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Eur J Cardiothorac Surg 2007;32:13-19. doi:10.1016/j.ejcts.2007.04.004
Copyright © 2007, European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved

Reviews

Epidural anesthesia in awake thoracic surgery

Tommaso Claudio Mineo*

Thoracic Surgery Division, Tor Vergata School of Thoracic Surgery, Policlinico Tor Vergata, Rome, Italy

Received 23 January 2007; received in revised form 19 March 2007; accepted 2 April 2007.

* Corresponding author. Address: Cattedra di Chirurgia Toracica, Università Tor Vergata, Policlinico Tor Vergata, V.le Oxford, 81, 00133 Rome, Italy. Tel.: +39 06 20902884; fax: +39 06 20902881. (Email: mineo{at}med.uniroma2.it).


   Abstract
Top
 Abstract
1. Introduction
 2. Physiologic effects of...
 3. Surgical management of...
 4. Resection of pulmonary...
 5. Lung volume reduction...
 6. Thymectomy for myasthenia...
 7. Complications of thoracic...
 8. Conclusions
 References
 
Despite the indisputable and well-known advantages of general anesthesia in thoracic surgery, this can trigger some adverse effects including an increased risk of pneumonia, impaired cardiac performance, neuromuscular problems, mechanical ventilation-induced injuries, which include barotrauma, volotrauma, atelectrauma, and biotrauma. In order to reduce the adverse effects of general anesthesia, thoracic epidural anesthesia has been recently employed to perform awake thoracic surgery procedures including coronary artery bypass, management of pneumothorax, resection of pulmonary nodules and solitary metastases, lung volume reduction surgery, and even transsternal thymectomy. The results achieved in this early series have been encouraging, although indications and many pathophysiologic aspects remain to be elucidated. In this review we have tried to provide a first-step analysis of the anecdotal reports available in the literature on this topic. We also desired to provide insights into the main physiologic effects of awake thoracic surgery with epidural anesthesia, with particular attention to the several issues raised by its application in patients with chronic obstructive pulmonary disease, which can represent one of the most stimulating challenges in this setting.

Key Words: Epidural anesthesia • VATS • Thoracoscopy • LVRS • Pulmonary nodule • Thoracic surgery


   1. Introduction
Top
 Abstract
 1. Introduction
2. Physiologic effects of...
 3. Surgical management of...
 4. Resection of pulmonary...
 5. Lung volume reduction...
 6. Thymectomy for myasthenia...
 7. Complications of thoracic...
 8. Conclusions
 References
 
Much is changed in thoracic surgery since Sauerbruch [1] expressed the conviction that only general anesthesia could avoid the fatal events inevitably triggered by the open pneumothorax deriving from surgical violation of the chest wall integrity.

At the beginning of the 20th century, ingenious but unreliable attempts aimed at avoiding surgical pneumothorax included the Sauerbruch's negative-pressure operating chamber [2] and the Brauer's positive-pressure ventilation chamber [3]. Both these methods were directed at maintaining the operated lung expanded during thoracotomy by respectively creating a negative-pressure environment within a closed operating chamber or maintaining a positive pressure within the airway by introducing the head of the patient into a positive-pressure closed box. However, it was only with the clinical application of general anesthesia and endotracheal-tube ventilation that modern thoracic surgery could eventually develop. Subsequently, one-lung ventilation by double-lumen endobronchial intubation introduced by Zavod in 1940 [4] and refined by Björk and Carlens in 1949 [5] proved a revolutionary advance and is still considered mandatory in both open and video-assisted thoracic surgery (VATS) procedures.

Despite the indisputable and well-known advantages of general anesthesia, this can trigger some adverse effects including an increased risk of pneumonia, impaired cardiac performance, and neuromuscular problems. In addition, during general anesthesia, mechanical ventilation can produce injuries, which include airway pressure-induced injury (barotrauma), lung inflation-induced injury (volotrauma), injury due to cyclic opening and closing of small airways/lung units (atelectrauma), and release of a variety of proinflammatory mediators (biotrauma) [6]. Yet, atelectasis in the dependent lung is a frequent finding during one-lung ventilation with muscle paralysis [7], and prolonged collapse of the nondependent lung can delay its complete re-expansion after weaning, leading to the development of further atelectasic areas.

In order to reduce the adverse effects of general anesthesia, thoracic epidural anesthesia (TEA) has been recently employed to perform awake thoracic surgery procedures including coronary artery bypass [8–12], management of pneumothorax [13–15], resection of pulmonary nodules [16] and solitary metastases [17], lung volume reduction (LVR) [18], and even transsternal thymectomy [19] (Table 1 ). The results achieved in these early series have been encouraging, although indications and many pathophysiologic aspects remain to be elucidated.


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  		Table 1 Published articles on awake thoracic surgery with epidural anesthesia
 
In this review we have tried to provide a first-step analysis of the anecdotal reports available in the literature on this topic. We also desired to provide insights on the main physiologic effects of awake thoracic surgery with epidural anesthesia, with particular attention to the several issues raised by its application in patients with chronic obstructive pulmonary disease, which can represent one of the most stimulating challenges in this setting.


