Epidural Catheterization in Cardiac Surgery: A Systematic Review and Risk Assessment of Epidural Hematoma

ABSTRACT

The potential benefits of epidural anesthesia on mortality, atrial fibrillation, and pulmonary complications must be weighed against the risk of epidural hematoma associated with intraoperative heparinization. This study aims to provide an updated assessment of the clinical risks of epidural anesthesia in cardiac surgery, focusing on the occurrence of epidural hematomas and subsequent paralysis. A systematic search of Embase, Medline, Ovid Central, Web of Science, and PubMed was conducted to identify relevant publications between 1966 and 2022. Two independent reviewers assessed the eligibility of the retrieved manuscripts. Studies reporting adult patients undergoing cardiac surgery with epidural catheterization were included. The incidence of hematomas was calculated by dividing the number of hematomas by the total number of patients in the included studies. Risk calculations utilized various denominators based on the rigor of trial designs, and the risks of hematoma and paralysis were compared to other commonly encountered risks. The analysis included a total of 33,089 patients who underwent cardiac surgery with epidural catheterization. No epidural hematomas were reported across all published RCTs, prospective, and retrospective trials. Four case reports associated epidural hematoma with epidural catheterization and perioperative heparinization. The risks of epidural hematoma and subsequent paralysis were estimated at 1:7643 (95% CI 1:3860 to 380,916) and 1:10,190 (95% CI 1:4781 to 0:1), respectively. The risk of hematoma is similar to the non-obstetric population (1:5405; 95% CI 1:4784 to 6134). The risk of hematoma in cardiac surgery patients receiving epidural anesthesia is therefore similar to that observed in some other surgical non-obstetric populations commonly exposed to epidural catheterization.

High Thoracic Epidural Anesthesia and Dexmedetomidine for Awake Off-Pump Coronary Artery Bypass Grafting: A Feasible Option for Patients with Severe Pulmonary Disease

High thoracic epidural anesthesia in cardiac surgery as the sole anesthetic technique is used in a select groups of patients having severe pulmonary co morbidities. We describe a case series of three patients at high risk for post operative pulmonary complications where this technique was used along with dexmedetomidine infusion for conscious sedation in off pump coronary artery bypass grafting. Proper selection of patients, proper placement of the epidural catheter at the appropriate level and timing of catheter insertion and removal are of paramount importance.

Off-pump awake coronary artery bypass grafting under high thoracic epidural anesthesia

Conventionally general anesthesia has been the preferred anesthetic technique for coronary artery bypass grafting (CABG). Ever since the first awake CABG the concept though appearing promising is still being continually evaluated. From the Indian perspective, the practice has been largely limited to certain institutions and seems to be not widely practiced across India. This case reports our experience with this technique from the western part of the country.

Superficial temporal artery-middle cerebral artery bypass using local anesthesia and a sedative without endotracheal general anesthesia

OBJECT

Superficial temporal artery (STA)-middle cerebral artery (MCA) bypasses have continually evolved, and new strategies have been advocated for reducing anesthetic or surgical morbidity and mortality. Further simplifying, and decreasing the invasiveness of, STA-MCA bypass by performing this operation without endotracheal general anesthesia was believed to be feasible in certain subsets of patients.

METHODS

The authors performed STA-MCA bypass using local anesthesia with a sedative in 10 patients with hemodynamically compromised occlusive cerebrovascular disease, as well as multiple comorbidities, between February 2010 and September 2011. The technique is based on the preoperative identification of the point at which the donor and recipient vessels are in closest proximity. Preoperative use of CT angiography allowed the authors to identify the target point precisely and use a minimally invasive procedure. All patients received dexmedetomidine as the sole sedative agent, together with scalp-blocking local anesthesia, with an unsecured airway.

RESULTS

Successful STA-MCA bypass surgeries were achieved via a preselected minimally invasive approach in all cases. There was good hemodynamic stability throughout surgery. No airway or ventilation complications occurred, and no patients were converted to general anesthesia. Subjectively, patients tolerated the technique well with a high rate of satisfaction. There were no perioperative morbidities or deaths. Postoperative MR angiography confirmed a patent bypass in all patients. All patients remained symptom free and returned to normal daily life following the operation.

CONCLUSIONS

This initial experience confirms the feasibility of performing STA-MCA bypass without endotracheal general anesthesia. This novel technique produced a high degree of patient satisfaction.

[Fast track in cardiac surgery]

Fast track in cardiac surgery is not well defined. In the past early or immediate extubation was used as a marker. After cardiac surgery this parameter is not sufficient. In addition to cardiorespiratory stability, circulatory and haemostatic homeostasis are also required. Therefore the current Fast Track concept includes a period of intensive monitoring of the patient postoperatively to establish stability. Thereafter intensive care medicine should not be required. Evolving new surgical concepts in combination with appropriate anaesthesiologic management will lead to wide application of fast track cardiac surgery in the future.

[Leipzig fast-track protocol for cardio-anesthesia. Effective, safe and economical]

BACKGROUND

In November 2005 a complex, multimodal anesthesia fast-track protocol (FTP) was introduced for elective cardiac surgery patients in the Cardiac Center of the University of Leipzig which included changing from an opioid regime to remifentanil and postoperative treatment in a special post-anesthesia recovery and care unit. The goal was to speed up recovery times while maintaining safety and improving costs.

METHOD

A total of 421 patients who underwent the FTP and were treated in the special recovery room were analyzed retrospectively. These patients were compared with patients who had been treated by a standard protocol (SP) prior to instituting the FTP. Primary outcomes were time to extubation, length of stay in the intensive care unit (ICU) and treatment costs.

RESULTS

The times to extubation were significantly shorter in the FTP group with 75 min (range 45-110 min) compared to 900 min (range 600-1140 min) in the SP group. Intensive care unit stay and hospital length of stay were also significantly shorter in the FTP group (p<0.01). The reduction of treatment costs of intensive care for FTP patients was 53.5% corresponding to savings of EUR 738 per patient in the FTP group compared with the SP group.

CONCLUSIONS

The Leipzig fast-track protocol for cardio-anesthesia including the central elements of switching opiate therapy to remifentanil and switching patient recovery to a special post-anesthesia recovery and care unit, shortened therapy times, is safe and economically effective.

[Coronary artery bypass grafting in conscious patients: a procedure with a perspective?]

Patients undergoing coronary artery bypass grafting increasingly show severe co-morbidities, which can negatively affect the outcome. Recent developments in cardiac surgery have therefore focused on minimizing the invasiveness of the procedure by revascularization on the beating heart without cardiopulmonary bypass, and by reducing surgical trauma using smaller surgical incisions. Progress in minimally invasive cardiac surgery has led to minimally invasive anesthesia, i.e. using high thoracic epidural anesthesia as the sole technique in the conscious patient (awake coronary artery bypass grafting, ACAB). Published data on ACAB procedures in smaller cohorts have demonstrated that the procedure is safe. Significant complications occurred in 7.1% of patients. A particular cause of concern during ACAB surgery is the development of spinal epidural hematoma the risk of which has been estimated to be as high as 1:1,000. A thorough risk-benefit analysis has therefore to be made. Currently, ACAB surgery remains limited to few specialized centers and highly selected patients.