Comparison of the Modulatory Effects of Four Different Fast-Track Anesthetic Techniques on the Inflammatory Response to Cardiac Surgery With Cardiopulmonary Bypass

Anti-inflammatory potential of remimazolam: A laboratory and clinical investigation

BACKGROUND

Anesthetic agents, particularly intravenous anesthetics, may affect immune function and tumorigenic factors. We herein investigated whether the anti-inflammatory effects of anesthetic agents are attributed to their antioxidant properties. The antioxidant and anti-inflammatory effects of remimazolam, a new anesthetic, remain unclear. We hypothesized that remimazolam exerts anti-inflammatory effects due to its antioxidant properties, which may affect the postoperative inflammatory response. This retrospective clinical study examined this hypothesis using laboratory and clinical approaches.

METHODS

The antioxidant effects of remimazolam and dexmedetomidine were assessed by electron spin resonance (ESR) spectroscopy, and postoperative inflammatory responses were compared in 143 patients who underwent transcatheter aortic valve replacement at Kindai University Hospital between April 2021 and December 2022. The primary endpoint was the presence or absence of the antioxidant effects of the anesthetics themselves using ESR.

RESULTS

Remimazolam at clinical concentrations exerted antioxidant effects, whereas dexmedetomidine did not. Increases in C-reactive protein (CRP) levels on POD3 from preoperative values were significantly smaller in the remimazolam group than in the dexmedetomidine group (1.33 ± 1.29 vs. 2.17 ± 1.84, p = .014).

CONCLUSIONS

Remimazolam exerted stronger anti-inflammatory effects than dexmedetomidine, and these effects were enhanced by its antioxidant properties, which may have affected postoperative CRP production.

Pain management and opioid stewardship in adult cardiac surgery: Joint consensus report of the PeriOperative Quality Initiative and the Enhanced Recovery After Surgery Cardiac Society

BACKGROUND

Opioid-based anesthesia and analgesia is a traditional component of perioperative care for the cardiac surgery patient. Growing enthusiasm for Enhanced Recovery Programs (ERPs) coupled with evidence of potential harm associated with high-dose opioids suggests that we reconsider the role of opioids in cardiac surgery.

METHODS

An interdisciplinary North American panel of experts, using a structured appraisal of the literature and a modified Delphi method, derived consensus recommendations for optimal pain management and opioid stewardship for cardiac surgery patients. Individual recommendations are graded based on the strength and level of evidence.

RESULTS

The panel addressed 4 main topics: the harms associated with historical opioid use, the benefits of more targeted opioid administration, the use of nonopioid medications and techniques, and patient and provider education. A key principle that emerged is that opioid stewardship should apply to all cardiac surgery patients, entailing judicious and targeted use of opioids to achieve optimal analgesia with the fewest potential side effects. The process resulted in the promulgation of 6 recommendations regarding pain management and opioid stewardship in cardiac surgery, focused on avoiding the use of high-dose opioids, as well as encouraging more widespread application of foundational aspects of ERPs, such as the use of multimodal nonopioid medications and regional anesthesia techniques, formal patient and provider education, and structured system-level opioid prescription practices.

CONCLUSIONS

Based on the available literature and expert consensus, there is an opportunity to optimize anesthesia and analgesia for cardiac surgery patients. Although additional research is needed to establish specific strategies, core principles of pain management and opioid stewardship apply to the cardiac surgery population.

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.

The effect of anesthesia on the postoperative systemic inflammatory response in patients undergoing surgery: A systematic review and meta-analysis

BACKGROUND

Surgical injury stimulates the systemic inflammatory response. The magnitude of the postoperative systemic inflammatory response has been shown to be significantly associated with short and long-term outcomes following surgery of varying severity. Different anesthetic techniques for surgery may have an impact on the postoperative systemic inflammatory response and on the rate of the postoperative infective complications.The aim of the present systematic review was to examine the relationship between perioperative anesthesia, the postoperative systemic inflammatory response and postoperative infective complications in patients undergoing surgery.

METHODS

This was carried out using PubMed and other established databases from 1987 up to March 2018. In particular, randomized controlled studies and systemic inflammation markers, interleukin 6 and C-reactive protein were examined.

RESULTS

Overall, 60 controlled, randomized clinical trials were included in the review. The mean or median values of both interleukin 6 and C-reactive protein were taken for each study and the mean value was calculated for each anesthetic group at sampling points of 12-24 and 24-72 hours for interleukin 6 and C-reactive protein respectively. When taking the magnitude of surgery into account, TIVA using propofol was significantly associated with a reduction in particular C-reactive protein (P = .04). However, there were no other specific anesthetic methods including general, regional and combined anesthetics that were associated with a reduction in either interleukin 6 or C-reactive protein.