   2. Physiologic effects of epidural anesthesia
Top
 Abstract
 1. Introduction
 2. Physiologic effects of...
3. Surgical management of...
 4. Resection of pulmonary...
 5. Lung volume reduction...
 6. Thymectomy for myasthenia...
 7. Complications of thoracic...
 8. Conclusions
 References
 
Many surgical procedures can be accomplished with satisfactory anesthesia and analgesia by epidural administration of local anesthetics. In addition, the sympathetic blockade can produce beneficial effects on several organ systems [20] including an increased gastrointestinal motility and perfusion or decreased myocardial ischemia and systemic stress response to surgery [20–23].

2.1 Effect on cardiovascular system
In awake patients under epidural anesthesia we can have the best type of monitoring, namely neurologic vigilance [24]. Instead, general anesthesia can induce a drop of systemic blood pressure to a critically low level during stabilization (usually a blood pressure around 80 mmHg). Yet, some patients experience hemodynamic compromise related to narcotic medication before intubation, which carries the risk of preoperative myocardial ischemia or infarction in patients with severe coronary artery disease [22,25–27]. Conversely, cardiovascular effects of epidural anesthesia include decreased determinants of myocardial oxygen demand [28], improved myocardial blood flow [29,30] and left ventricular function [31], and reduced thrombotic-related complications [32]. Furthermore, it has been shown that epidural anesthesia can reduce heart rate and occurrence of arrhythmias during manipulation of the heart [33,34].

2.2 Effect on lung function
The impact of epidural anesthesia on lung function can be ambiguous. Satisfactory analgesia and the avoidance of mechanical irritation must be balanced against the possible alteration of lung function by epidural motor blockade of respiratory muscles and the potentially detrimental effects of sympatheticolysis, leaving an unopposed vagal tone with potentially increased bronchial tone and reactivity.

TEA has proven to be particularly beneficial in combination with general anesthesia with volatile anesthetics to reduce the adverse effects of total intravenous anesthesia. In particular, it has shown to reduce impact on physiologic mechanism of hypoxic pulmonary vasoconstriction, and pulmonary and systemic hemodynamics. Yet, complications such as infections and atelectasis can be improved by epidural anesthetic treatment [35]. Furthermore, recent studies have suggested that TEA combined with general anesthesia improved arterial oxygenation during one-lung ventilation, resulted in better cardiac output stability, and reduced time to extubation [36].

Early postoperative lung function is influenced by residual muscular relaxation, the time of extubation, pain therapy, and vigilance. Immediately after an operation, the ability to cough seems to be one of the most important factors affecting lung function and is depending, to a great extent, on the efficacy of diaphragmatic contraction and pain relief. On the other hand, with general anesthesia, reduced vigilance, muscular rest relaxation, and possibly impaired diaphragmatic function can lead to prolonged mechanical ventilation, which is a risk factor for pulmonary infections and morbidity.

The physiological effects of TEA on lung function are determined by the extension of the motor blockade depending on the height of the insertion of the catheter, the choice of local anesthetic, and its concentration.

With a limited sensory block from dermatom T1 to T5, vital capacity is decreased by 5.6% and forced expiratory volume in 1 s (FEV1) by 4.9% [37], an effect that can be explained by a direct motor blockade of intercostal muscles [38]. On the other hand, studies in patients with chronic obstructive pulmonary disease have shown that an epidural block with 0.5% bupivacaine leads to a decrease in vital capacity and FEV1 of only 8%. In this respect, the change in posture has to be also taken into account, since this alone can account for a decrease in vital capacity and FEV1 of up to 23% [39–43]. In fact, there exists evidence that TEA improves postoperative lung function in comparison with general anesthesia alone. At least two effects contribute to this improvement. On the one hand, TEA improves diaphragmatic function and on the other, it provides better postoperative analgesia than patient-controlled intravenous administration of opioids. Yet, there seems to be a direct effect on diaphragmatic contractility and breathing pattern under epidural anesthesia [44].

2.3 Effect in patients with chronic obstructive pulmonary disease
Potential adverse effects of general anesthesia can be particularly dangerous in patients with chronic obstructive pulmonary disease. Indeed, in addition to the aforementioned adverse effects related to mechanical and single-lung ventilation, general anesthesia with instrumentation of the airways can elicit bronchospasm and life-threatening complications. Therefore, it is not surprising that surgical procedures performed under epidural anesthesia are associated with fewer respiratory complications [45–47].

However, the use of TEA in respiratory compromised patients raises some concerns. First, the motor blockade that is associated with epidural anesthesia might lead to respiratory failure in patients with an already compromised respiratory function. Secondly, the sympathetic blockade, which is also associated with TEA, would lead to an increased bronchial tone and airway hyperreactivity. Thirdly, use of TEA in awake thoracic procedures can induce hypercapnia, particularly in patients with severe emphysema. On the other hand, neither the arterial–alveolar difference in O2 nor the direct measurement of shunt was negatively affected by TEA [35].

