Epidural Analgesia in Cardiac Surgery: An Updated Risk Assessment
Introduction. The use of epidural anesthesia carries risks that have been known for 50 years. The debate about the use of locoregional technique in cardiac anesthesia continues. The objective of this report is to estimate the risks and their variability of a catheter-related epidural hematoma in cardiac surgery patients and to compare it with other anesthetic and medical procedures.
Methods. Case series reporting the use of epidural anesthesia in cardiac surgery were researched through Medline. Additional references were retrieved from the bibliography of published articles and from the internet. Risks of complications in other anesthetic and medical activity were retrieved from recent reviews.
Results. Based on the present evidence, the risk of epidural hematoma in cardiac surgery is 1:12,000 (95% CI of 1:2100 to 1:68,000), which is comparable to the risk in the nonobstetrical population of 1:10,000 (95% CI 1:6700 to 1:14,900). The risk of epidural hematoma is comparable to the risk of receiving a wrong blood product or the yearly risk of having a fatal road accident in Western countries.
Conclusions. The risk of a hematoma after epidural in cardiac surgery is comparable to other nonobstetrical surgical procedures. Its routine application in a controlled setting should be encouraged.
Bracco D, Favre JB, Bissonnette B, et al. 2001. Human errors in a multidisciplinary intensive care unit: a 1-year prospective study. Intensive Care Med 27:137-45.nBracco D, Noiseux N, Prieto I, Basile F, Hemmerling TM. 2007. Acute spinal artery syndrome after off-pump coronary artery bypass graft surgery using combined thoracic epidural and general anesthesia. J Cardiothorac Vasc Anesth [in press].nCase AS, Ramsey PS. 2005. Spontaneous epidural hematoma of the spine in pregnancy. Am J Obstet Gynecol 193:875-7.nChakravarthy M, Nadiminti S, Krishnamurthy J, et al. 2004. Temporary neurologic deficits in patients undergoing cardiac surgery with thoracic epidural supplementation. J Cardiothorac Vasc Anesth 18:512-20.nChakravarthy M, Thimmangowda P, Krishnamurthy J, Nadiminti S, Jawali V. 2005. Thoracic epidural anesthesia in cardiac surgical patients: a prospective audit of 2,113 cases. J Cardiothorac Vasc Anesth 19:44-8.nChaney MA. 2006. Risk of hematoma after epidural anesthesia and analgesia for cardiac surgery. Anesth Analg 103:1327-8.nChaney MA. 2006. The use of epidural analgesia in cardiac surgery should be encouraged. Anesth Analg 103:1592-3.nGoldstein S, Dean D, Kim SJ, et al. 2001. A survey of spinal and epidural techniques in adult cardiac surgery. J Cardiothorac Vasc Anesth 15;2:158-68.nHanley JA, Lipmann-Hand A. 1983. If nothing goes wrong, is everything all right? Interpreting zero numerators. JAMA 249:1743-5.nHemmerling TM, Djaiani G, Babb P, Williams JP. 2006. The use of epidural analgesia in cardiac surgery should be encouraged. Anesth Analg 103:1592.nHemmerling TM, Olivier JF, Basile F, Prieto I. 2004. Epidural hematoma after anticoagulation with a thoracic epidural catheter in place: a mere coincidence? Anesth Analg 99:1267-8; author reply 1268.nHerout PM, Erstad BL. 2004. Medication errors involving continuously infused medications in a surgical intensive care unit. Crit Care Med 32:428-32.nHo AM, Li PT, Karmakar MK. 2006. Risk of hematoma after epidural anesthesia and analgesia for cardiac surgery. Anesth Analg 103:1327.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.nHyderally HA. 2005. Epidural hematoma unrelated to combined spinalepidural anesthesia in a patient with ankylosing spondylitis receiving aspirin after total hip replacement. Anesth Analg 100:882-3, table of contents.nJack ES, Scott NB. 2006. The risk of vertebral canal complications in 2837 cardiac surgery patients with thoracic epidurals. Acta Anaesthesiol Scand 2006. Online first at http://www.blackwellsynergy.com/doi/abs/10.1111/j.1399-6576.2006.01168.x'>http://www.blackwellsynergy.com/doi/abs/10.1111/j.1399-6576.2006.01168.xnLandrigan CP, Rothschild JM, Cronin JW, et al. 2004. Effect of reducing interns' work hours on serious medical errors in intensive care units. N Engl J Med 351:1838-48.nLundstrom T. 2007. Mandatory reporting of untoward events and nosocomial infections. Presentation at the 36th Annual SCCM congress. Orlando, FL: SCCM; February 17th 2007.nMedical Protection Society UK. 2004. Education and publications—UK casebook 2004 (3)—August: Epidural emergency. URL: http://www.medicalprotection.org/Default.aspx?DN=f4adbf0-cf77-494e-87b9-627ac967a86c'>http://www.medicalprotection.org/Default.aspx?DN=f4adbf0-cf77-494e-87b9-627ac967a86cnMehta RH, Grab JD, O'Brien SM, et al; Society of Thoracic Surgeons National Cardiac Surgery Database Investigators. 2006. Bedside tool for predicting the risk of postoperative dialysis in patients undergoing cardiac surgery. Circulation 114:2208-16.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.nRosen DA, Hawkinberry DW 2nd, Rosen KR, et al. 2004. An epidural hematoma in an adolescent patient after cardiac surgery. Anesth Analg 98:4:966-9, table of contents.nRuppen W, Derry S, McQuay HJ, Moore RA 2006. Incidence of epidural haematoma and neurological injury in cardiovascular patients with epidural analgesia/anaesthesia: systematic review and meta-analysis. BMC Anesthesiol 12;6:10.nRuppen W, Derry S, McQuay H, Moore RA. 2006. Incidence of epidural hematoma, infection, and neurologic injury in obstetric patients with epidural analgesia/anesthesia. Anesthesiology 105:394-9.nSafdar N, Dezfulian C, Collard HR, Saint S. 2005. Clinical and economic consequences of ventilator-associated pneumonia: a systematic review. Crit Care Med 33:2184-93.nSharma S, Kapoor MC, Sharma VK, Dubey AK. 2004. Epidural hematoma complicating high thoracic epidural catheter placement intended for cardiac surgery. J Cardiothorac Vasc Anesth 18:6:759-62.nShroyer AL, Coombs LP, Peterson ED, et al; Society of Thoracic Surgeons. 2003. The Society of Thoracic Surgeons: 30-day operative mortality and morbidity risk models. Ann Thorac Surg 75:1856-64; discussion 1864-5.nStainsby D, Russell J, Cohen H, Lilleyman J. 2005. Reducing adverse events in blood transfusion. Br J Haematol 131:8-12.nYoshida S, Nitta Y, Oda K. 2005. Anterior spinal artery syndrome after minimally invasive direct coronary artery bypass grafting under general combined epidural anesthesia. Jpn J Thorac Cardiovasc Surg 53:230-3.n
