Epidural Anesthesia Improves Outcome and Resource Use in Cardiac Surgery: A Single-Center Study of a 1293-Patient Cohort
AbstractThoracic epidural anesthesia (TEA) combined with general anesthesia in cardiac surgery has the potential to initiate earlier spontaneous ventilation and extubation, improved hemodynamics, less arrhythmia or myocardial ischemia, and an attenuated neurohormonal response. The aim of the current study was to characterize the correlation between TEA and postoperative resource use or outcome in a consecutive-patient cohort. The study was performed in a tertiary care, 3-surgeon, university-affiliated hospital that performs 350 to 400 cardiac surgeries per year. All 1293 adult patients who underwent cardiac surgery between July 1, 2002, and February 1, 2006, were included. Patients were assigned to anesthesiologists practicing TEA (TEA group, n = 506) or not (control group, n = 787) for cardiac surgery. The preoperative parameter values and Parsonnet scores for the 2 groups were similar. The 2 groups had the same distribution of surgery types. The TEA group presented with fewer intensive care unit (ICU) complications, such as delirium, pneumonia, and acute renal failure, and presented with better myocardial protection. The TEA group presented with a higher proportion of immediately postoperative extubations and with shorter ventilation times and ICU stays. Total ICU costs decreased from US $18,700 to $9900 per patient. Combining TEA and general anesthesia for cardiac surgery allows a significant change in anesthesia strategy. This change improves immediate postoperative outcomes and reduces the use and costs of ICU resources.
Anim-Somuah M, Smyth R, Howell C. 2005. Epidural versus nonepidural or no analgesia in labour. Cochrane Database Syst Rev CD000331.nArmitage P, Berry G. 1994. Statistical Methods in Medical Research. 3rd ed. London: Blackwell.nBracco D, Noiseux N, Prieto I, Basile F, Hemmerling T. 2007. Acute spinal artery syndrome after off-pump coronary artery bypass graft surgery using combined thoracic epidural and general anesthesia. J Cardiothorac Vasc Anesth 21:709-11.nBrucek PJ, Straka Z, Vanek T, Jares M. 2003. Less invasive cardiac anesthesia: an ultra-fast-track procedure avoiding thoracic epidural analgesia. Heart Surg Forum 6:E107-10.nChaney MA. 2006. Intrathecal and epidural anesthesia and analgesia for cardiac surgery. Anesth Analg 102:45-64.nCheng DC. 1995. Pro: early extubation after cardiac surgery decreases intensive care unit stay and cost. J Cardiothorac Vasc Anesth 9:460-4.nCheng DC. 2005. Regional analgesia and ultra-fast-track cardiac anesthesia. Can J Anaesth 52:12-7.nClowes GH Jr, Neville WE, Hopkins A, Anzola J, Simeone FA. 1954. Factors contributing to success or failure in the use of a pump oxygenator for complete by-pass of the heart and lung, experimental and clinical. Surgery 36:557-79.nDasta JF, McLaughlin TP, Mody SH, Tak Piech C. 2005. Daily cost of an intensive care unit day: the contribution of mechanical ventilation. Crit Care Med 33:1266-71.nDjaiani G, Fedorko L, Beatties WS. 2005. Regional anesthesia in cardiac surgery: a friend or foe? Semin Cardiothorac Vasc Anesth 9:87-104.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.nEly EW, Inouye SK, Bernard GR, et al. 2001. Delirium in mechanically ventilated patients: validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU). JAMA 286:2703-10.nGarner J, Jarvis W, Emori T, Horan T, Hughes J. 1996. CDC definitions for nosocomial infections. In: Olmsted R, editor. APIC infection control and applied epidemiology: principles and practice. St. Louis: Mosby. p A1-20.nGiebler RM, Scherer RU, Peters J. 1997. Incidence of neurologic complications related to thoracic epidural catheterization. Anesthesiology 86:55-63.nGrimes DA, Schulz KF. 2002. Cohort studies: marching toward outcome. Lancet 359:341-5.nHall SV, Johnson EE, Hedley-Whyte J. 1974. Renal hemodynamics and function with continuous positive-pressure ventilation in dogs. Anesthesiology 41:452-61.nHemmerling TM, Basile F, Noiseux N, Prieto I. 2006. Bypassing the ICU after OPCABG: a prospective audit. Anesth Analg 102:SCA–80.nHemmerling TM, Noiseux N, Basile F, Noel MF, Prieto I. 2005. Awake cardiac surgery using a novel anesthetic technique. Can J Anaesth 52:1088-92.nHemmerling TM, Prieto I, Choiniere JL, Basile F, Fortier JD. 2004. Ultra-fast-track anesthesia in off-pump coronary artery bypass grafting: a prospective audit comparing opioid-based anesthesia vs thoracic epidural-based anesthesia. Can J Anaesth 51:163-8.nHoar PF, Hickey RF, Ullyot DJ. 1976. Systemic hypertension following myocardial revascularization: a method of treatment using epidural anesthesia. J Thorac Cardiovasc Surg 71:859-64.