2.4 The problem of permissive hypercapnia
Awake thoracic surgery has shown that simple administration of oxygen through a Venturi mask can prevent hypoxemia while hypercapnia develops frequently, particularly in patients with chronic obstructive pulmonary disease. Yet, there seems to be a direct relationship between operative time and severity of hypercapnia. The pathophysiology of this event is not fully understood, although hypoventilation due to partial collapse of the operated lung and a rebreathing effect seem reasonable hypotheses.

Another interesting feature is that even in patients with severe emphysema undergoing LVR, perioperative hypercapnia rarely becomes clinically dangerous. This feature, which has been already extensively investigated in critically ill patients during intensive care unit stay, has led to the development of the concept of ‘permissive hypercapnia’ [48], which is rarely a life-threatening condition and may even exert some potentially beneficial effects including increased parenchymal compliance and improved ventilation/perfusion matching [49,50]. Yet, the hypercapnic-mediated sympathicoadrenal effects of increased preload, decreased afterload, and increased heart rate lead to a net increase in cardiac output. Hence, it is against this background that one must be judicious with hypercapnia in any patient on ß-adrenergic antagonists, or those with heart failure or coronary artery disease. Furthermore, the increase in cerebral blood flow with hypercapnic acidosis must be considered carefully in any patient as a potential risk for raised intracranial pressure [51]. Finally, the marked sympathetic activation of hypercapnic acidosis, particularly when combined with arterial hypoxemia, can reduce glomerular filtration and increase fluid retention [52].


   3. Surgical management of spontaneous pneumothorax
Top
 Abstract
 1. Introduction
 2. Physiologic effects of...
 3. Surgical management of...
4. Resection of pulmonary...
 5. Lung volume reduction...
 6. Thymectomy for myasthenia...
 7. Complications of thoracic...
 8. Conclusions
 References
 
Awake VATS represents a particularly attractive approach for treatment of spontaneous pneumothorax, due to the simplicity of the surgical procedure and the peculiar characteristics of this young and healthy patient population. Furthermore, diffuse pleural adhesions, which can contraindicate awake VATS, are exceedingly rare in these patients [53].

In 1997, Nezu et al. [54] have reported satisfactory results with awake VATS bullectomy, with sole intercostal blockade, while use of TEA has been anecdotally investigated in this setting [13,14,55]. Sugimoto et al. [14] employed this approach to treat intractable pneumothoraces following lung transplantation, and suggested that this approach might reveal particularly appealing in patients with posttransplantation bronchial stenosis and living-donor lobar transplantation in whom single-lung ventilation might be difficult to maintain.

We believe that the use of TEA is particularly appealing when VATS bullectomy with pleural abrasion is preferred since an optimal somatosensory block is advisable to minimize perioperative thoracic pain. Furthermore, we have found that since TEA obviates the need of a deep sedation, an interactive cooperation between the surgeon and the conscious patient is allowed.

In a small randomized study, we have recently shown that awake VATS bullectomy with pleural abrasion was feasible and well tolerated by our young cohort, although 12% of recruitable patients refused randomization and preferred a non-awake procedure. Yet, in the awake group, global operating room time and hospital stay were shorter, and hospital charges were lower than those of the control group undergoing the same procedure under general anesthesia with one-lung ventilation [15].


   4. Resection of pulmonary nodules
Top
 Abstract
 1. Introduction
 2. Physiologic effects of...
 3. Surgical management of...
 4. Resection of pulmonary...
5. Lung volume reduction...
 6. Thymectomy for myasthenia...
 7. Complications of thoracic...
 8. Conclusions
 References
 
In 2004 [16] we had reported results of a randomized study on awake VATS resection of solitary pulmonary nodules which was easily and safely performed under TEA with no mortality and negligible morbidity. No particular surgical training was necessary and the only two failures were due to the presence of extensive and dense pleural adhesions that, thus, represented the only contraindication for the procedure. In addition, awake pulmonary resection was easily accepted and well tolerated by the patients.

Avoidance of general anesthesia reflected in a faster recovery with immediate return to many daily life activities including drinking, eating, and walking. As a result, the hospital stay was significantly shorter than in the control group.

One of our major concerns related to the risk of operating on a ventilating lung rendered surgical maneuvers more difficult due to the lung movements and the lack of a sufficient ‘operating space’. Instead, we had earlier noticed that the open pneumothorax created after trocars’ insertion produced a satisfactory lung collapse which did not hamper surgical maneuvers.

As expected, arterial oxygenation worsened slightly during the first postoperative day, but this impairment was greater in the general anesthesia group than in the awake group. One concern relates to the patient participation in operating room conversations when unexpected lung cancer is encountered. We believe that in these delicate instances, special care must be devoted by the operating team in reassuring the patient while explaining the reasons that require conversion to general anesthesia and thoracotomy.