How to Cite
Author Disclosure & Copyright Transfer Agreement
In order to publish the original work of another person(s), The Heart Surgery Forum® must receive an acknowledgment of the Author Agreement and Copyright Transfer Statement transferring to Forum Multimedia Publishing, L.L.C., a subsidiary of Carden Jennings Publishing Co., Ltd. the exclusive rights to print and distribute the author(s) work in all media forms. Failure to check Copyright Transfer agreement box below will delay publication of the manuscript.
A current form follows:
The author(s) hereby transfer(s), assign(s), or otherwise convey(s) all copyright ownership of the manuscript submitted to Forum Multimedia Publishing, LLC (Publisher). The copyright transfer covers the exclusive rights to reproduce and distribute the article and the material contained therein throughout the world in all languages and in all media of expression now known or later developed, including but not limited to reprints, photographic reproduction, microfilm, electronic data processing (including programming, storage, and transmission to other electronic data record(s), or any other reproductions of similar nature), and translations.
However, Publisher grants back to the author(s) the following:
- The right to make and distribute copies of all or part of this work for use of the author(s) in teaching;
- The right to use, after publication in The Heart Surgery Forum, all or part of the material from this work in a book by the author(s), or in a collection of work by the author(s);
- The royalty-free right to make copies of this work for internal distribution within the institution/company that employs the author(s) subject to the provisions below for a work-made-for-hire;
- The right to use figures and tables from this work, and up to 250 words of text, for any purpose;
- The right to make oral presentations of material from this work.
Publisher reserves the right to grant or refuse permission to third parties to republish all or part of the article or translations thereof. To republish, such third parties must obtain written permission from the Publisher. (This is in accordance with the Copyright Statute, United States Code, Title 17. Exception: If all authors were bona fide officers or employees of the U.S. Government at the time the paper was prepared, the work is a “work of the US Government” (prepared by an officer or employee of the US Government as part of official duties), and therefore is not subject to US copyright; such exception should be indicated on signature lines. If this work was prepared under US Government contract or grant, the US Government may reproduce, royalty-free, all or portions of this work and may authorize others to do so, for official US Government purposes only, if the US Government contract or grant so requires.
I have participated in the conception and design of this work and in the writing of the manuscript and take public responsibility for it. Neither this manuscript nor one with substantially similar content under my authorship has been published, has been submitted for publication elsewhere, or will be submitted for publication elsewhere while under consideration by The Heart Surgery Forum, except as described in an attachment. I have reviewed this manuscript (original version) and approve its submission. If I am listed above as corresponding author, I will provide all authors with information regarding this manuscript and will obtain their approval before submitting any revision. I attest to the validity, accuracy, and legitimacy of the content of the manuscript and understand that Publisher assumes no responsibility for the validity, accuracy, and legitimacy of its content. I warrant that this manuscript is original with me and that I have full power to make this Agreement. I warrant that it contains no matter that is libelous or otherwise unlawful or that invades individual privacy or infringes any copyright or other proprietary right. I agree to indemnify and hold Publisher harmless of and from any claim made against Publisher that relates to or arises out of the publication of the manuscript and agree that this indemnification shall include payment of all costs and expenses relating to the defense of any such claim, including all reasonable attorney’s fees.
I warrant that I have no financial interest in the drugs, devices, or procedures described in the manuscript (except as disclosed in the attached statement).
I state that the institutional Human Subjects Committee and/or the Ethics Committee approved the clinical protocol reported in this manuscript for the use of experimental techniques, drugs, or devices in human subjects and appropriate informed consent documents were utilized.
Furthermore, I state that any and all animals used for experimental purposes received humane care in USDA registered facilities in compliance with the “Principles of Laboratory Animal Care” formulated by the National Society for Medical Research and the “Guide for the Care and Use of Laboratory Animals” prepared by the Institute of Laboratory Animal Resources and published by the National Institutes of Health (NIH Publication No. 85-23, revised 1985).