CONCLUSION

There is some evidence that anesthetic regimens may reduce the magnitude of the postoperative systemic inflammatory response. However, the studies were heterogeneous and generally of low quality.Future, well conducted, adequately powered studies are required to clarify the effect of anesthesia on the postoperative systemic inflammatory response and infective complications.

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.

Fast-track cardiac care for adult cardiac surgical patients

BACKGROUND

Fast-track cardiac care is a complex intervention involving several components of care during cardiac anaesthesia and in the postoperative period, with the ultimate aim of early extubation after surgery, to reduce length of stay in the intensive care unit and in the hospital. Safe and effective fast-track cardiac care may reduce hospital costs. This is an update of a Cochrane review first published in 2003, updated in 2012 and updated now in 2016.

OBJECTIVES

To determine the safety and effectiveness of fast-track cardiac care compared with conventional (not fast-track) care in adult patients undergoing cardiac surgery. Fast-track cardiac care intervention includes administration of low-dose opioid-based general anaesthesia or use of a time-directed extubation protocol, or both.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 5), MEDLINE (January 2012 to May 2015), Embase (January 2012 to May 2015), the Cumulative Index to Nursing and Allied Health Literature (CINAHL; January 2012 to May 2015) and the Institute for Scientific Information (ISI) Web of Science (January 2012 to May 2015), along with reference lists of articles, to identify additional trials. We applied no language restrictions.

SELECTION CRITERIA

We included all randomized controlled trials of adult cardiac surgical patients (coronary artery bypass grafts, aortic valve replacement, mitral valve replacement) that compared fast-track cardiac care and conventional (not fast-track) care groups. We focused on the following fast-track interventions, which were designed for early extubation after surgery: administration of low-dose opioid-based general anaesthesia during cardiac surgery and use of a time-directed extubation protocol after surgery. The primary outcome was risk of mortality. Secondary outcomes included postoperative complications, reintubation within 24 hours of surgery, time to extubation, length of stay in the intensive care unit and in the hospital, quality of life after surgery and hospital costs.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted study data. We contacted study authors for additional information. We calculated a Peto odds ratio (OR) for risk of mortality and used a random-effects model to report risk ratio (RR), mean difference (MD) and 95% confidence intervals (95% CIs) for all secondary outcomes.

MAIN RESULTS

We included 28 trials (4438 participants) in the updated review. We considered most participants to be at low to moderate risk of death after surgery. We assessed two studies as having low risk of bias and 11 studies high risk of bias. Investigators reported no differences in risk of mortality within the first year after surgery between low-dose versus high-dose opioid-based general anaesthesia groups (OR 0.53, 95% CI 0.25 to 1.12; eight trials, 1994 participants, low level of evidence) and between a time-directed extubation protocol versus usual care (OR 0.80, 95% CI 0.45 to 1.45; 10 trials, 1802 participants, low level of evidence).Researchers noted no significant differences between low-dose and high-dose opioid-based anaesthesia groups in the following postoperative complications: myocardial infarction (RR 0.98, 95% CI 0.48 to 1.99; eight trials, 1683 participants, low level of evidence), stroke (RR 1.17, 95% CI 0.36 to 3.78; five trials, 562 participants, low level of evidence) and tracheal reintubation (RR 1.77, 95% CI 0.38 to 8.27; five trials, 594 participants, low level of evidence).Comparisons with usual care revealed no significant differences in the risk of postoperative complications associated with a time-directed extubation protocol: myocardial infarction (RR 0.59, 95% CI 0.27 to 1.31; eight trials, 1378 participants, low level of evidence), stroke (RR 0.85, 95% CI 0.33 to 2.16; 11 trials, 1646 participants, low level of evidence) and tracheal reintubation (RR 1.34, 95% CI 0.74 to 2.41; 12 trials, 1261 participants, low level of evidence).Although levels of heterogeneity were high, low-dose opioid anaesthesia was associated with reduced time to extubation (reduction of 4.3 to 10.5 hours, 14 trials, 2486 participants, low level of evidence) and length of stay in the intensive care unit (reduction of 0.4 to 7.0 hours, 12 trials, 1394 participants, low level of evidence). Use of a time-directed extubation protocol was associated with reduced time to extubation (reduction of 3.7 to 8.8 hours, 16 trials, 2024 participants, low level of evidence) and length of stay in the intensive care unit (reduction of 3.9 to 10.5 hours, 13 trials, 1888 participants, low level of evidence). However, these two fast-track care interventions were not associated with reduced total length of stay in the hospital (low level of evidence).

