FANZCA,
This study received grants from the Australian Society of Anaesthetists and the Australian and New Zealand College of Anaesthetists.
Presented in part at the annual meeting of the Australian and
New Zealand College of Anaesthetists, Brisbane, Australia, May 12,
2002, and at the Australian Society of Anaesthetists National Scientific Conference, Adelaide, Australia, October 26, 2002.
Accepted for publication September 14, 2004.
Address correspondence and reprint requests to Michael J. Barrington, FANZCA, Department of Anaesthesia, St. Vincents Hospital, Melbourne, PO Box 2900, Fitzroy, Victoria 3065, Australia.
Address e-mail to Michael.Barrington@svhm.org.au.
DOI: 10.1213/01.ANE.0000146437.88485.47
2005 by the International Anesthesia Research Society
0003-2999/05
troponin I levels between study groups. The time to tracheal extubation [median (interquartile range)] in the
HTEA group was 15 min (10 320 min), compared with
430 min (284 590 min) in the GA group (P 0.0001).
Analgesia was improved in the HTEA group compared
with the GA group. Mean arterial blood pressure poststernotomy and systemic vascular resistance in the intensive care unit were lower in the HTEA group. We
conclude that HTEA for CABG surgery had no effect on
troponin release but improved postoperative analgesia
and was associated with a reduced time to extubation.
(Anesth Analg 2005;100:9218)
921
922
a number of studies to improve postoperative analgesia (1,8,11), analgesic regimens and their efficacy are
also institution specific, and thus a third aim of our
study was to assess the effect of HTEA on the quality
of postoperative analgesia.
Methods
The St. Vincents Hospital human research ethics
committee approved this prospective randomized
controlled trial, and written informed consent was
obtained from all patients. All patients scheduled
for elective CABG surgery (using cardiopulmonary
bypass (CPB)) were eligible. Exclusion criteria were
emergency or repeat CABG surgery, combined
valve and CABG surgery, aspirin ingestion within
6 days of surgery, a platelet count 150 109/L, an
international normalized ratio 1.1, active neurological disease, and cutaneous disorders at the epidural insertion site. Patients were randomized the
day before surgery to the GA group or the combined
GA and HTEA group. The random-allocation sequence was computer-generated in permuted blocks
of four and enclosed in sequentially numbered
opaque sealed envelopes.
Patients randomized to the HTEA group had an
epidural catheter (20-gauge; Portex, Hythe, Kent, UK)
inserted the day before surgery at T1-2 or T2-3 by
using a midline approach and loss-of-resistance-tosaline technique. Epidural catheters were inserted
with patients sitting, by using an 18-gauge needle with
the bevel directed cephalad, advanced into the epidural space 4 cm, and flushed with saline. Patients
received their usual cardiac medications on the day of
surgery. Premedication consisted of temazepam 20 mg
and ranitidine 150 mg orally and morphine 0.10
0.15 mg/kg IM 2 h before anesthetic induction.
After initiation of ECG monitoring (leads II and V5
monitored) and insertion of invasive monitoring (radial artery cannula and pulmonary artery catheter),
epidural block was established with 5 mL of ropivacaine 1% and fentanyl 50 g. The block was assessed
20 min later by using loss of temperature sensation to
ice, with success defined as a block over the T1 to
T6 dermatomes. If required, the block was extended
with 2 mL of ropivacaine 1%.
GA was induced with midazolam (0.05 0.1 mg/kg),
fentanyl (715 g/kg for the GA group and 57 g/kg
for the HTEA group), propofol (20-mg increments as
required), and rocuronium (0.6 mg/kg). GA was
maintained with propofol 3 6 mg kg1 h1. Further
doses of rocuronium 10 mg were given only for overt
patient movement, with no additional rocuronium
given after CPB. Intraoperative hemodynamic management was standardized although, to represent routine practice, anesthesiologists defined acceptable limits to optimize individual patient management.
ANESTH ANALG
2005;100:9218
1
Martin B, Murphy F, Levy T, et al. Cardiac isoform of troponin-I
(c-TnI): a sensitive marker of perioperative myocardial infarction
(PMI) in CABG surgery [abstract]. Br J Anaesth 1999;82:A10.
