Scale (VAS) scores at 2, 12, 24 and 48 h postoperatively and the incidence of apnea and severe hypotension were recorded. The results showed that the gender, age, weight, operative time and remifentanil consumption were comparable among 3 groups. Patients in EAS group had the lowest VAS scores postoperatively among the three groups (P<0.05). The total dose of sufentanil was 115±6.0 μg in EAS group, significantly lower than that in control (134.3±5.9 μg) and sham (133.5±7.0 μg) groups. Similarly, the rescue dose of dezocine was the least in EAS group (P<0.05) among the three groups. Plasma β-EP levels in EAS group at T3 (176.90±45.73) and T4 (162.96±35.00 pg/mL) were significantly higher than those in control (132.33±36.75 and 128.79±41.24 pg/mL) and sham (136.56±45.80 and 129.85±36.14 pg/mL) groups, P<0.05 for all. EAS could decrease the release of PGE2. Plasma PGE2 levels in EAS group at T2 and T3 (41±5 and 40±5 pg/mL respectively) were significantly lower than those in control (64±5 and 62±7 pg/mL) and sham (66±6 and 62±6 pg/mL) groups. Plasma 5-HT levels in EAS group at T2 (133.66±40.85) and T3 (154.66±52.49 ng/mL) were significantly lower than those in control (168.33±56.94 and 225.28±82.03) and sham (164.54±47.53 and 217.74±76.45 ng/mL) groups. For intra-group comparison, plasma 5-HT and PGE2 levels in control and sham groups at T2 and T3, and β-EP in EAS group at T3 and T4 were significantly higher than those at T1 (P<0.05); PGE2 and 5-HT levels in EAS group showed no significant difference among the different time points (P>0.05). No apnea or severe hypotension was observed in any group. It was concluded that intraoperative ipsilateral EAS at PC4 and PC6 provides effective postoperative analgesia for patients undergoing radical esophagectomy with remifentanil anesthesia and significantly decrease requirement for parental narcotics. The underlying mechanism may be related to stimulation of the release of endogenous β-EP and inhibition of inflammatory mediators (5-HT and PGE2).

Impact of epidural analgesia on mortality and morbidity after surgery: systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

To quantify benefit and harm of epidural analgesia, compared with systemic opioid analgesia, in adults having surgery under general anesthesia.

BACKGROUND

It remains controversial whether adding epidural analgesia to general anesthesia decreases postoperative morbidity and mortality.

METHODS

We searched CENTRAL, EMBASE, PubMed, CINAHL, and BIOSIS till July 2012. We included randomized controlled trials comparing epidural analgesia (with local anesthetics, lasting for ≥ 24 hours postoperatively) with systemic analgesia in adults having surgery under general anesthesia, and reporting on mortality or any morbidity endpoint.

RESULTS

A total of 125 trials (9044 patients, 4525 received epidural analgesia) were eligible. In 10 trials (2201 patients; 87 deaths), reporting on mortality as a primary or secondary endpoint, the risk of death was decreased with epidural analgesia (3.1% vs 4.9%; odds ratio, 0.60; 95% confidence interval, 0.39-0.93). Epidural analgesia significantly decreased the risk of atrial fibrillation, supraventricular tachycardia, deep vein thrombosis, respiratory depression, atelectasis, pneumonia, ileus, and postoperative nausea and vomiting, and also improved recovery of bowel function, but significantly increased the risk of arterial hypotension, pruritus, urinary retention, and motor blockade. Technical failures occurred in 6.1% of patients.

CONCLUSIONS

In adults having surgery under general anesthesia, concomitant epidural analgesia reduces postoperative mortality and improves a multitude of cardiovascular, respiratory, and gastrointestinal morbidity endpoints compared with patients receiving systemic analgesia. Because adverse effects and technical failures cannot be ruled out, individual risk-benefit analyses and professional care are recommended.

Thoracic epidural anesthesia improves early outcome in patients undergoing cardiac surgery for mitral regurgitation: a propensity-matched study

OBJECTIVE

There are no large studies that investigate the effect of thoracic epidural anesthesia (TEA) combined with general anesthesia (GA) in patients undergoing valvular surgery. The authors hypothesized that TEA might improve clinically relevant endpoints in patients with primary mitral regurgitation.

