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In patients undergoing cardiac surgery, thoracic epidural analgesia combined with general anaesthesia results in faster recovery and fewer c
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     a Department of Cardiac Anaesthesia, Aberdeen Royal Infirmary, Aberdeen, AB25 2ZN, UK

    b Department of Cardiothoracic Surgery, Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL, UK

    c Department of Cardiothoracic Surgery, Wythenshawe Hospital, Manchester, UK

    Abstract

    A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether the use of thoracic epidural anaesthesia (TEA) in combination with general anaesthesia during adult cardiac surgery resulted in a faster recovery, fewer complications and shorter length of hospital stay. Altogether 313 papers were identified on Medline and 368 on Embase using the reported search of which 15 represented the best evidence on the topic. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses were tabulated. We conclude that the use of TEA in combination with general anaesthesia results in more rapid extubation and significantly better pain relief in patients undergoing cardiac surgery. In addition, common postoperative complications such as chest infection, dysrhythmia, confusional states, renal failure and psychological sequelae may be decreased although there is currently no evidence that its use decreases length of hospital stay. Finally, whilst there are case reports of neurological injury secondary to epidural haematoma in the literature these are rare and a number of large studies have been performed confirming the safety of the technique when basic precautions regarding technical aspects of the procedure and coagulation management are followed.

    Key Words: Cardiac surgery; Thoracic epidural anaesthesia; Postoperative complications

    1. Introduction

    A best evidence topic was constructed according to a structured protocol. This protocol is fully described in the ICVTS [1].

    2. Clinical scenario

    You are the anaesthetist assessing a 75-year-old current smoker with an exercise tolerance of only 200 yds, who is due to have coronary grafting tomorrow. You approach the surgeon to suggest that you place a thoracic epidural prior to induction. He is reluctant for you to do this as he says that epidurals can be dangerous with full heparinisation and anyway he isn't aware of any evidence that it speeds recovery. You decide to summarize the evidence for him.

    3. Three-part question

    In [adult patients undergoing cardiac surgery], is the use of [Thoracic epidural anaesthesia] associated with [faster recovery, fewer complications and shorter length of stay].

    4. Search strategy

    Medline-1966 to October-2005, EMBASE-1980 to 2005 Week 43 using OVID interface. [exp Cardiopulmonary Bypass/OR CABG.mp OR exp Thoracic Surgery/OR exp Cardiac surgical procedures/OR Coronary art$ bypass.mp. OR Cardiopulmonary bypass.mp OR exp Cardiopulmonary Bypass/OR exp Cardiovascular Surgical Procedures/OR exp Thoracic Surgical Procedures/OR exp Coronary Artery Bypass/OR cardiac transplantation.mp. OR exp Heart Transplantation/] AND [exp Anesthesia, Epidural/OR Epidural anaesthesia.mp OR exp Analgesia, Epidural/OR epidural analgesia.mp OR exp Anesthesia, Conduction/ae,cl,st,td,mo OR exp Anesthesia, Local/ad,ae,ct,st,td,mo OR exp Anesthesia, Spinal/ae,ct,st,td,mo OR exp Nerve Block/ae,ct,st,td,mo] AND [exp anesthesia recovery period/OR exp Recovery of function/OR ‘Length of Stay’/OR exp Intraoperative Complications/OR exp Postoperative Complications/OR surgical complications.mp OR ‘Postoperative Complications’/] LIMIT [humans AND english language].

    5. Search outcome

    Using the reported search, 313 papers were identified on Medline and 368 on Embase. Fifteen papers represented the best evidence on the subject and are summarised in Table 1. A further six papers were not summarised due to small study size, non-randomised design and our own space constraints [16–22].

    6. Results

    Various benefits have been reported in combining thoracic epidural anaesthesia (TEA) with general anaesthesia (GA) during cardiac surgery. Liu [2] performed a meta-analysis in 2004, which studied outcomes of 1178 patients from 15 studies including eight identified in our search. They found that the use of TEA led to earlier extubation (Mean Difference –4.5 h; 95% CI –7 to –2; P=0.0005) and improved pain scores at rest and with activity compared to GA alone.

