Use of High-Thoracic Epidural Analgesia in Pulmonary Endarterectomy: A Randomized Feasibility Study
Background: The suitability of combined high-thoracic epidural anesthesia for pulmonary endarterectomy was studied.
Methods: A prospective randomized clinical study was conducted in a university medical center from November 2005 to December 2006. The primary endpoint of this study was to evaluate perioperative hemodynamic data; secondary endpoints were to evaluate the duration of artificial ventilation, length of stay in the intensive care unit, and the impact on postoperative morbidity and mortality.
Results: The 16 patients in the study group received high-thoracic epidural anesthesia plus general anesthesia; the 16 control patients received total intravenous anesthesia alone. Hemodynamic parameters and drug use, as well as the time to extubation, rate of complications, postoperative pain, the length of intensive care unit stay, and mortality, were recorded. The 2 groups were comparable with respect to hemodynamic stability during induction of anesthesia. The study group patients had significantly lower sufentanil consumption (mean ± SD, 2.1 ± 0.7 ?g/kg versus 9.1 ± 3.1 ?g/kg; P <.001), a shorter period of artificial ventilation (34 ± 35 hours versus 52 ± 49 hours; P = .0318), and lower postoperative pain scores at 3 hours (0.10 ± 0.26 versus 0.93 ± 1.38; P = .015), 12 hours (0.14 ± 0.53 versus 0.93 ± 0.79; P = .002), and 24 hours (0.35 ± 0.49 versus 1.33 ± 1.04; P = .007).
Conclusions: This study has shown that combined epidural and general anesthesia is a suitable anesthetic option in patients who are selected for pulmonary endarterectomy. It provides hemodynamic stability and reduces the duration of tracheal intubation postoperatively and improves postoperative pain relief, although this option has not been shown to decrease either the length of the intensive care unit stay or mortality.
Ballantyne J, Carr D, deFerranti S, et al. 1998. The comparative effects of postoperative analgesic therapies on pulmonary outcome: cumulative meta-analyses of randomized, controlled trials. Anesth Analg 86:598-612.nBoyd O, Murdoch LJ, Mackay CJ, Bennett ED, Grounds RM. 1994. The cardiovascular changes associated with equipotent anaesthesia with either propofol or isoflurane: particular emphasis on right ventricular function. Acta Anaesth Scand 38:357-62.nChoi SU, Lee HW, Lim HJ, Yoon SM, Chang SH. 2007. The effects of propofol on cardiac function after 4 hours of cold cardioplegia and reperfusion. J Cardiothorac Vasc Anesth 21:678-82.nDesborough JP. 1996. Thoracic epidural analgesia in cardiac surgery. Anaesthesia 51:805-7.nFedullo PF, Augre WR, Kerr KM, Rubin LJ. 2001. Chronic thromboembolic pulmonary hypertension. N Engl J Med 345:1465-72.nFillinger MP, Yeager MP, Dodds TM, Fillinger MF, Whalen PK, Glass DD. 2002. Epidural anesthesia and analgesia: effects on recovery from cardiac surgery. J Cardiothorac Vasc Anesth 16:15-20.nHendolin H, Lahtinen J, Lansimies E, Turrurainen T, Partanen K. 1987. The effect of thoracic epidural analgesia on respiratory function after cholecystectomy. Acta Anesthesiol Scand 31:645-51.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.nJamieson SW, Kapelanski DP, Sakakibara N, et al. 2003. Pulmonary endarterectomy: experience and lesson learned in 1,500 cases. Ann Thorac Surg 76:1457-64.nKili¸kan L, Solak M, Bayindir O. 2005. Thoracic epidural anesthesia preserves myocardial function during intraoperative and postoperative period in coronary surgery bypass grafting operation. J Cardiovasc Surg (Torino) 46:559-67.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 S, Carpenter R, Mackey D, et al. 1995. Effects of perioperative analgesic technique on rate of recovery after colon surgery. Anesthesiology 83:757-65.nManecke GR. 2006. Anesthesia for pulmonary endarterectomy. Semin Thorac Cardiovasc Surg 18:236-42.nMartens E, Saldien V, Coppejans H, et al. 2001. Target controlled infusion of remifentanyl and propofol for cesarean section in a patient with multivariant disease and severe pulmonary hypertension. Acta Anest Belg 52:207-9.nMartin C, Saux P, Albanese J, Bonneru JJ, Gouin F. 1987. Right ventricular function during positive end-expiratory pressure: thermodilution evaluation and clinical application. Chest 92:999-1004.nPansard J, Mankikian B, Bertrand M, Kieffer E, Clergue F, Viars P. 1993. Effects of thoracic extradural block on diaphragmatic electrical activity and contractility after upper abdominal surgery. Anesthesiology 78:63-71.nPengo V, Lensing A, Prins M, et al. 2004. Incidence of chronic thromboembolic pulmonary hypertension after pulmonary embolism. N Engl J Med 350:2257-64.nPriestley MC, Cope L, Halliwell R, et al. 2002. Thoracic epidural anesthesia for cardiac surgery: the effects on tracheal intubation time and length of hospital stay. Anesth Analg 94:275-82.nRiedel M, Stanek V, Widimsky J, Prerovsky I. 1982. Longterm follow-up of patients with pulmonary embolism: late prognosis and evolution of hemodynamic and respiratory data. Chest 81:151-8.nRoscoe A, Klein A. 2008. Pulmonary endarterectomy. Curr Opin Anaesth 21:18-20.nRubes D, Lips M, Cermak T, et al. 2005. High thoracic epidural anaesthesia and analgesia in cardiac surgery: a retrospective study EJA. Eur J Anaesthesiol 22(suppl 35):35.nRuppen W, Derryl 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 6:10.nSwenson JD, Hullander RM, Wingler K, Leivers D. 1994. Early extubation after cardiac surgery using combined intrathecal sufentanil, and morphine. J Cardiothorac Vasc Anesth 8:509-14.nThistlethwaite PA, Madani M, Jamieson SW. 2006. Outcomes of pulmonary endarterectomy surgery. Semin Thorac Cardiovasc Surg 18:257-64.nWeiss BM, Maggiorini M, Jenni R, et al. 2000. Pregnant patient with primary pulmonary hypertension: inhaled pulmonary vasodilators and epidural anesthesia for cesarean delivery. Anesthesiology 92:1191-4.n
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