ANESTH ANALG
2005;100:9218
CARDIOVASCULAR ANESTHESIA
BARRINGTON ET AL.
EPIDURAL ANESTHESIA FOR CORONARY ARTERY BYPASS SURGERY
Hemodynamic measurements were recorded immediately before induction, 5 min after tracheal intubation, 12 min poststernotomy, and 10 min after separation from CPB. Measurements consisted of heart
rate, MAP, mean pulmonary arterial pressure, central
venous pressure, pulmonary artery occlusion pressure
(PAOP), cardiac index (mean of three determinations
by thermodilution), and systemic vascular resistance
(SVR). Baseline left ventricular (LV) function was
scored after induction by using transesophageal echocardiography based on a 16-segment model (16). Segments were scored as 1, normal; 2, mild hypokinesis;
3, severe hypokinesis; 4, akinesis; 5, dyskinesis; and 6,
aneurysmal. An LV score was calculated by totaling
the scores of the 16 segments. After CPB, the LV was
assessed for new segmental wall motion abnormalities
(SWMAs). Intraoperative and postoperative vasoactive drug requirements were recorded.
To facilitate early tracheal extubation, the propofol
infusion was ceased at sternal closure, and minute
ventilation was reduced to stimulate spontaneous
ventilation. The time to tracheal extubation was measured from the time of surgical dressings. The anesthesiologist tracheally extubated patients in the operating
room if extubation criteriarespiratory rate 10 20
breaths/min, responsiveness to voice, end-tidal CO2
50 mm Hg, Sao2 94% with a fraction of inspired
oxygen of 1.0, hemodynamic stability, minimal chest
drain output (not requiring transfusion or consideration for surgical reexploration) and temperature
35.9Cwere achieved within 30 min. For patients
not extubated in the operating room, postoperative
management of ventilation and extubation followed
existing unit guidelines (17). Patients were required to
respond appropriately to voice, have an acceptable
ventilatory pattern and arterial blood gas analysis,
and be hemodynamically stable. The first postextubation arterial blood gas (at approximately 30 min), complications, chest tube drainage, and day of discharge
were recorded. Hemodynamic measurements were repeated in the intensive care unit (ICU) at two or more
time points.
The GA group received an initial loading dose of
morphine 0.1 0.2 mg/kg after separation from CPB
and infiltration of ropivacaine 3 mg/kg into chest
drain sites. Pain management in the ICU followed
existing guidelines (17), including titration of morphine increments (1 mg) and commencement of a
morphine infusion (after tracheal extubation) that continued until the morning of postoperative Day 2. In
the HTEA group, an epidural infusion (ropivacaine
0.2% and fentanyl 2 g/mL) was commenced 1 h after
the induction of GA at an hourly rate equal to the
required initial loading volume and was continued
until the morning of postoperative day 3. If epidural
analgesia was inadequate, the infusion was increased
by 2 mL/h after a bolus of 2 mL. All patients received
923
acetaminophen 1 g rectally at the completion of surgery. Pain rescue medication for both groups consisted of indomethacin 100 mg/12 h and oxycodone
5 mg/6 h. HTEA patients with a failed block received
a morphine infusion as was used in the GA group.
Pain scores were measured with a visual analog
scale (VAS) of 0 100 mm at 4 time points (separated
by 4 6 h) during the first 24 h after tracheal extubation and at 2 time points (separated by 8 12 h) in the
second and third 24-h periods after surgery. VAS pain
scores were measured at rest and with coughing. Side
effects and complications of analgesia were recorded
at each analgesia assessment. Sedation was graded as
0, fully alert; 1, mildly drowsy; 2, moderately drowsy,
easily rousable; 3, very drowsy but rousable; and 4,
difficult to rouse or unrousable. Nausea was graded as
0, no nausea; 1, nausea but no vomiting; and 2, nausea
and vomiting. Motor and sensory block were recorded
in the HTEA group. Motor block in the upper limb
was graded as 0, none; 1, mild hand weakness; 2,
elbow weakness; and 3, weakness involving the shoulder. A research nurse or investigator usually performed these assessments. After hours, some of the
assessments were performed by appropriately briefed
ICU nurses and anesthesiology residents.
