Immediate Extubation after Aortic Valve Surgery Using High Thoracic Epidural Anesthesia
DOI:
https://doi.org/10.1532/hsf.1149Abstract
Purpose: Fast-track anesthesia has gained widespread use in cardiac centers around the world. No study has focused on immediate extubation after aortic valve surgery. This study examines the feasibility and hemodynamic stability of immediate extubation after simple or combined aortic valve surgery using thoracic epidural anesthesia.
Methods: Thirty patients undergoing aortic valve surgery with an ejection fraction of more than 30% were included in this prospective audit. After insertion of a high thoracic epidural catheter, induction with fentanyl 2 to 4 m g/kg, administration of propofol 1 to 2 mg/kg, and endotracheal intubation facilitated by rocuronium, anesthesia was maintained with sevoflurane titrated according to bispectral index (target, 50). Perioperative analgesia was provided by high thoracic epidural analgesia (TEA) (bupivacaine 0.125% 6-14 mL/h). Hemodynamic data were compared by Friedman test. P .05 was considered to show a significant difference. Data are presented as median (25th-75th percentile).
Results: Patients underwent simple aortic valve surgery (n = 17) or combined aortic valve surgery (n = 13) with additional coronary artery bypass grafting (n = 8), replacement of the ascending aorta (Bentall procedure) (n = 4), and repair of open foramen ovale (n = 1). All 30 patients were extubated within 15 minutes after surgery at 36.5 ° C (36.4 ° C-36.6 ° C). There was no need for reintubation. Pain scores were low immediately after surgery and 6, 24, and 48 hours after surgery at 0 (0-3.5), 0 (0-2), 0 (0-2), and 0 (0-2), respectively. During and up to 6 hours after surgery, there was no significant hemodynamic change due to TEA. Fifteen of 30 patients needed temporary pacemaker activation. There were no complications related to TEA. Conclusions: Immediate extubation is feasible after aortic valve surgery with high thoracic epidural analgesia and maintenance of hemodynamic stability throughout surgery. Immediate extubation after aortic valve surgery is a promising new path in cardiac anesthesia.
References
Blomberg S, Emanuelsson H, Ricksten SE. 1989. Thoracic epidural anesthesia and central hemodynamics in patients with unstable angina pectoris. Anesth Analg 69:558-62.nBlomberg S, Ricksten SE. 1988. Thoracic epidural anaesthesia decreases the incidence of ventricular arrhythmias during acute myocardial ischaemia in the anaesthetized rat. Acta Anaesthesiol Scand 32:173-8.nBlomberg S, Ricksten SE. 1990. Effects of thoracic epidural anaesthesia on central haemodynamics compared to cardiac beta adrenoceptor blockade in conscious rats with acute myocardial infarction. Acta Anaesthesiol Scand 34:1-7.nCanto M, Casas A, Sanchez M, et al. 2002. Thoracic epidurals in heart valve surgery: neurologic risk evaluation. J Cardiothorac Vasc Anesth 16:723-7.nDjaiani GN, Ali M, Heinrich L, et al. 2001. Ultra-fast-track anesthetic technique facilitates operating room extubation in patients undergoing off-pump coronary revascularization surgery. J Cardiothorac Vasc Anesth 15:152-7.nFawcett WJ, Edwards RE, Quinn AC, et al. 1997. Thoracic epidural analgesia started after cardiopulmonary bypass: adrenergic, cardiovascular and respiratory sequelae. Anaesthesia 52:294-9.nBlomberg S, Curelaru I, Emanuelsson H, et al. 1989. Thoracic epidural anaesthesia in patients with unstable angina pectoris. Eur Heart J 10:437-44.nBlomberg S, Emanuelsson H, Kvist H, et al. 1990. Effects of thoracic epidural anesthesia on coronary arteries and arterioles in patients with coronary artery disease. Anesthesiology 73:840-7.nHendolin H, Lahtinen J, Lansimies E, et al. 1987. The effect of thoracic epidural analgesia on respiratory function after cholecystectomy. Acta Anaesthesiol Scand 3:645-51.nHo AMH, Chung DC, Joynt GM. 2000. Neuraxial blockade and hematoma in cardiac surgery: estimating the risk of a rare adverse event that has not (yet) occurred. Chest 117:551-5.nHorlocker TT, Wedel DJ, Benzon H, et al. 2003. Regional anesthesia in the anticoagulated patient: defining the risks (the second ASRA Consensus Conference on Neuraxial Anesthesia and Anticoagulation). Reg Anesth Pain Med 28:172-97.nKock M, Blomberg S, Emanuelsson H, et al. 1990. Thoracic epidural anesthesia improves global and regional left ventricular function during stress-induced myocardial ischemia in patients with coronary artery disease. Anesth Analg 71:625-30.nRoyse CF, Royse AG, Soeding PF. 1999. Routine immediate extubation after cardiac operation: a review of our first 100 patients. Ann Thorac Surg 68:1326-9.nRoyse C, Roye A, Soeding P, et al. 2003. Prospective randomized trial of high thoracic epidural analgesia for coronary artery bypass surgery. Ann Thorac Surg 75:93-100.nStraka Z, Brucek P, Vanek T, et al. 2002. Routine immediate extubation for off-pump coronary artery bypass grafting without thoracic epidural analgesia. Ann Thorac Surg 74:1544-7.nVandermeulen EP, Van Aken H, Bermylen J. 1994. Anticoagulants and spinal-epidural anesthesia. Anesth Analg 79:1165-77.nWilliams JP. 2002. Thoracic epidural anesthesia for cardiac surgery. Can J Anesth 49:R1-6.n
