Effectiveness and Safety of Thoracic Epidural Analgesia for Postoperative Complications after Cardiac Surgery: A Systematic Review_Chinese Journal of Evidence-Based Medicine

Authors：

WEI Guo , XUAN Yan , ZHENG Hong ,  WANG Jiang

Department of Anesthesiology, The First Affiliated Hospital of Xinjiang Medical University, Urumqi 830054, China;

Corresponding author：

WANG Jiang, Email: 710985259@qq.com

Keywords：

Cardiac surgery; Epidural analgesia; General anesthesia; Systematic review; Meta-analysis; Randomized controlled trial

DOI：

10.7507/1672-2531.20130211

Video：

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Objective 　To systematically review the effectiveness and safety of thoracic epidural analesis (TEA) for postoperative complications after cardiac surgery.
Methods 　Such databases as PubMed, Science Citation Index, EMbase, The Cochrane Library, CNKI and CBM were electronically searched from inception to October 2012 for collecting the randomized controlled trials on the effectiveness and safety of thoracic epidural analgesisa for postoperative complications after cardiac surgery. Two reviewers independently screened literature according to inclusion and exclusion criteria, extracted data, and assessed the methodological quality of the included studies. Then, meta-analysis was performed using RevMan 5.1 software.
Results 　Totally 14 studies were eligible, involving 1 942 patients. The results of meta-analysis showed that, TEA combined with general anesthesia (GA) was superior to GA alone in reducing the incidences of myocardial ischemia/infarction (RR=0.63, 95%CI 0.41 to 0.96, P=0.03), respiratory complications (RR=0.55, 95%CI 0.40 to 0.75, P=0.000 1), supraventricular arrhythmias (RR=0.64, 95%CI 0.47 to 0.88, P=0.005), and duration of mechanical ventilation (MD= –2.15, 95%CI –3.72 to –0.58, P=0.007), with significant differences.
Conclusions 　Current evidence shows that, TEA after surgery is effective in reducing the incidences of myocardial ischemia/infarction, respiratory complications, supraventricular arrhythmias, and duration of mechanical ventilation. There is the lack of data on the adverse events of TEA (mainly referring to epidural hematoma). Due to limited quality and quantity of the included studies, patients’ conditions should be fully considered before applying TEA in clinical practice.

Citation： WEI Guo,XUAN Yan,ZHENG Hong,WANG Jiang. Effectiveness and Safety of Thoracic Epidural Analgesia for Postoperative Complications after Cardiac Surgery: A Systematic Review. Chinese Journal of Evidence-Based Medicine, 2013, 13(10): 1229-1235. doi: 10.7507/1672-2531.20130211 Copy