In a more recent study, thoracoscopic metastasectomy under sole TEA for peripheral solitary lung metastases has been performed by the authors of this review [17]. In this study, the awake procedure proved safely feasible while global operating room time and hospital stay were significantly shorter than those of the control group operated under general anesthesia. Finally, oncologic results were comparable between the groups.


   5. Lung volume reduction surgery
Top
 Abstract
 1. Introduction
 2. Physiologic effects of...
 3. Surgical management of...
 4. Resection of pulmonary...
 5. Lung volume reduction...
6. Thymectomy for myasthenia...
 7. Complications of thoracic...
 8. Conclusions
 References
 
In a recent pilot study, we have reported that awake nonresectional LVR was safely performed under sole TEA [18].

Avoidance of general anesthesia reflected in an easier patient acceptance of the procedure and allowed a more rapid recovery with immediate return to common daily life activities. In addition, in the awake group nonfatal complications were less frequent and hospital stay was significantly shorter than that of the control group operated under general anesthesia. Finally, at the 6-month follow-up, significant incremental improvements occurred in clinical and respiratory function measures after awake LVR, and these improvements did not differ from those achieved in the control group.

Theoretically, an open pneumothorax could have compressed the dependent lung, eventually resulting in functional compromise. However, in our series, apart from a temporary permissive hypercapnia, respiratory function remained satisfactory throughout the procedure. We hypothesized that maintained diaphragmatic motion could have decreased the detrimental effect of the abdominal pressure, leading the paralyzed diaphragm to compress the dependent lung during general anesthesia [56].

In our study the perioperative raise in CO2 was well tolerated by the patients and resolved more rapidly than in the control group. We believe that this effect can be addressed to the better synchronization of rib cage–abdominal motion, which we have immediately observed after awake LVR. In fact, after LVR, the greater contribution of abdominal volume changes to tidal volume is consistent with a reduction of inspiratory loading and a greater force-generating capacity of the diaphragm due to resizing of the chest and diaphragmatic dome [57]. Unfortunately, these beneficial effects of LVR are lost in the early postoperative period in patients receiving general anesthesia.

Increasing health care costs have led economic aspects to become more and more prevalent in surgical practise. Fewer financial resources and reduced intensive care unit capacities have led to the development of the fast-track concept, namely early extubation and possibly earlier discharge from the hospital. Actual benefits of fast tracking remain controversial [58,59]. Nonetheless, we have demonstrated that employment of TEA without general anesthesia for awake LVR did not require postoperative intensive care unit stay. Patients were monitored for few hours in the recovery room and were subsequently transferred to the ward where they could immediately start walking, eating, and drinking as desired. As a result, this new surgical approach might eventually improve the cost-effectiveness of the procedure.


   6. Thymectomy for myasthenia gravis
Top
 Abstract
 1. Introduction
 2. Physiologic effects of...
 3. Surgical management of...
 4. Resection of pulmonary...
 5. Lung volume reduction...
 6. Thymectomy for myasthenia...
7. Complications of thoracic...
 8. Conclusions
 References
 
Thymectomy for myasthenia gravis (MG) requires special attention as far as type of anesthesia and use of muscle relaxants are concerned [60]. In fact, patients with MG are usually sensitive to the effects of nondepolarizing muscle relaxants [61–63], which can also interact with anticholinesterase drugs administered as therapeutic agents [64]. Although various anesthetic procedures have been reported in patients with MG, almost all of them are intravenous or epidural techniques, and entail use of volatile agents and tracheal intubation [60].

In 2004, Tsunezuka et al. [19] reported on awake extended transsternal thymectomy performed in three low-risk patients with moderately generalized MG under sole TEA. The mean operating time was 2 h, and all patients were able to drink and walk within 1 h after the operation. The authors concluded that this procedure was advantageous in that avoidance of muscle relaxants and volatile anesthetic agents prevented the laryngeal injury and potential postoperative respiratory failure.

Despite the fact that this result seems encouraging, there are several issues which can be critically raised. First, paralyzing drugs are not necessarily used for endotracheal intubation in such patients; secondly, management of unexpected life-threatening events requiring urgent endotracheal intubation under less-than-ideal circumstances might result in far greater probability of laryngeal injury than when done electively. Furthermore, extended thymectomy exposes the patient to risk of inadvertent pleural cavity opening on both sides, a situation which can be difficult to manage without endotracheal ventilation [65].