A formal sample size determination based on cTnI
was not possible because cTnI data after CABG surgery with the Abbott AxSYM analyzer were not available at the time of study inception. The confidence
interval for differences in median cTnI levels between
groups was calculated to assess the precision of our
data and, hence, the adequacy of our sample size.
Nonparametric confidence intervals were calculated
using Confidence Interval Analysis software (BMJ
Books, London, UK).
For our secondary end-point, sample size was calculated by using a mean time to tracheal extubation of
240 min, with an sd of 200 min (17). A clinically
significant difference was determined to be a 50%
reduction; this required a sample size of 45 in each
group. Between-group analyses were performed with
the Mann-Whitney U-test or Students t-test, depending on the distribution and character of the data. Bonferronis correction was used for multiple comparisons for hemodynamic data. Categorical data were
compared by using Fishers exact test. Time to tracheal
extubation was analyzed with Kaplan-Meier survival
curves and log-rank tests for differences between
groups. The level of significance was taken as 0.05.
Data were analyzed with StatView 4 (Abacus Concepts, Berkeley, CA) and Stata Version 7.0 (Stata
Corporation, College Station, TX).
Results
One-hundred-twenty patients were randomized to 2
groups of 60 from December 1999 to March 2002. All
924
ANESTH ANALG
2005;100:9218
GA group
(n 60)
HTEA group
(n 60)
P value
53/7
62 (10)
27.7 (4)
39
35
4
20
24
2
1
38
24
21
21
44
3 (23)
17 (1619)
83 (25)
576 (202)
1166 (400)
105 (31)
266 (57)
32.5 (0.9)
36.3 (0.4)
3 (34)
51/9
63 (9)
27.1 (4)
36
25
8
20
27
11
12
32
15
21
22
41
2 (2 3)
17 (1619)
77 (22)
537 (116)
1082 (293)
98 (25)
258 (47)
32.5 (0.9)
36.3 (0.3)
3 (34)
NS
NS
NS
NS
NS
NS
NS
0.016
0.002
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
GA general anesthesia; HTEA high thoracic epidural anesthesia; NS not significant; NYHA New York Heart Association; LV score cumulative
score based on 16 segment model; ACE angiotensin-converting enzyme; CPB cardiopulmonary bypass.
Data are n, mean (sd), or median (interquartile range).
a
A patient who claimed to have ceased smoking for 2 mo before surgery.
b
Total volume given.
ANESTH ANALG
2005;100:9218
CARDIOVASCULAR ANESTHESIA
BARRINGTON ET AL.
EPIDURAL ANESTHESIA FOR CORONARY ARTERY BYPASS SURGERY
925
HTEA (n 60)
Dose (mg)
Dose (mg)
P value
2.0 (1.03.3)
10 (5.018)
53
30
2.0 (1.03.5)
6.0 (6.012.8)
45
37
NS
NS
1.0 (0.124.7)
2.0 (0.280.2)
21 (4.071.1)
8
13
58
1.0 (0.22.8)
2.0 (0.59.4)
16 (3.818.8)
6
21
51
NS
NS
0.01a
GA general anesthesia; HTEA high thoracic epidural anesthesia; NS, not significant; GTN glyceryl trinitrate.
Data are expressed as median (interquartile range) or n (number of patients requiring treatment).
a
For dosage only.
926
ANESTH ANALG
2005;100:9218
Table 3. Intensive Care Unit Pao2, Paco2, Lactate, and Hemodynamic Variables
Variable
a
P value
112 (94146)
48 (4450)
1.8 (1.42.5)
2.8 (2.53.2)
1008 (8311146)
784 (613940)
121 (98157)
51 (4657)
1.4 (1.21.9)
2.9 (2.63.31)
861 (7611072)
694 (600821)
NS
0.006
0.005
NS
0.03
0.07
GA general anesthesia; HTEA high thoracic epidural anesthesia; IQR interquartile range; NS not significant; SVR systemic vascular resistance.
a
First postextubation arterial blood gas.
b
Mean of the lowest SVR calculated in the intensive care unit.