DESIGN

Propensity-matched study.

SETTING

Cardiac surgery.

PARTICIPANTS

Patients scheduled for mitral valve repair or replacement were studied.

INTERVENTIONS

A propensity model was constructed to match 33 patients receiving TEA combined with GA with 33 patients receiving standard GA alone.

MEASUREMENTS AND MAIN RESULTS

Overall, the TEA group suffered fewer adverse events than the GA group: 10 (30%) v 23 (10%) with p = 0.002. In particular, the TEA group had a lower incidence of pulmonary events, 6 (18%) v 15 (45%) with p = 0.02, and of cardiac events, 8 (24%) v 16 (49%) with p = 0.04. Median (interquartile) time on mechanical ventilation was reduced in the TEA group, 11 (9-15) v 17 (12-36) with p = 0.007.

CONCLUSIONS

This propensity-matched study suggested that TEA might be advantageous in patients undergoing surgery for mitral regurgitation.

Meta-analysis of randomized controlled trials on the efficacy of thoracic epidural anesthesia in preventing atrial fibrillation after coronary artery bypass grafting

Background

Postoperative atrial fibrillation (POAF) is one of the most common complications in patients undergoing coronary artery bypass grafting (CABG). The goal of this meta-analysis was to evaluate the efficacy of thoracic epidural anesthesia (TEA) in preventing POAF in adult patients undergoing CABG.

Methods

MEDLINE and EMBASE were searched to identify randomized controlled trails in adult patients undergoing CABG who were randomly assigned to receive general anesthesia plus thoracic epidural anesthesia (GA + TEA) or general anesthesia only (GA). Two authors independently extracted data using a standardized Excel file. The primary outcome measure was the incidence of POAF. We used DerSimonian-Laird random-effects models to compute summary risk ratios with 95% confidence intervals.

Results

Five studies involving 540 patients met our inclusion criteria. No significant difference in the incidence of POAF was observed between the two groups (risk ratio, 0.61; 95% confidence interval, 0.33 to 1.12; P = 0.11), with significant heterogeneity among the studies (I² = 73%, P = 0.005). Sensitivity analyses by primary endpoint, methodological quality and surgical technique yielded similar results.

Conclusions

The limited evidence suggests that TEA shows no beneficial efficacy in preventing POAF in adult patients undergoing CABG. However, the results of this meta-analysis should be interpreted with caution due to significant heterogeneity of the studies included. Thus, the potential infuence of TEA on the incidence of atrial fibrillation following CABG warrants further investigation.

Epidural anesthesia and postoperative analgesia with ropivacaine and fentanyl in off-pump coronary artery bypass grafting: a randomized, controlled study

Background

Our aim was to assess the efficacy of thoracic epidural anesthesia (EA) followed by postoperative epidural infusion (EI) and patient-controlled epidural analgesia (PCEA) with ropivacaine/fentanyl in off-pump coronary artery bypass grafting (OPCAB).

Methods

In a prospective study, 93 patients were scheduled for OPCAB under propofol/fentanyl anesthesia and randomized to three postoperative analgesia regimens aiming at a visual analog scale (VAS) score < 30 mm at rest. The control group (n = 31) received intravenous fentanyl 10 μg/ml postoperatively 3-8 mL/h. After placement of an epidural catheter at the level of Th₂-Th₄ before OPCAB, a thoracic EI group (n = 31) received EA intraoperatively with ropivacaine 0.75% 1 mg/kg and fentanyl 1 μg/kg followed by continuous EI of ropivacaine 0.2% 3-8 mL/h and fentanyl 2 μg/mL postoperatively. The PCEA group (n = 31), in addition to EA and EI, received PCEA (ropivacaine/fentanyl bolus 1 mL, lock-out interval 12 min) postoperatively. Hemodynamics and blood gases were measured throughout 24 h after OPCAB.