   7. Complications of thoracic epidural anesthesia
Top
 Abstract
 1. Introduction
 2. Physiologic effects of...
 3. Surgical management of...
 4. Resection of pulmonary...
 5. Lung volume reduction...
 6. Thymectomy for myasthenia...
 7. Complications of thoracic...
8. Conclusions
 References
 
Potential complications of TEA may reduce acceptance and enthusiasm for this technique. Local anesthetic neurotoxicity is a well-known phenomenon related to the type and concentration of anesthetic and systemic absorption. High doses of intrathecal lidocaine have been associated with neurologic side-effects not related to hemorrhage and infection [66,67]. Systemic absorption of local anesthetics at high doses can produce seizures, loss of airway protective reflexes, respiratory depression, coma cardiac arrhythmias, hemodynamic instability, and motor autonomic blockade (urinary retention, weakness) in 0–45% of patients [68–70]. Hypotension and bradycardia are two important potential hemodynamic consequences induced by sympatheticolysis. A prospective multicenter randomized trial has found the incidence of hypotension after epidural–general anesthesia, defined as a >30% reduction from baseline blood pressure, to be 41% compared with 23% after general anesthesia alone [71].

The use of TEA in patients undergoing cardiac and thoracic surgery is controversial, because of the risk of vertebral canal hematoma [72]. Yet, neurological complications, including spinal cord injury [73], may arise during administration of the block, since the needle or catheter may result in direct nerve trauma. The injection of irritant drugs can also cause neurological damage. We must, therefore, be meticulous when injecting drugs into the epidural space. Accidental dural puncture during needle insertion occurred in 0.16–1.3% instances in a series of 51,000 epidural catheters, and subsequent postdural headaches developed in 16–86% of these patients [74–77].

The increasing use of anticoagulant therapy in surgical patients and, in particular, the variety of low-molecular weight heparins available, may make it difficult to safely perform epidural anesthesia. Incidence of hemorrhagic complications has been variable in the literature. In one investigation, Ho et al. [78] have reported a risk of epidural hematoma formation in cardiosurgical patients between 1 in 1.500–150.000 within a 95% confidence interval. Renck [79] calculated an incidence for adverse events of 1:143.000 for an overall population receiving epidural catheters for noncardiac surgery. Recent communications in the medical press have suggested that the rate of vertebral canal complications following epidural catheter placement, in particular, the incidence of epidural abscess is increasing in frequency [80,81]. On the other hand, a very recent wide retrospective analysis [82] indicates that thoracic epidural anesthesia and analgesia are safe in patients receiving cardiac surgery with no epidural hematoma or abscess recorded in 2837 patients. Finally, in a recent meta-analysis [83] the calculated relative risks for spinal hematoma and injury were 0.0002% and 0.0005%, respectively. A further potential risk of high TEA is phrenic nerve palsy caused by inadvertently high anesthetic levels [84]. On the other hand, in awake thoracic surgery, many potential risks of endotracheal intubation, including trauma to teeth or vocal cords and peri-intubational hypoxia, are avoided.


   8. Conclusions
Top
 Abstract
 1. Introduction
 2. Physiologic effects of...
 3. Surgical management of...
 4. Resection of pulmonary...
 5. Lung volume reduction...
 6. Thymectomy for myasthenia...
 7. Complications of thoracic...
 8. Conclusions
References
 
Recent reports have suggested that several surgical thoracic procedures can be easily and safely carried out through this novel and globally less invasive approach which is easily accepted by both patients and clinicians. This surgical modality holds promise and might eventually result to be more cost-effective than equivalent procedures performed under general anesthesia due to reduced hospitalization and overall charges. However, initial encouraging results must be interpreted with caution and enthusiasm mitigated since they are still insufficient to draw any reasonable conclusion on pertinent indications, pathophysiology effects, and potential benefit. Furthermore, use of TEA exposes to risks of potential major complications that one must be aware of particularly in patients undergoing anticoagulant therapy.

Nonetheless, we believe that this represents a new and fully explorable field, which might evolve unexpectedly in an era in which efficacy, rapidity, and low costs are unceasingly required for modern surgery.

In conclusion, despite the fact that further investigation is needed, we confide that the mystic taboo of primitive men that Sauerbruch thought to be extended to surgeons entering the chest without general anesthesia [1] might wean in the near future as an ancestral nightmare is dispersed by sunrise.


   References
Top
 Abstract
 1. Introduction
 2. Physiologic effects of...
 3. Surgical management of...
 4. Resection of pulmonary...
 5. Lung volume reduction...
 6. Thymectomy for myasthenia...
 7. Complications of thoracic...
 8. Conclusions
 References
 