GA
HTEA
17.2 (10.726.4)
9.1 (4.925.9)
17.0 (10.427.9)
9.1 (6.021.0)
32
19
2
35
20
1
GA general anesthesia; HTEA high thoracic epidural anesthesia; IQR interquartile range; troponin I 12 and 24 h samples taken 12 and 24 h after release
of aortic cross-clamp; Q wave new persistent Q wave on Day 5.
Figure 2. Visual analog scale scores for pain with coughing for the
first 72 h. Boxes represent median and interquartile range; horizontal bars represent 5th and 95th percentiles. Shaded boxes high
thoracic epidural anesthesia group; open boxes general anesthesia group. P 0.0001 at all time points.
Discussion
In this prospective randomized study, HTEA for elective CABG surgery had no effect on biochemical or
ECG markers of myocardial ischemia or infarction.
ANESTH ANALG
2005;100:9218
CARDIOVASCULAR ANESTHESIA
BARRINGTON ET AL.
EPIDURAL ANESTHESIA FOR CORONARY ARTERY BYPASS SURGERY
927
References
1. Liem TH, Hasenbos MA, Booij LH, Gielen MJ. Coronary artery
bypass grafting using two different anesthetic techniques. II.
Postoperative outcome. J Cardiothorac Vasc Anesth 1992;6:
156 61.
2. Liem TH, Booij LH, Gielen MJ, et al. Coronary artery bypass
grafting using two different anesthetic techniques. III. Adrenergic responses. J Cardiothorac Vasc Anesth 1992;6:1627.
928
ANESTH ANALG
2005;100:9218
17. Silbert BS, Santamaria JD, OBrien JL, et al. Early extubation
following coronary artery bypass surgery: a prospective randomized controlled trialthe Fast Track Cardiac Care Team.
Chest 1998;113:1481 8.
18. Gensini GF, Fusi C, Conti AA, et al. Cardiac troponin I and
Q-wave perioperative myocardial infarction after coronary artery bypass surgery. Crit Care Med 1998;26:1986 90.
19. Bimmel D, Patermann B, Schlosser T, et al. Do we still need
CK-MB in coronary artery bypass grafting surgery? J Cardiovasc Surg (Torino) 2003;44:191 6.
20. Jacquet L, Noirhomme P, El Khoury G, et al. Cardiac troponin I
as an early marker of myocardial damage after coronary bypass
surgery. Eur J Cardiothorac Surg 1998;13:378 84.
21. Greenson N, Macoviak J, Krishnaswamy P, et al. Usefulness of
cardiac troponin I in patients undergoing open heart surgery.
Am Heart J 2001;141:44755.
22. Cheng DC, Chung F, Burns RJ, et al. Postoperative myocardial
infarction documented by technetium pyrophosphate scan using single-photon emission computed tomography: significance
of intraoperative myocardial ischemia and hemodynamic control. Anesthesiology 1989;71:818 26.
23. 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;93:528 35.
24. Straka Z, Brucek P, Vanek T, et al. Routine immediate extubation for off-pump coronary artery bypass grafting without thoracic epidural analgesia. Ann Thorac Surg 2002;74:1544 7.
25. Hemmerling TM, Prieto I, Choiniere JL, et al. 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 2004;51:
163 8.
26. 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;16:21 6.
27. Liem TH, Booij LH, Hasenbos MA, Gielen MJ. Coronary artery
bypass grafting using two different anesthetic techniques. I.
Hemodynamic results. J Cardiothorac Vasc Anesth 1992;6:
148 55.
28. Jideus L, Joachimsson PO, Stridsberg M, et al. Thoracic epidural anesthesia does not influence the occurrence of postoperative sustained atrial fibrillation. Ann Thorac Surg 2001;
72:6571.
29. 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;117:5515.