1.	Mangano DT. Assessment of the patient with cardiac disease: An anesthesiologist’s paradigm. Anesthesiology, 1999, 92(5): 1521-1526.
2.	Coriat P, Beaussier M. Fast-tracking after coronary artery bypass graft surgery. Anesth Analg, 2001, 92(5): 1081-1083.
3.	Sabaté S, Mases A, Guilera N, et al. Incidence and predictors of major perioperative adverse cardiac and cerebrovascular events in non-cardiac surgery. Br J Anaesth, 2011, 107(6): 879-890.
4.	Scott NB, Turfrey DJ, Ray DA, et al. A prospective randomized study of the potential benefits of thoracic epidural anesthesia and analgesia in patients undergoing coronary artery bypass grafting.Anesth Analg, 2001, 93(3): 528-535.
5.	Djaiani G. Thoracic epidural anesthesia as an adjunct to general anesthesia for cardiac surgery: Effects on ventilationperfusion relationships. J Cardiothorac Vasc Anesth, 2000, 14(3): 359-360.
6.	Priestley MC, Cope L, Halliwell R, et al. Thoracic epidural anesthesia for cardiac surgery: The effects on tracheal intubation time and length of hospital stay. Anesth Analg, 2002, 94(2): 275-282.
7.	Nygård E, Kofoed KF, Freiberg J, et al. Effects of high thoracic epidural analgesia on myocardial blood flow in patients with ischemic heart disease. Circulation, 2005, 111(17): 2165-2170.
8.	Beattie WS, Badner NH, Choi PT. Meta-analysis demonstrates statistically significant reduction in postoperative myocardial infarction with the use of thoracic epidural analgesia. Anesth Analg, 2003, 97(3): 919-920.
9.	Ballantyne JC, Carr DB, deFerranti S, et al. The comparative effects of postoperative analgesic therapies on pulmonary outcome: Cumulative meta-analyses of randomized, controlled trials. Anesth Analg, 1998, 86(3): 598-612.
10.	Stenseth R, Bjella L, Berg EM, et al. Effects of thoracic epidural analgesia on pulmonary function after coronary artery bypass surgery. Eur J Cardiothorac Surg, 1996, 10(10): 859-865.
11.	Ho AM, Chung DC, Joynt GM. Neuraxial blockade and hematoma in cardiac surgery: Estimating the risk of a rare adverse event that has not (yet) occurred. Chest, 2000, 117(2): 551-555.
12.	Royse C, Royse A, Soeding P, et al. Prospective randomized trial of high thoracic epidural analgesia for coronary artery bypass surgery. Ann Thorac Surg, 2003, 75(1): 93-100.
13.	Kiliçkan L, Gonca S, Dalçik C, et al. General anesthesia with thoracic epidural anesthesia in the cardiopulmonary bypass surgery reduces apoptosis by upregulating antiapoptotic protein Bcl-2. J Cardiovasc Surg (Torino), 2006, 47(3): 315-322.
14.	Kerstein J, Soodan A, Qamar M, et al. Giving IV and oral amiodarone perioperatively for the prevention of postoperative atrial fibrillation in patients undergoing coronary artery bypass surgery: The GAP study. Chest, 2004, 126(3): 716-724.
15.	Burgess DC, Kilborn MJ, Keech AC. Interventions for prevention of post-operative atrial fibrillation and its complications after cardiac surgery: A meta-analysis. Eur Heart J, 2006, 27(23): 2846-2857.
16.	Cheng DC. Fast-track cardiac surgery:Economic implications in postoperative care. J Cardiothorac Vasc Anesth, 1998, 12(1): 72-79.
17.	Cheng DC, Karski J, Peniston C, et al. Early tracheal extubation after coronary artery bypass graft surgery reduces costs and improves resource use: A prospective, randomized, controlled trial. Anesthsiology, 1996, 85(6): 1300-1310.
18.	Silbert BS, Santamaria JD, O’Brien JL, et al. Early extubation following coronary artery bypass surgery: A prospective randomized controlled trial. The Fast Track Cardiac Care Team. Chest, 1998, 113(6): 1481-1488.
19.	Liu SS, Block BM, Wu CL. Effects of perioperative central neuraxial analgesia on outcome after coronary artery bypass surgery: A meta-analysis. Anesthesiology, 2004, 101(1): 153-161.
20.	Loick HM, Schmidt C, van Aken H, et al. High thoracic epidural anesthesia, but not clonidine, attenuates the perioperative stress response via sympatholysis and reduces the release of troponin T in patients undergoing coronary artery bypass grafting. Anesth Analg, 1999, 88(4): 701-709.
21.	Bach F, Grundmann U, Bauer M, et al. Modulation of the inflammatory response to cardiopulmonary bypass by dopexamine and epidural anesthesia. Acta Anaesthesiol Scand, 2002, 46(10): 1227-1235.
22.	de Vries AJ, Mariani MA, van der Maaten JM, et al. To ventilate or not after minimally invasive direct coronary artery bypass surgery: The role of epidural anesthesia. J Cardiothorac Vasc Anesth, 2002, 16(1): 21-26.
23.	Berendes E, Schmidt C, van Aken H, et al. Reversible cardiac sympathectomy by high thoracic epidural anesthesia improves regional left ventricular function in patients undergoing coronary artery bypass grafting: A randomized trial. Arch Surg, 2003, 138(12): 1283-1290.
24.	Kendall JB, Russell GN, Scawn ND, et al. A prospective, randomised, single-blind pilot study to determine the effect of anaesthetic technique on troponin T release after off-pump coronary artery surgery. Anaesthesia, 2004, 59(6): 545-549.
25.	Barrington MJ, Kluger R, Watson R, et al. Epidural anesthesia for coronary artery bypass surgery compared with general anesthesia alone does not reduce biochemical markers of myocardial damage. Anesth Analg, 2005, 100(4): 921-928.
26.	Hansdottir V, Philip J, Olsen MF, et al. Thoracic epidural versus intravenous patient-controlled analgesia after cardiac surgery: A randomized controlled trial on length of hospital stay and patient-perceived quality of recovery. Anesthesilogy, 2006, 104(1): 142-151.
27.	Bakhtiary F, Therapidis P, Dzemali O, et al. Impact of high thoracic epidural anesthesia on incidence of perioperative atrial fibrillation in off-pump coronary bypass grafting: A prospective randomized study. J Thorac Cardiovasc Surg, 2007, 134(2), 460-464.
28.	Caputo M, Alwair H, Rogers CA, et al. Myocardial, inflammatory, and stress responses in off-pump coronary artery bypass graft surgery with thoracic epidural anesthesia. Ann Thorac Surg, 2009, 87(4): 1119-1126.
29.	Svircevic V, Nierich AP, Moons KG, et al. Thoracic epidural anesthesia for cardiac surgery: A randomized trial. Aneshesilogy, 2011, 114(2): 262-270.
30.	周新, 程红. 胸部硬膜外阻滞在心脏开胸手术术后镇痛的临床研究. 四川医学杂志, 2010, 31(3): 344-346.

