Nonanalgesic benefits of combined thoracic epidural analgesia with general anesthesia in high risk elderly off pump coronary artery bypass patients

Abstract

Objective: Epidural anesthesia is a central neuraxial block technique with many applications. It is a versatile anesthetic technique, with applications in surgery, obstetrics and pain control. Its versatility means it can be used as an anesthetic, as an analgesic adjuvant to general anesthesia, and for postoperative analgesia. Off pump coronary artery bypass (OPCAB) surgery triggers a systemic stress response as seen in coronary artery bypass grafting (CABG). Thoracic epidural anesthesia (TEA), combined with general anesthesia (GA) attenuates the stress response to CABG. There is Reduction in levels of Plasma epinephrine, Cortisol and catecholamine surge, tumor necrosis factor-Alpha( TNF ά), interleukin-6 and leucocyte count. Design: A prospective randomised non blind study. Setting: A clinical study in a multi specialty hospital. Participants: Eighty six patients. Material and Methods/intervention: The study was approved by hospital research ethics committee and written informed consent was obtained from all patients. Patients were randomised to receive either GA plus epidural (study group) or GA only (control group). Inclusion Criteria (for participants) were -Age ≥ 70 years, Patient posted for OPCAB surgery, and patient with comorbidities (diabetes mellitus, chronic obstructive pulmonary disease, cerebrovascular disease, peripheral vascular disease, renal dysfunction). Serum concentration of Interlukin: - 6, TNF ά, cortisol, Troponin - I, CK-MB, and HsCRP (highly sensitive C reactive protein), was compared for both the group and venous blood samples were collected and compared just after induction, at day 2, and day 5 postoperatively. Time to mobilization, extubation, total intensive care unit stay and hospital stay were noted and compared. Independent t test was used for statistical analysis. Primary Outcomes: Postoperative complications, total intensive care unit stay and hospital stay. Secondary Outcome: Stress response. Result: Study group showed decreased Interlukin - 6 at day 2, TNF ά at day 2 and 5,troponin I at day 5, and decreased total hospital stay ( p < 0.05). Conclusion: Thoracic epidural anesthesia decreases stress and inflammatory response to surgery and decreases hospital stay. However a large multicentre study may be needed to confirm it.

Keywords

• Chronic obstructive pulmonary disease; Coronary artery bypass; Outcome; Spirometry
• Body mass index; Body position; Heart position; Pulmonary function; Transesophageal echocardiography
• Cardioversion; Etomidate; Propofol
• Anesthesia; Echocardiography; General; Pulmonary artery catheterization; Pulmonary wedge pressure; Transesophageal
• Class IV laser; Low level laser therapy; Multimodal analgesia; Off-pump coronary artery bypass graft; Postoperative pain
• Dexmedetomidine; Junctional ectopic tachycardia; Tetralogy of Fallot
• Anticoagulants; Antiplatelet therapies; Critically ill patients; Intensive Care Unit; Percutaneous tracheostomy; Procedure related bleeding complications
• European System for Cardiac Operative Risk Evaluation-II; Indian population; Risk scoring systems; Validation
• Anesthetic technique; Survival; Transapical; Transcatheter aortic valve implantation; Transfemoral
• Analgesia; Tapentadol; Tramadol
• Exchange transfusion; Heart valve surgery; Hemoglobin; Sickle cell disease
• Aristotle comprehensive complexity score; Congenital heart surgery; Weight-for-age; Z score
• Preoperative Anemia and Cardiac Surgery; Propensity Matching; Valvular Heart Disease
• Coronary artery bypass grafting; Coronary sinus blood flow; Left internal mammary artery; Transesophageal echocardiography; Velocity time integral
• Coronary artery bypass grafting
• inflammatory markers
• off pump coronary artery bypass
• thoracic epidural anesthesia