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Eur J Cardiothorac Surg 2001;20:858-860
© 2001 Elsevier Science NL

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Thoracic epidural anesthesia for off-pump coronary artery bypass without intubation

^a Department of Cardiac Surgery, Kralovske Vinohrady University Hospital, Prague, Czech Republic
^b Department of Cardiology, Kralovske Vinohrady University Hospital, Prague, Czech Republic

Received 27 February 2001; received in revised form 10 July 2001; accepted 18 July 2001.

Corresponding author. Department of Cardiac Surgery, FNKV, Srobarova 50, CZ-100 34 Prague 10, Czech Republic. Tel.: +420-2-67163422; fax: +420-2-67163260
e-mail: vanek{at}fnkv.cz

	Abstract

Top Abstract 1. Introduction 2. Patients and technique 3. Results 4. Discussion References

 
Thoracic epidural anesthesia without intubation was used in 10 patients undergoing off-pump coronary artery reconstruction performed through median sternotomy. Considering the preoperative finding of impaired pulmonary function, all were moderate-risk patients for surgery using conventional general anesthesia with intubation. All patients had an uneventful postoperative course. In indicated cases, we regard thoracic epidural anesthesia as a suitable method again modifying the term ‘minimally invasive’ in cardiac surgery.

Key Words: Thoracic epidural anesthesia • Off-pump coronary artery surgery

	1. Introduction

Top Abstract 1. Introduction 2. Patients and technique 3. Results 4. Discussion References

 
The term ‘minimally invasive’ in cardiac surgery should imply ‘minimal side effects’ for the patient [1]. Seen from this point of view, ‘minimally invasive’ could refer not only to non-use of extracorporeal circulation but, also, to avoidance of general anesthesia with intubation and, consequently, all the risks associated with this type of anesthesia. Thoracic epidural anesthesia (TEA) is used in some departments of cardiac surgery; however, a combination of general anesthesia with intubation and TEA is involved [2]. The benefits include, most importantly, earlier extubation, especially so in procedures ‘on the beating heart’ [3]. Coronary artery bypass grafting, using left or right anterior small thoracotomy in patients without endotracheal general anesthesia, was first reported by Karagoz et al. in 2000 [4]. Our article describes a technique of TEA without intubation for off-pump coronary artery bypass (OPCAB) grafting through conventional median sternotomy in moderate-risk patients because of impaired pulmonary function as assessed by pre-operative spirometry.

	2. Patients and technique

Top Abstract 1. Introduction 2. Patients and technique 3. Results 4. Discussion References

 
From October 1999 through December 2000, we operated on 10 patients using TEA without intubation; OPCAB was performed in all. Their basic demographic data, results of preoperative spirometry, left ventricular ejection fraction, sites of distal anastomoses and left internal thoracic artery (LITA) usage are shown in Table 1.

Some of the patients experienced respiratory relief soon after the administration of the local anesthetic into epidural space, still before the administration of general anesthetics; no bronchospasm or bronchial hyperreactivity due to sympathetic blockade was observed. During surgery, we provided patients with oxygen face masks thus maintaining oxygen saturation levels consistently over 90%, as measured by pulse oximetry. Intraoperative blood gas values were determined by several collections of arterial blood from the radial artery (Fig. 1) .

View larger version (10K): [in this window] [in a new window]   Fig. 1. Intraoperative and the first postoperative arterial blood gas results. Open circles represent PaO2 and closed circles PaCO2 Time 1=before sternotomy; 2=sternal retraction; 3=30 min after sternotomy; 4=end of the procedure; 5=the first post-op results.

The epidural catheter was left in situ until the next day, with the administration of bupivacaine 0.5% 5 ml into the catheter filter at an interval of 4–6 h providing for good postoperative analgesia.

	3. Results

Top Abstract 1. Introduction 2. Patients and technique 3. Results 4. Discussion References

 
The perioperative course of all patients was uneventful. No development of Horner's syndrome (as the landmark of cervical sympathetic blockade) was observed. The somatosensory and motor block at T1 to T8 was achieved (with intercostal muscle paralysis) while adequate diaphragmatic respiration was preserved. There was no respiratory arrest, no patient was converted to general anesthesia with intubation.