AUTHORS' CONCLUSIONS

Low-dose opioid-based general anaesthesia and time-directed extubation protocols for fast-track interventions have risks of mortality and major postoperative complications similar to those of conventional (not fast-track) care, and therefore appear to be safe for use in patients considered to be at low to moderate risk. These fast-track interventions reduced time to extubation and shortened length of stay in the intensive care unit but did not reduce length of stay in the hospital.

Thoracic epidural anesthesia improves outcomes in patients undergoing cardiac surgery: meta-analysis of randomized controlled trials

To assess the efficacy of thoracic epidural anesthesia (TEA) with or without general anesthesia (GA) versus GA in patients who underwent cardiac surgery, PubMed, Embase, the Cochrane online database, and Web of Science were searched with the limit of randomized controlled trials (RCTs) relevant to ‘thoracic epidural anesthesia’ and ‘cardiac surgery’. Studies were identified and data were extracted by two reviewers independently. The quality of included studies was also assessed according to the Cochrane handbook. Outcomes of mortality, cardiac and respiratory functions, and treatment-associated complications were pooled and analyzed. The comprehensive search yielded 2,230 citations, and 25 of them enrolling 3,062 participants were included according to the inclusion criteria. Compared with GA alone, patients received TEA and GA showed reduced risks of death, myocardial infarction, and stroke, though there were no significant differences (P > 0.05). With regard to treatment-related complications, the pooled results for respiratory complications (risk ratio (RR), 0.69; 95% CI: 0.51, 0.91, P < 0.05), supraventricular arrhythmias (RR, 0.61; 95% CI: 0.42, 0.87, P < 0.05), and pain (mean difference (MD), −1.27; 95% CI: −2.20, −0.35, P < 0.05) were 0.69, 0.61, and −1.27, respectively. TEA was also associated with significant reduction of stays in intensive care unit (MD, −2.36; 95% CI: −4.20, −0.52, P < 0.05) and hospital (MD, −1.51; 95% CI: −3.03, 0.02, P > 0.05) and time to tracheal extubation (MD, −2.06; 95% CI:−2.68, −1.45, P < 0.05). TEA could reduce the risk of complications such as supraventricular arrhythmias, stays in hospital or intensive care unit, and time to tracheal extubation in patients who experienced cardiac surgery.

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.

Acute Effect of Intravenous Administration of Magnesium Sulfate on Serum Levels of Interleukin-6 and Tumor Necrosis Factor-α in Patients Undergoing Elective Coronary Bypass Graft With Cardiopulmonary Bypass

Background:

Cardiovascular problems are among the most common health issues. A considerable number of cardiac patients undergo cardiac surgery, and coronary artery disease patients constitute about two-thirds of all these surgeries. The application of cardiopulmonary bypass (CBP) usually results in some untoward effects.

Objectives:

Studies have suggested magnesium sulfate (MgSO4) as an anti-inflammatory agent in a coronary artery bypass graft (CABG). This study aimed to assess the effect of an IV MgSO₄ infusion during elective CABG (with CBP) on the blood levels of interleukin-6 (IL-6) and tumor necrosis factor alpha (TNF-α).

Materials and Methods:

During a 12 month period, after review board approval and based on inclusion and exclusion criteria, 90 patients were selected and entered randomly into one of the two study groups (MgSO4 or placebo). Anesthesia, surgery and CBP were performed in exactly the same way, except for the use of MgSO4 or a placebo. Both preoperative and postoperative plasma levels of IL-6 and TNF-α were checked and compared between the two groups using an ELISA.

Results:

There was no difference found between the two groups with regard to; gender, basic variables, Ejection Fraction (EF), CBP time and aortic cross-clamp time. The preoperative levels of IL-6 and TNF-α were not different; however, their postoperative levels were significantly higher in the placebo group (P value = 0.01 for IL-6 and 0.005 for TNF-α).

Conclusions:

This study showed that MgSO4 infusion could suppress part of the inflammatory response after CABG with CBP. This was demonstrated by decreased levels of interleukin-6 and TNF-α in postoperative serum levels in elective CABG with CBP.