1. Mangano DT. Assessment of the patient with cardiac disease: An anesthesiologist’s paradigm. Anesthesiology, 1999, 92(5): 1521-1526.
2. Coriat P, Beaussier M. Fast-tracking after coronary artery bypass graft surgery. Anesth Analg, 2001, 92(5): 1081-1083.
3. Sabaté S, Mases A, Guilera N, et al. Incidence and predictors of major perioperative adverse cardiac and cerebrovascular events in non-cardiac surgery. Br J Anaesth, 2011, 107(6): 879-890.
4. Scott NB, Turfrey DJ, Ray DA, et al. A prospective randomized study of the potential benefits of thoracic epidural anesthesia and analgesia in patients undergoing coronary artery bypass grafting.Anesth Analg, 2001, 93(3): 528-535.
5. Djaiani G. Thoracic epidural anesthesia as an adjunct to general anesthesia for cardiac surgery: Effects on ventilationperfusion relationships. J Cardiothorac Vasc Anesth, 2000, 14(3): 359-360.
6. Priestley MC, Cope L, Halliwell R, et al. Thoracic epidural anesthesia for cardiac surgery: The effects on tracheal intubation time and length of hospital stay. Anesth Analg, 2002, 94(2): 275-282.
7. Nygård E, Kofoed KF, Freiberg J, et al. Effects of high thoracic epidural analgesia on myocardial blood flow in patients with ischemic heart disease. Circulation, 2005, 111(17): 2165-2170.
8. Beattie WS, Badner NH, Choi PT. Meta-analysis demonstrates statistically significant reduction in postoperative myocardial infarction with the use of thoracic epidural analgesia. Anesth Analg, 2003, 97(3): 919-920.
9. Ballantyne JC, Carr DB, deFerranti S, et al. The comparative effects of postoperative analgesic therapies on pulmonary outcome: Cumulative meta-analyses of randomized, controlled trials. Anesth Analg, 1998, 86(3): 598-612.
10. Stenseth R, Bjella L, Berg EM, et al. Effects of thoracic epidural analgesia on pulmonary function after coronary artery bypass surgery. Eur J Cardiothorac Surg, 1996, 10(10): 859-865.
11. Ho AM, Chung DC, Joynt GM. Neuraxial blockade and hematoma in cardiac surgery: Estimating the risk of a rare adverse event that has not (yet) occurred. Chest, 2000, 117(2): 551-555.
12. Royse C, Royse A, Soeding P, et al. Prospective randomized trial of high thoracic epidural analgesia for coronary artery bypass surgery. Ann Thorac Surg, 2003, 75(1): 93-100.
13. Kiliçkan L, Gonca S, Dalçik C, et al. General anesthesia with thoracic epidural anesthesia in the cardiopulmonary bypass surgery reduces apoptosis by upregulating antiapoptotic protein Bcl-2. J Cardiovasc Surg (Torino), 2006, 47(3): 315-322.
14. Kerstein J, Soodan A, Qamar M, et al. Giving IV and oral amiodarone perioperatively for the prevention of postoperative atrial fibrillation in patients undergoing coronary artery bypass surgery: The GAP study. Chest, 2004, 126(3): 716-724.
15. Burgess DC, Kilborn MJ, Keech AC. Interventions for prevention of post-operative atrial fibrillation and its complications after cardiac surgery: A meta-analysis. Eur Heart J, 2006, 27(23): 2846-2857.
16. Cheng DC. Fast-track cardiac surgery:Economic implications in postoperative care. J Cardiothorac Vasc Anesth, 1998, 12(1): 72-79.