  1. Sauerbruch F. Master surgeon. New York: Thomas Y. Crowell Company; 1953p. 92.
  2. Sauerbruch F. Zur pathologie des offenen pneumothorax und die grundlagen meinees verfahrens zu seiner ausschaltung. Mitteilungen aus den Grenzgebieten der Medizin und Chirurgie 1904;13:399-482.
  3. Brauer L. Die ausschaltung der pneumothoraxfolgen mit hilfe des ueberdruckverfahrens. Mitteilungen aus den Grenzgebieten der Medizin und Chirurgie 1904;13:483-500.
  4. Zavod WA. Bronchospirography 1. Description of the catheter and the technique of intubation. J Thorac Surg 1940;10:27-31.
  5. Björk VO, Carlens E. The prevention of spread during pulmonary resection by use of a double-lumen catheter. J Thorac Surg 1950;20:151-157.[Medline]
  6. Whitehead T, Slutsky AS. The pulmonary physician in critical care. 7: ventilator induced lung injury. Thorax 2002;57:635-642.[Abstract/Free Full Text]
  7. Tokics L, Hedenstierna G, Svensson L, Brismar B, Cederlund T, Lundquist H, Strandberg A. V/Q distribution and correlation to atelectasis in anesthetize paralyzed humans. J Appl Physiol 1996;81:1822-1833.[Abstract/Free Full Text]
  8. Karagoz HY, Sonmez B, Bakkaloglu B, Kurtoglu M, Erdinç 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]
  9. Karagoz HY, Kurtoglu M, Bakkaloglu B, Sonmez B, Cetintas T, Bayazit K. Coronary artery bypass grafting in the awake patient: three years’ experience in 137 patients. J Thorac Cardiovasc Surg 2003;125:1401-1404.[Abstract/Free Full Text]
  10. Paiste J, Bjerke R, Williams JP, Zenati M, Nagy GE. Minimally invasive direct coronary artery bypass surgery under high thoracic epidural. Anesth Analg 2001;93:1486-1488.[Abstract/Free Full Text]
  11. Anderson MB, Kwong KF, Furst AJ, Salerna TA. Thoracic epidural anesthesia for coronary bypass via left anterior thoracotomy in the conscious patient. Eur J Cardiothorac Surg 2001;20:415-417.[Abstract/Free Full Text]
  12. Meininger D, Neidhart G, Bremerich DH, Aybek T, Lischke V, Byhahn C, Kessler P. Coronary artery bypass grafting via sternotomy in conscious patients. World J Surg 2003;27:534-538.[CrossRef][Medline]
  13. Mukaida T, Andou A, Date H, Aoe M, Shimizu N. Thoracoscopic operation for secondary pneumothorax under local and epidural anesthesia in high-risk patients. Ann Thorac Surg 1998;65:924-926.[Abstract/Free Full Text]
  14. Sugimoto S, Date H, Sugimoto R, Okazaki M, Aoe M, Sano Y, Simizy N. Thoracoscopic operation with local and epidural anesthesia in the treatment of penumothorax after lung transplantation. J Thorac Cardiovasc Surg 2005;130:1219-1220.[Free Full Text]
  15. Pompeo E, Tacconi F, Mineo D, Mineo TC. The role of awake video-assisted thoracoscopic surgery in spontaneous pneumothorax. J Thorac Cardiovasc Surg 2007;133:786-790.[Abstract/Free Full Text]
  16. Pompeo E, Mineo D, Rogliani P, Sabato AF, Mineo TC. Feasibility and results of awake thoracoscopic resection of solitary pulmonary nodules. Ann Thorac Surg 2004;78:1761-1768.[Abstract/Free Full Text]
  17. Pompeo E, Mineo TC. Awake pulmonary metastasectomy. J Thorac Cardiovasc Surg 2007;133:960-966.[Abstract/Free Full Text]
  18. Mineo TC, Pompeo E, Mineo D, Tacconi F, Marino M, Sabato AF. Awake nonresectional lung volume reduction surgery. Ann Surg 2006;243:131-136.[CrossRef][Medline]
  19. Tsunezuka Y, Oda M, Matsumoto I, Tamura M, Watanabe G. Extended thymectomy in patients with myasthenia gravis with high thoracic epidural anesthesia alone. World J Surg 2004;28:962-965.[CrossRef][Medline]
  20. Basse L, Raskow HH, Jacobsen DH, Sonne E, Billesbolle P, Hendel HW, Rosemberg J, Kehlet H. Accelerated postoperative recovery programme after colonic resection improves physical performance, pulmonary function and body composition. Br J Surg 2002;89:446-453.[CrossRef][Medline]
  21. Loick HM, Schmidt C, Van Aken H, Junker R, Erren M, Berendes E, Rolf N, Meissner A, Schmid C, Scheld HH, Mölhoff T. 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;88:701-709.[Abstract/Free Full Text]
  22. Olausson K, Magnusdottir H, Lurje L, Wennerblom B, Emanuelsson H, Ricksten SE. Anti-ischemic and anti-anginal effects of thoracic epidural anesthesia versus those of conventional medical therapy in the treatment of severe refractory unstable angina pectoris. Circulation 1997;96:2178-2182.[Abstract/Free Full Text]