Etiology and use of the "hanging drop" technique: a review

Background. The hanging drop (HD) technique presumably relies on the presence of subatmospheric epidural pressure. It is not clear whether this negative pressure is intrinsic or an artifact and how it is affected by body position. There are few data to indicate how often HD is currently being used. Methods. We identified studies that measured subatmospheric pressures and looked at the effect of the sitting position. We also looked at the technique used for cervical and thoracic epidural anesthesia in the last 10 years. Results. Intrinsic subatmospheric pressures were measured in the thoracic and cervical spine. Three trials studied the effect of body position, indicating a higher incidence of subatmospheric pressures when sitting. The results show lower epidural pressure (−10.7 mmHg) with the sitting position. 28.8% of trials of cervical and thoracic epidural anesthesia that documented the technique used, utilized the HD technique. When adjusting for possible bias, the rate of HD use can be as low as 11.7%. Conclusions. Intrinsic negative pressure might be present in the cervical and thoracic epidural space. This effect is more pronounced when sitting. This position might be preferable when using HD. Future studies are needed to compare it with the loss of resistance technique.

Epidural analgesia for cardiac surgery

BACKGROUND

A combination of general anaesthesia (GA) with thoracic epidural analgesia (TEA) may have a beneficial effect on clinical outcomes by reducing the risk of perioperative complications after cardiac surgery.

OBJECTIVES

The objective of this review was to determine the impact of perioperative epidural analgesia in cardiac surgery on perioperative mortality and cardiac, pulmonary or neurological morbidity. We performed a meta-analysis to compare the risk of adverse events and mortality in patients undergoing cardiac surgery under general anaesthesia with and without epidural analgesia.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2012, Issue 12) in The Cochrane Library; MEDLINE (PubMed) (1966 to November 2012); EMBASE (1989 to November 2012); CINHAL (1982 to November 2012) and the Science Citation Index (1988 to November 2012).

SELECTION CRITERIA

We included randomized controlled trials comparing outcomes in adult patients undergoing cardiac surgery with either GA alone or GA in combination with TEA.

DATA COLLECTION AND ANALYSIS

All publications found during the search were manually and independently reviewed by the two authors. We identified 5035 titles, of which 4990 studies did not satisfy the selection criteria or were duplicate publications, that were retrieved from the five different databases. We performed a full review on 45 studies, of which 31 publications met all inclusion criteria. These 31 publications reported on a total of 3047 patients, 1578 patients with GA and 1469 patients with GA plus TEA.

MAIN RESULTS

Through our search (November 2012) we have identified 5035 titles, of which 31 publications met our inclusion criteria and reported on a total of 3047 patients. Compared with GA alone, the pooled risk ratio (RR) for patients receiving GA with TEA showed an odds ratio (OR) of 0.84 (95% CI 0.33 to 2.13, 31 studies) for mortality; 0.76 (95% CI 0.49 to 1.19, 17 studies) for myocardial infarction; and 0.50 (95% CI 0.21 to 1.18, 10 studies) for stroke. The relative risks (RR) for respiratory complications and supraventricular arrhythmias were 0.68 (95% CI 0.54 to 0.86, 14 studies) and 0.65 (95% CI 0.50 to 0.86, 15 studies) respectively.

AUTHORS' CONCLUSIONS

This meta-analysis of studies, identified to 2010, showed that the use of TEA in patients undergoing coronary artery bypass graft surgery may reduce the risk of postoperative supraventricular arrhythmias and respiratory complications. There were no effects of TEA with GA on the risk of mortality, myocardial infarction or neurological complications compared with GA alone.

Fast-track cardiac care for adult cardiac surgical patients

BACKGROUND

Fast-track cardiac care is a complex intervention involving several components of care during cardiac anaesthesia and in the postoperative period, all with the ultimate aim of early extubation after surgery, to reduce the length of stay in the intensive care unit and in the hospital. Safe and effective fast-track cardiac care may reduce hospital costs. This is an update of a Cochrane review published in 2003.

OBJECTIVES

To update the evidence on the safety and effectiveness of fast-track cardiac care compared to conventional (not fast-track) care in adult patients undergoing cardiac surgery.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2012, Issue 3), MEDLINE (January 1966 to April 2012), EMBASE (January 1980 to April 2012), CINAHL (January 1982 to April 2012), and ISI Web of Science (January 2003 to April 2012). We searched reference lists of articles and contacted experts in the field.