    Scott [3], Turfrey [4], Barrington [5], Priestley [6], and Royse [7] have all confirmed these findings. The meta-analysis also identified a decrease in pulmonary complications (OR 0.41; 95% CI 0.27–0.60; P<0.00001) with Scott reporting a lower incidence of chest infection and better maximal inspiratory lung volume [3], and Royse identifying better postoperative lung function and cooperation with physiotherapy in their TEA groups [7]. However, Priestly reported no difference in blood gases, spirometry or chest X-ray appearances in their postoperative TEA group [6].

    Liu also reported decreased dysrhythmias with TEA (OR 0.52; 95% CI 0.29–0.93; P=0.03) although there were no significant differences in myocardial infarction and mortality [2]. But whilst Scott and Turfrey both identified lower incidences of atrial fibrillation (AF) with TEA [3,4], Barrington, Priestley and Royse did not [5–7]. Scott discontinued -blockade postoperatively which may be a confounding factor and it shas been suggested that his use of Clonidine as an epidural adjunct might enhance TEA anti-dysrhythmic effect [5,8]. Jideus found no difference in the proportion of patients developing AF [9]. Nygard studied the effects of TEA, Amiodarone or both as prophylaxis against AF and found Amiodarone, but not TEA, to be protective [8].

    A number of studies have looked at biochemical markers of myocardial injury in patients undergoing cardiac surgery utilising TEA. No differences in CK-MB, TnT or cortisol were found [5,6,10]. Significant reductions in Neuropeptide-Y, ANP and BNP have been shown [9–11].

    There is currently no evidence to suggest that the use of TEA is associated with earlier hospital discharge although this in part may be confounded by the populations studied. For example, 60% of Scott's study population were in receipt of allowances if they stayed in hospital [3]! Fillinger also found no significant cost benefits in using TEA [10].

    There is no agreement on the optimal TEA drug regime. Bupivacaine and Ropivacaine are widely used and whilst most authors used opioid supplementation, the two studies reporting greatest anti-dysrhythmic effect used Clonidine [3,4].

    The major disadvantage of TEA remains the fear of epidural haematoma in the soon-to-be anticoagulated patient. Whilst a small number of individual cases have been reported, increasing number of audits and cohort studies including those by Salvi [12], Chakravarthy [13], Sanchez [14], and Pastor [15], which specifically looked for neurological complications, seem to confirm the apparent safety of the technique when basic sensible precautions are taken. Chakravarthy reported only four temporary neurological deficits in a large series of 2113 epidurals in cardiac surgery patients over a 13-year period [13]. A small proportion of their patients experienced dural or bloody taps but in most cases epidurals were resited and surgery proceeded. Likewise Pastor et al. reported a low incidence of dural puncture although three of his series and one each of Scott's, Turfrey's and Salvi's patients underwent negative MRI scanning after developing suspicious lower limb signs [3,4,12,15].

    In 2000, Ho et al. [16] used mathematical modelling to calculate the statistical risk of epidural haematoma following TEA as between 1:150,000 and 1:1,500 (95% confidence) and up to 1:1,000 (99% confidence) based on published data available at that time. They also acknowledged the importance of factors including presence of a normal coagulation system prior to insertion and removal of the catheter, avoidance of repeated attempts, postponing surgery in the presence of a bloody tap and close neurological surveillance in minimising risk. These precautions are repeated in most studies. Also, eight studies inserted the epidural the day before surgery [5–9,11,13,14] and Scott recommended that TEA should only be used in an institution with immediate MRI availability.

    7. Clinical bottom line

    TEA in combination with general anaesthesia results in more rapid extubation and significantly better pain relief. There may also be a lower incidence of respiratory, cardio-vascular, and renal complications although the length of hospital stay is not affected. The optimal drug regime has probably not been established. Whilst there is a theoretical risk of epidural haematoma and a few have been reported, the risks appear small on the basis of the evidence available and are minimised by the use of sensible precautions to ensure normal haemostasis prior to catheter insertion and removal.

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