  23. Rutberg H, Hakanson E, Anderberg B, Jorfeldt L, Martensson J, Schildt B. Effects of the extradural administration of morphine or bupivacaine on the endocrine response to upper abdominal surgery. Br J Anaesth 1984;56:233-238.[Abstract/Free Full Text]
  24. Aybek T, Kessler P, Dogan S, Neidhart G, Khan MF, Wimmer-Greinecker G, Moritz A. Awake coronary artery bypass grafting: utopia or reality?. Ann Thorac Surg 2003;75:1165-1170.[Abstract/Free Full Text]
  25. Tarhan S, Moffitt EA, Taylor WF, Giuliani ER. Myocardial infarction after general anesthesia. JAMA 1972;220:1451-1454.[Abstract/Free Full Text]
  26. Seegobin RD, Goodland FC, Wilmshurst TH, Johnston J, Wainwright C, Norman J, Conway N. Postoperative myocardial damage in patients with coronary artery disease undergoing major noncardiac surgery. Can J Anaesth 1991;38:1005-1011.[Medline]
  27. Blomberg S, Emanuelsson H, Kvist H, Lamm C, Pontel J, Vaaqstein F, Ricksten SE. Effects of thoracic epidural anesthesia on coronary arteries and arterioles in patients with coronary artery disease. Anesthesiology 1990;73:840-847.[Medline]
  28. Blomberg S, Emanuelsson H, Ricksten SE. Thoracic epidural anesthesia and central hemodynamics in patients with unstable angina pectoris. Anesth Analg 1989;69:558-562.[Abstract/Free Full Text]
  29. Davis RF, DeBoer LWV, Maroko PR. Thoracic epidural anesthesia reduces myocardial infarct size after coronary occlusion in dogs. Anesth Analg 1986;65:711-717.[Abstract/Free Full Text]
  30. Klassen GA, Bramwell RS, Bromage PR, Zborowska-Sluis DT. Effect on acute sympathectomy by epidural anesthesia on the canine coronary circulation. Anesthesiology 1980;52:8-15.[CrossRef][Medline]
  31. Kock M, Blomberg S, Emanuelsson H, Lomsky M, Stromblad SO, Ricksten SE. Thoracic epidural anesthesia improves global and regional left ventricular function during stress-induced myocardial ischemia in patients with coronary artery disease. Anesth Analg 1990;71:625-630.[Abstract/Free Full Text]
  32. Williams JP, Sullivan EA, Ramakrishna H. Effects of thoracic epidural anesthesia on the coagulation system. Clin Anesth 1999;13:31-56Jacobaeus H. The practical importance of thoracoscopy in surgery of the chest. Surg Gynecol Obstet 1922;34:289-296.
  33. Mark DB, Lam LC, Lee KI, Johns RH, Pryor DB, Stack RS, Williams RB, Clapp-Channing NE, Califf RM, Hlatky MA. Effects of coronary angioplasty, coronary bypass surgery, and medical therapy on employment in patients with coronary artery disease. A prospective comparison study. Ann Intern Med 1994;120:111-117.[Abstract/Free Full Text]
  34. Ribakove GH, Miller JS, Anderson RV, Grossi EA, Applebaum RM, Cutler WM, Buttenheim PM, Baumann FG, Galloway AC, Colvin SB. Minimally invasive port-access coronary artery bypass grafting with early angiographic follow-up: initial clinical experience. J Thorac Cardiovasc Surg 1998;115:1101-1110.[Abstract/Free Full Text]
  35. Groeben H. Epidural anesthesia and pulmonary function. J Anesth 2006;20:290-299.[CrossRef][Medline]
  36. Von Dossow V, Welte M, Zaune U, Martin E, Walter M, Rückert J, Kox WJ, Spies CD. Thoracic epidural anesthesia combined with general anesthesia: the preferred anesthetic technique for thoracic surgery. Anesth Analg 2001;92:848-854.[Abstract/Free Full Text]
  37. Sundberg A, Wattwil M, Arvill A. Respiratory effects of high thoracic epidural anesthesia. Acta Anaesthesiol Scand 1986;30:215-217.[Medline]
  38. Takasaki M, Takahashi T. Respiratory function during cervical and thoracic extradural analgesia in patients with normal lungs. Br J Anaesth 1980;52:1271-1275.[Abstract/Free Full Text]
  39. Groeben H, Schäfer B, Pavlakovic G, Silvanus MT, Peter J. Lung function under high thoracic segmental epidural anesthesia with ropivacaine or bupivacaine in patients with severe obstructive pulmonary disease undergoing breast surgery. Anaesthesiology 2002;96:536-541.[CrossRef][Medline]
  40. Harrop-Griffiths AW, Ravalia A, Browne DA, Robinson PN. Regional anaesthesia and cough effectiveness. Anaesthesia 1991;46:11-13.[CrossRef][Medline]
  41. Blair E, Hickam JB. The effect of change in body composition on lung volume and intrapulmonary gas mixing in normal subjects. J Clin Invest 1955;34:383-389.[Medline]
  42. Scott NB, Mogensen T, Bigler D, Lund C, Kehlet H. Continuous thoracic extradural 0.5% bupivacaine with or without morphine: effect on quality of blockade, lung function and the surgical stress response. Br J Anaesth 1989;62:253–57.