17. Cheng DC, Karski J, Peniston C, et al. Early tracheal extubation after coronary artery bypass graft surgery reduces costs and improves resource use: A prospective, randomized, controlled trial. Anesthsiology, 1996, 85(6): 1300-1310.
18. Silbert BS, Santamaria JD, O’Brien JL, et al. Early extubation following coronary artery bypass surgery: A prospective randomized controlled trial. The Fast Track Cardiac Care Team. Chest, 1998, 113(6): 1481-1488.
19. Liu SS, Block BM, Wu CL. Effects of perioperative central neuraxial analgesia on outcome after coronary artery bypass surgery: A meta-analysis. Anesthesiology, 2004, 101(1): 153-161.
20. Loick HM, Schmidt C, van Aken H, et al. High thoracic epidural anesthesia, but not clonidine, attenuates the perioperative stress response via sympatholysis and reduces the release of troponin T in patients undergoing coronary artery bypass grafting. Anesth Analg, 1999, 88(4): 701-709.
21. Bach F, Grundmann U, Bauer M, et al. Modulation of the inflammatory response to cardiopulmonary bypass by dopexamine and epidural anesthesia. Acta Anaesthesiol Scand, 2002, 46(10): 1227-1235.
22. de Vries AJ, Mariani MA, van der Maaten JM, et al. To ventilate or not after minimally invasive direct coronary artery bypass surgery: The role of epidural anesthesia. J Cardiothorac Vasc Anesth, 2002, 16(1): 21-26.
23. Berendes E, Schmidt C, van Aken H, et al. Reversible cardiac sympathectomy by high thoracic epidural anesthesia improves regional left ventricular function in patients undergoing coronary artery bypass grafting: A randomized trial. Arch Surg, 2003, 138(12): 1283-1290.
24. Kendall JB, Russell GN, Scawn ND, et al. A prospective, randomised, single-blind pilot study to determine the effect of anaesthetic technique on troponin T release after off-pump coronary artery surgery. Anaesthesia, 2004, 59(6): 545-549.
25. Barrington MJ, Kluger R, Watson R, et al. Epidural anesthesia for coronary artery bypass surgery compared with general anesthesia alone does not reduce biochemical markers of myocardial damage. Anesth Analg, 2005, 100(4): 921-928.
26. Hansdottir V, Philip J, Olsen MF, et al. Thoracic epidural versus intravenous patient-controlled analgesia after cardiac surgery: A randomized controlled trial on length of hospital stay and patient-perceived quality of recovery. Anesthesilogy, 2006, 104(1): 142-151.
27. Bakhtiary F, Therapidis P, Dzemali O, et al. Impact of high thoracic epidural anesthesia on incidence of perioperative atrial fibrillation in off-pump coronary bypass grafting: A prospective randomized study. J Thorac Cardiovasc Surg, 2007, 134(2), 460-464.
28. Caputo M, Alwair H, Rogers CA, et al. Myocardial, inflammatory, and stress responses in off-pump coronary artery bypass graft surgery with thoracic epidural anesthesia. Ann Thorac Surg, 2009, 87(4): 1119-1126.
29. Svircevic V, Nierich AP, Moons KG, et al. Thoracic epidural anesthesia for cardiac surgery: A randomized trial. Aneshesilogy, 2011, 114(2): 262-270.
30. 周新, 程红. 胸部硬膜外阻滞在心脏开胸手术术后镇痛的临床研究. 四川医学杂志, 2010, 31(3): 344-346.

Chinese Journal of Evidence-Based Medicine

Effectiveness and Safety of Thoracic Epidural Analgesia for Postoperative Complications after Cardiac Surgery: A Systematic Review

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