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      Neuraxial anesthesia for cardiac surgery: thoracic epidural and high spinal anesthesia - why is it different?

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          Abstract

          Anesthesiologists can offer much more then stable blood pressure and heart rate in the intraoperative period. By choosing appropriate anesthetic techniques they can tremendously influence perioperative stress. This may positively impact on the overall surgical outcome. One of the most intriguing aspects of neuraxial anesthesia is its ability to attenuate the stress response to surgery.

          At present there is no agreement on the clinical importance of such a response but there is substantial indirect evidence that it may play an important role in a patient’s outcome. Neuraxial anesthesia supplemented by general anesthesia is justified and can be safely used in cardiac surgery.

          The authors of this expert opinion prefer spinal anesthesia to thoracic epidural anesthesia and have been using it routinely for the last 20 years without any neurological complications. The risk of spinal hematoma from a 27G spinal needle prior to full heparinization is unknown but in our opinion is remote. Both epidural and spinal techniques can and should have a place in modern cardiac anesthesia practice and should be further investigated.

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          Most cited references 14

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          Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial.

            (2008)
          Trials of beta blockers in patients undergoing non-cardiac surgery have reported conflicting results. This randomised controlled trial, done in 190 hospitals in 23 countries, was designed to investigate the effects of perioperative beta blockers. We randomly assigned 8351 patients with, or at risk of, atherosclerotic disease who were undergoing non-cardiac surgery to receive extended-release metoprolol succinate (n=4174) or placebo (n=4177), by a computerised randomisation phone service. Study treatment was started 2-4 h before surgery and continued for 30 days. Patients, health-care providers, data collectors, and outcome adjudicators were masked to treatment allocation. The primary endpoint was a composite of cardiovascular death, non-fatal myocardial infarction, and non-fatal cardiac arrest. Analyses were by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00182039. All 8351 patients were included in analyses; 8331 (99.8%) patients completed the 30-day follow-up. Fewer patients in the metoprolol group than in the placebo group reached the primary endpoint (244 [5.8%] patients in the metoprolol group vs 290 [6.9%] in the placebo group; hazard ratio 0.84, 95% CI 0.70-0.99; p=0.0399). Fewer patients in the metoprolol group than in the placebo group had a myocardial infarction (176 [4.2%] vs 239 [5.7%] patients; 0.73, 0.60-0.89; p=0.0017). However, there were more deaths in the metoprolol group than in the placebo group (129 [3.1%] vs 97 [2.3%] patients; 1.33, 1.03-1.74; p=0.0317). More patients in the metoprolol group than in the placebo group had a stroke (41 [1.0%] vs 19 [0.5%] patients; 2.17, 1.26-3.74; p=0.0053). Our results highlight the risk in assuming a perioperative beta-blocker regimen has benefit without substantial harm, and the importance and need for large randomised trials in the perioperative setting. Patients are unlikely to accept the risks associated with perioperative extended-release metoprolol.
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            A prospective randomized study of the potential benefits of thoracic epidural anesthesia and analgesia in patients undergoing coronary artery bypass grafting.

            We performed an open, prospective, randomized, controlled study of the incidence of major organ complications in 420 patients undergoing routine coronary artery bypass graft surgery with or without thoracic epidural anesthesia and analgesia (TEA). All patients received a standardized general anesthetic. Group TEA received TEA for 96 h. Group GA (general anesthesia) received narcotic analgesia for 72 h. Both groups received supplementary oral analgesia. Twelve patients were excluded-eight in Group TEA and four in Group GA-because of incomplete data collection. New supraventricular arrhythmias occurred in 21 of 206 patients (10.2%) in Group TEA compared with 45 of 202 patients (22.3%) in Group GA (P = 0.0012). Pulmonary function (maximal inspiratory lung volume) was better in Group TEA in a subset of 93 patients (P < 0.0001). Extubation was achieved earlier (P < 0.0001) and with significantly fewer lower respiratory tract infections in Group TEA (TEA = 31 of 206, GA = 59 of 202; P = 0.0007). There were significantly fewer patients with acute confusion (GA = 11 of 202, TEA = 3 of 206; P = 0.031) and acute renal failure (GA = 14 of 202, TEA = 4 of 206; P = 0.016) in the TEA group. The incidence of stroke was insignificantly less in the TEA group (GA = 6 of 202, TEA = 2 of 206; P = 0.17). There were no neurologic complications associated with the use of TEA. We conclude that continuous TEA significantly improves the quality of recovery after coronary artery bypass graft surgery compared with conventional narcotic analgesia.
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              Cardiovascular response to large doses of intravenous morphine in man.

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                Author and article information

                Journal
                HSR Proc Intensive Care Cardiovasc Anesth
                HSR Proc Intensive Care Cardiovasc Anesth
                2037-0504
                hsrp
                HSR Proceedings in Intensive Care & Cardiovascular Anesthesia
                EDIMES Edizioni Internazionali Srl
                2037-0504
                2037-0512
                2011
                : 3
                : 1
                : 25-28
                Affiliations
                Department of Cardiac Anesthesia, LIBIN Cardiovascular Institute of Alberta, Foothills Medical Centre University of Calgary, Calgary, Alberta, Canada
                Author notes
                Richard Kowalewski MD, PhD. FRCPC Department of Cardiac Anesthesia Foothills Medical Centre, University of Calgary Calgary, Alberta, Canada; E-mail: ogopogo@ 123456me.com
                Article
                201101025
                3484610
                23440039
                Copyright © 2011, HSR Proceedings in Intensive Care and Cardiovascular Anesthesia

                This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License 3.0, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license.See: http://creativecommons.org/licenses/by-nc/3.0/ and http://creativecommons.org/licenses/by-nc/3.0/legalcode.

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