None of the patients developed hemorrhagic complication or epidural compression caused by the use of low-dose heparin (1 mg/kg), despite the epidural puncture done directly before surgery; the careful and strictly atraumatic technique of epidural catheter placement was essential. TEA was not used in patients receiving aspirin for 5 days prior to surgery.

An initial drop in systemic blood pressure caused by vasodilatation in TEA was merely moderate and was controlled by i.v. administration of crystalloid/colloidal solution (500–1000 ml) or by repeated single doses of methoxamine (Vasoxine Glaxo Wellcome, UK) of up to 20 mg. The hemodynamic stability of TEA patients during manipulation with the heart did not vary from those under standard general anesthesia. The patients tolerated well Trendelenburg positioning. If this increase in preload failed to restore adequate hemodynamic values (mean arterial pressure >60 mmHg, mixed venous oxygen saturation >60%), repeated single i.v. shots of methoxamine or ephedrine (Ephedrin Hoechst-Biotika, Slovakia) up to a total dose of 50 mg were used again. In two patients dobutamine (Dobutrex Lilly, Germany) 3–5 µg/kg per min was started, but there was no need for a pulmonary artery catheter.

Contact with the patients could be established immediately after the procedures (lasting 216 min on average), and their pulmonary and general rehabilitation could be initiated. The technique of TEA without intubation was subjectively tolerated well by all patients. The postoperative course was smooth with a maximum length of hospital stay 5 days.

	4. Discussion

Top Abstract 1. Introduction 2. Patients and technique 3. Results 4. Discussion References

 
The above technique eliminates the potential pulmonary complications associated with general anesthesia plus intubation [5]. Our report shows the method may benefit even patients with impaired pulmonary function. None of our patients experienced deterioration of pulmonary disease; the latest five cases indicate that the method could allow for even complete revascularization with the use of arterial grafts. Our experience with all these first patients is excellent but, as with all new techniques, many questions arise (e.g. the actual benefit to the patient including improvement of ventilation-perfusion relationships [6] and a decrease in perioperative stress and troponin release [7], criteria for performing TEA procedure without intubation), which warrant future studies.

	Footnotes

 
Presented at the 16th Annual Meeting of the European Association of Cardio-thoracic Anaesthesiologists, Weimar, Germany, May 16–19, 2001.

	References

Top Abstract 1. Introduction 2. Patients and technique 3. Results 4. Discussion References

 

1. Borst C., Grundeman P.F. Minimally invasive coronary artery bypass grafting: an experimental prospective. Circulation 1999;99:1400-1403.[Free Full Text]
2. Peterson K.L., deCampli W.M., Pike N.A., Robbins R.C., Reitz B.A. A report of two hundred twenty cases of regional anesthesia in pediatric cardiac surgery. Anesth Analg 2000;90:1014-1019.[Abstract/Free Full Text]
3. Niereich A.P., Diephus J., Jansen E.W., van Dijk D., Lahpor J.R., Borst C., Knape J.T. Embracing the heart: perioperative management of patients undergoing off-pump coronary artery bypass grafting using the octopus tissue stabilizer. J Cardiothorac Vasc Anesth 1999;13:123-129.[Medline]
4. Karagoz H.Y., Sönmez B., Bakkalogu B., Kurtologu M., Erdinc M., Türkeli A., Bayazit K. Coronary artery bypass grafting in the conscious patient without endotracheal general anesthesia. Ann Thorac Surg 2000;70:91-96.[Abstract/Free Full Text]
5. Johnson D., Hurst T., Thomson D., Mycyk T., Burbridge B., To T., Mayers I. Respiratory function after cardiac surgery. J Cardiothorac Vasc Anesth 1996;10:571-577.[Medline]
6. Tenling A., Joachimsson P.O., Tyden H., Wegenius G., Hedenstierna G. Thoracic epidural anesthesia as an adjunct to general anesthesia for cardiac surgery: effect on ventilation-perfusion relationships. J Cardiothorac Vasc Anesth 1999;13:258-264.[Medline]
7. Loick H.M., Schmidt C., Van Aken H., Junker R., Erren M., Berendes E., Rolf N., Meissner A., Schmid C., Scheld H.H., Mollhoff T. Thoracic epidural anesthesia, but not clonidine, attenuates perioperative stress response via sympatholysis and reduces the release of troponin T in patients undergoing coronary artery bypass grafting. Anesth Analg 1999;88:701-709.[Abstract/Free Full Text]

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