Results

During OPCAB, EA decreased arterial pressure transiently, counteracted changes in global ejection fraction and accumulation of extravascular lung water, and reduced the consumption of propofol by 15%, fentanyl by 50% and nitroglycerin by a 7-fold, but increased the requirements in colloids and vasopressors by 2- and 3-fold, respectively (P < 0.05). After OPCAB, PCEA increased PaO₂/FiO₂ at 18 h and decreased the duration of mechanical ventilation by 32% compared with the control group (P < 0.05).

Conclusions

In OPCAB, EA with ropivacaine/fentanyl decreases arterial pressure transiently, optimizes myocardial performance and influences the perioperative fluid and vasoactive therapy. Postoperative EI combined with PCEA improves lung function and reduces time to extubation.

Trial Registration

NCT01384175

Assessment of pulmonary function tests in cardiac patients

This study was aimed to assess the pulmonary function tests (PFTs) in cardiac patients; with ischemic or rheumatic heart diseases as well as in patients who underwent coronary artery bypass graft (CABG) or valvular procedures. For the forty eligible participants, the pulmonary function was measured using the spirometry test before and after the cardiac surgery. Data collection sheet was used for the patient's demographic and intra-operative information. Cardiac diseases and surgeries had restrictive negative impact on PFTs. Before surgery, vital capacity (VC), forced vital capacity (FVC), forced expiratory volume in the first second (FEV1), ratio between FEV1 and FVC, and maximum voluntary ventilation (MVV) recorded lower values for rheumatic patients than ischemic patients (P values were 0.01, 0.005, 0.0001, 0.031, and 0.035, respectively). Moreover, patients who underwent valvular surgery had lower PFTs than patients who underwent CABG with significant differences for VC, FVC, FEV1, and MVV tests (P values were 0.043, 0.011, 0.040, and 0.020, respectively). No definite causative factor appeared to be responsible for those results although mechanical deficiency and incisional chest pain caused by cardiac surgery are doubtful. More comprehensive investigation is required to resolve the case.

Adding regional analgesia to general anaesthesia: increase of risk or improved outcome?

Although it is clear that regional analgesia in association with general anaesthesia substantially reduces postoperative pain, the benefits in terms of overall perioperative outcome are less evident. The aim of this nonsystematic review was to evaluate the effect on middle and long-term postoperative outcomes of adding regional perioperative analgesia to general anaesthesia. This study is based mostly on systematic reviews, large epidemiological studies and large or high-quality randomized controlled trials that were selected and evaluated by the author. The endpoints that are discussed are perioperative morbidity, cancer recurrence, chronic postoperative pain, postoperative rehabilitation and risk of neurologic damage. Epidural analgesia may have a favourable but very small effect on perioperative morbidity. The influence of other regional anaesthetic techniques on perioperative morbidity is unclear. Preliminary data suggest that regional analgesia might reduce the incidence of cancer recurrence. However, adequately powered randomized controlled trials are lacking. The sparse literature available suggests that regional analgesia may prevent the development of chronic postoperative pain. Rehabilitation in the immediate postoperative period is possibly improved, but the advantages in the long term remain unclear. Permanent neurological damage is extremely rare. In conclusion, while the risk of permanent neurologic damage remains extremely low, evidence suggests that regional analgesia may improve relevant outcomes in the long term. The effect size is mostly small or the number-needed-to-treat is high. However, considering the importance of the outcomes of interest, even minor improvement probably has substantial clinical relevance.

[Fast track in thoracic surgery]

Patients undergoing thoracic surgery are threatened by pulmonary complications such as pneumonia and atelectasis. Age, preoperative FEV(1), operative time and extent of resection are predictors for adverse outcome. Reported morbidity after lung resection is as high as 42% and mortality up to 7%. Fast track in thoracic surgery aims at reducing morbidity and mortality rates after lung resection by introducing specific measures into the pre-, intra- and postoperative periods. Basic fast track elements in thoracic surgery are smoking cessation, preoperative physiotherapy, micronutrient supplementation, high thoracic epidural anesthesia, fluid restriction, early mobilization and enteral feeding. The effectiveness of these individual measures has been proven of value in perioperative care, however, evidence on multimodal therapy regimens in thoracic surgery is limited. In particular it remains to be elucidated which patients should be fast tracked in order to improve outcomes.