SELECTION CRITERIA

All randomized controlled trials of adult cardiac surgical patients (coronary artery bypass grafts, aortic valve replacement, mitral valve replacement) that compared fast-track cardiac care and conventional (not fast-track) care groups were included. We focused on the following fast-track interventions that were designed for early extubation after surgery, administration of low-dose opioid based general anaesthesia during cardiac surgery and the use of a time-directed extubation protocol after surgery. The primary outcome was the risk of mortality. Secondary outcomes included postoperative complications, reintubation within 24 hours of surgery, time to extubation, length of stay in the intensive care unit and in the hospital, quality of life after surgery and hospital costs.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted the data. Study authors were contacted for additional information. We used a random-effects model and reported relative risk (RR), mean difference (MD) and 95% confidence intervals (95% CI).

MAIN RESULTS

Twenty-five trials involving 4118 patients were included in the review. There were two studies with a low risk of bias and nine studies with a high risk of bias. There were no differences in the risk of mortality within the first year after surgery between low-dose versus high-dose opioid based general anaesthesia groups (RR 0.58, 95% CI 0.28 to 1.18) and between early extubation protocol versus usual care groups (RR 0.84, 95% CI 0.40 to 1.75).There were no significant differences between low-dose versus high-dose opioid based anaesthesia groups for postoperative complications: myocardial infarction (RR 0.98, 95% CI 0.48 to 1.99), reintubation (RR 1.77, 95% CI 0.38 to 8.27), acute renal failure (RR 1.19, 95% CI 0.33 to 4.33), major bleeding (RR 0.48, 95% CI 0.16 to 1.44), and stroke (RR 1.17, 95% CI 0.36 to 3.78). Compared to the usual care, there were no significant differences in the risk of postoperative complications associated with early extubation: myocardial infarction (RR 0.94, 95% CI 0.55 to 1.60), reintubation (RR 1.91, 95% CI 0.90 to 4.07), acute renal failure (RR 0.77, 95% CI 0.19 to 3.10), major bleeding (RR 0.80, 95% CI 0.45 to 1.44), stroke (RR 0.87, 95% CI 0.31 to 2.46), major sepsis (RR 1.25, 95% CI 0.08 to 19.75) and wound infection (RR 0.67, 95% CI 0.25 to 1.83).Although there were high levels of heterogeneity, both low-dose opioid anaesthesia and the use of time-directed extubation protocols were associated with reductions in the time to extubation (3.0 to 10.5 hours) and in the length of stay in the intensive care unit (0.4 to 8.7 hours). However, these fast-track care interventions were not associated with reductions in the total length of stay in hospital. One high quality cost-effectiveness analysis included in a randomized controlled trial showed that early extubation was likely to be cost-effective.

AUTHORS' CONCLUSIONS

The use of low-dose opioid based general anaesthesia and time-directed protocols for fast-track interventions have similar risks of mortality and major postoperative complications to conventional (not fast-track) care, and therefore appear to be safe in patients considered to be at low to moderate risk. These fast-track interventions reduced the time to extubation and shortened the length of stay in the intensive care unit, but did not reduce the length of stay in the hospital.

Epidural analgesia improves outcome in cardiac surgery: a meta-analysis of randomized controlled trials

OBJECTIVE

The authors conducted a review of randomized studies to determine whether there were any advantages for clinically relevant outcomes by adding epidural analgesia in patients undergoing cardiac surgery under general anesthesia.

DESIGN

Meta-analysis.

SETTING

Hospitals.

PARTICIPANTS

A total of 2366 patients from 33 randomized trials.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

DATA SOURCES AND STUDY SELECTION

PubMed, BioMedCentral, CENTRAL, EMBASE, Cochrane Central Register of Controlled Trials, and conference proceedings were searched (updated January 2008) for randomized trials that compared general anesthesia with an anesthetic plan including general anesthesia and epidural analgesia in cardiac surgery. Two independent reviewers appraised study quality, with divergences resolved by consensus. Overall analysis showed that epidural analgesia reduced the risk of the composite endpoint mortality and myocardial infarction (30/1125 [2.7%] in the epidural group v 64/1241 [5.2%] in the control arm, odds ratio [OR] = 0.61 [0.40-0.95], p = 0.03 number needed to treat [NNT] = 40), the risk of acute renal failure (35/590 [5.9%] in the epidural group v 54/618 [8.7%] in the control arm, OR = 0.56 [0.34-0.93], p = 0.02, NNT = 36), and the time of mechanical ventilation (weighted mean differences = -2.48 hours [-2.64, -2.32], p < 0.001).

CONCLUSIONS

This analysis suggested that epidural analgesia on top of general anesthesia reduced the incidence of perioperative acute renal failure, the time on mechanical ventilation, and the composite endpoint of mortality and myocardial infarction in patients undergoing cardiac surgery.