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.nHutcheson J, Sonntag H, Hill E, Hanekop G, Kazmair S. 2005. High thoracic epidural anesthesia's effect on myocardial blood flow, oxygen consumption, myocardial work and markers of ischemia during coronary artery bypass grafting: a randomised controlled trial. Anesth Analg 102:SCA–13.nKuiper JW, Groeneveld AB, Slutsky AS, Plotz FB. 2005. Mechanical ventilation and acute renal failure. Crit Care Med 33:1408-15.nLagunilla J, García-Bengochea JB, Fernández AL, et al. 2006. High thoracic epidural blockade increases myocardial oxygen availability in coronary surgery patients. Acta Anaesthesiol Scand 50:780-6.nLawrence DR, Valencia O, Smith EEJ, Murday A, Treasure T. 2000. Parsonnet score is a good predictor of the duration of intensive care unit stay following cardiac surgery. Heart 83:429-32.nLiem TH, Booij LH, Gielen MJ, Hasenbos MA, van Egmond J. 1992. Coronary artery bypass grafting using two different anesthetic techniques: part 3: adrenergic responses. J Cardiothorac Vasc Anesth 6:162-7.nLiem TH, Booij LH, Hasenbos MA, Gielen MJ. 1992. Coronary artery bypass grafting using two different anesthetic techniques: part 1: hemodynamic results. J Cardiothorac Vasc Anesth 6:148-55.nLiem TH, Hasenbos MA, Booij LH, Gielen MJ. 1992. Coronary artery bypass grafting using two different anesthetic techniques: part 2: postoperative outcome. J Cardiothorac Vasc Anesth 6:156-61.nLiu SS, Block BM, Wu CL. 2004. Effects of perioperative central neuraxial analgesia on outcome after coronary artery bypass surgery: a meta-analysis. Anesthesiology 101:153-61.nMamdani M, Sykora K, Li P, et al. 2005. Reader's guide to critical appraisal of cohort studies: 2. Assessing potential for confounding. BMJ 330:960-2.nMoen V, Dahlgren N, Irestedt L. 2004. Severe neurological complications after central neuraxial blockades in Sweden 1990-1999. Anesthesiology 101:950-9.nNewcombe RG. 1998. Interval estimation for the difference between independent proportions: comparison of eleven methods. Stat Med 17:873-90.nNewcombe RG. 1998. Two-sided confidence intervals for the single proportion: comparison of seven methods. Stat Med 17:857-72.nNormand SLT, Sykora K, Mamdani M, Rochon PA, Anderson GM. 2005. Reader's guide to critical appraisal of cohort studies: 3. Analytical strategies to reduce confounding. BMJ 330:1021-3.nOxelbark S, Bengtsson L, Eggersen M, et al. 2001. Fast track as a routine for open heart surgery. Eur J Cardiothorac Surg 19:460-3.nPetrovski V, Slavevski D, Stoicovski E, et al. 2006. The advantages of combined epidural and general anesthesia vs. conventional general anesthesia in off pump coronary artery bypass surgery. Anesth Analg 102:SCA–68.nRochon PA, Gurwitz JH, Sykora K, et al. 2005. Reader's guide to critical appraisal of cohort studies: 1. Role and design. BMJ 330:895-7.nSAS Institute. 2003. JMP statistical software, version 126.96.36.199. Cary, NC: SAS Institute.nSong D, Chung F, Ronayne M, Ward B, Yosendran S, Sibbick C. 2004. Fast-tracking (bypassing the PACU) does not reduce nursing workload after ambulatory surgery. Br J Anaesth 93:768-74.nStraka Z, Brucek P, Vanek T, Votava J, Widimsky P. 2002. Routine immediate extubation for off-pump coronary artery bypass grafting without thoracic epidural analgesia. Ann Thorac Surg 74:1544-7.nTaniguchi M, Kasaba T, Takasaki M. 1997. Epidural anesthesia enhances sympathetic nerve activity in the unanesthetized segments in cats. Anesth Analg 84:391-7.nVandermeulen E. 2005. Anaesthesia and new antithrombotic drugs. Curr Opin Anaesthesiol 18:353-9.nWalji S, Peterson RJ, Neis P, DuBroff R, Gray WA, Benge W. 1999. Ultra-fast track hospital discharge using conventional cardiac surgical techniques. Ann Thorac Surg 67:363-9; discussion 369-70.nWaurick R, Van Aken H. 2005. Update in thoracic epidural anaesthesia. Best Pract Res Clin Anaesthesiol 19:201-13.n
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