  43. Fawcett WJ, Edwards RE, Quinn AC, Mac Donald IA, Hall GM. Thoracic epidural analgesia started after cardiopulmonary bypass. Anaesthesia 1997;52:294-299.[CrossRef][Medline]
  44. Warner DO, Warner MA, Ritman EL. Human chest wall function during epidural anesthesia. Anesthesiology 1996;85:761-773.[CrossRef][Medline]
  45. Cheney FW, Posner KL, Caplan RA. Adverse respiratory events infrequently leading to malpractice suits. A closed claims analysis. Anesthesiology 1991;75:932-939.[CrossRef][Medline]
  46. Shnider SM, Pappeer EM. Anesthesia for the asthmatic patient. Anesthesiology 1961;22:886-892.[Medline]
  47. Tahran S, Moffitt EA, Sessler AD, Douglas WW, Taylor WF. Risk of anesthesia and surgery in patients with chronic bronchitis and chronic obstructive pulmonary disease. Surgery 1973;74:720-726.[Medline]
  48. Kregenow DA, Swenson ER. The lung and carbon dioxide: implications for permissive and therapeutic hypercapnia. Eur Respir J 2002;20:6-11.[Free Full Text]
  49. Wildeboer-Venema F. The influences of temperature and humidity upon the isolated surfactant film of the dog. Respir Physiol 1980;39:63-71.[CrossRef][Medline]
  50. Brogan TV, Robertson HT, Souders JE, Swenson ER. Carbon dioxide added to the latter half of inspiration improves Va/Q matching without causing respiratory acidosis. FASEB J 2002;16:A876.
  51. Feihl F, Perret C. Permissive hypercapnia: how permissive should we be?. Am J Respir Crit Care Med 1994;150:1722-1737.[Medline]
  52. DiBona GF, Kopp UC. Neural control of renal function. Physiol Rev 1997;77:75-197.[Abstract/Free Full Text]
  53. Janssen JP, Schramel FMNH, Sutedja TG, Cuesta MA, Oosterhuis W, Postmus PE. Videothoracoscopic appearance of first and recurrent pneumothorax. Chest 1995;108:330-334.[CrossRef][Medline]
  54. Nezu K, Kushibe K, Tojo T, Takahama M, Kitamura S. Thoracoscopic wedge resection of blebs under local anesthesia with sedation for treatment of a spontaneous pneumothorax. Chest 1997;111:230-235.[Medline]
  55. Yokoyama T, Tomoda M, Kanbara T, Nishiyama T, Manabe M. Epidural anesthesia for a patient with catamenial pneumothorax. Masui 2001;50:290-292.[Medline]
  56. Cohen E. Physiology of the lateral position and one-lung ventilation. Chest Surg Clin North Am 1997;7:753-771.[Medline]
  57. Bloch KE, Li Y, Zhang J, Bingisser R, Kaplan V, Weder W, Russi E. Effect of surgical lung volume reduction on breathing patterns in severe emphysema. Am J Respir Crit Care Med 1997;156:553-560.[Abstract/Free Full Text]
  58. Lazar HL, Fitzgerald CA, Ahmad T, Bao Y, Colton T, Shapira OM, Shamin RJ. Early discharge after coronary artery bypass graft surgery: are patients really going home earlier?. J Thorac Cardiovasc Surg 2001;121:943-950.[Abstract/Free Full Text]
  59. Montes FR, Sanchez SI, Giraldo JC, Rincon JD, Rincon IE, Vanegas MV, Charris H. The lack of benefit of tracheal extubation in the operating room after coronary artery bypass surgery. Anesth Analg 2000;91:776-780.[Abstract/Free Full Text]
  60. Abel M, Eisenkraft JB. Anesthetic implications of myasthenia gravis. Mt Sinai J Med 2002;69:31-37.[Medline]
  61. Kim JM, Mangold J. Sensitivity to both vecuronium and neostigmine in a seronegative myasthenic patient. Br J Anaesth 1989;63:497-500.[Abstract/Free Full Text]
  62. Lumb AB, Calder I. "Cured" myasthenia gravis and neuromuscular blockade. Anesthesia 1989;44:828-830.[CrossRef][Medline]
  63. Enoki T, Yoshiyuki N, Hirokawa Y, Nomura N, Atano Y, Mori K. Marked sensitivity to pancuronium in a patient without clinical manifestations of myasthenia gravis. Anesth Analg 1989;69:840-842.[Free Full Text]
  64. Paterson IG, Hood JR, Russel SH, Weston, MD, Hirsh NP. Mivacurium in the myasthenic patient. Br J Anaesth 1994;73:494-498.[Abstract/Free Full Text]
  65. Mulder DG. Invited commentary to: extended thymectomy in patients with myasthenia gravis with high thoracic epidural anesthesia alone. World J Surg 2004;28:965-966.[CrossRef]
  66. Ready LB, Plumer MH, Haschke RH, Austin E, Sumi SM. Neurotoxicity of intrathecal local anesthetics in rabbits. Anesthesiology 1985;63:364-370.[CrossRef][Medline]
  67. Rigler ML, Drasner K, Krejcie TC, Yelich SJ, Scholmick FT, DeFontes J, Bohner D. Cauda equine syndrome after continuous spinal anesthesia. Anesth Analg 1991;72:275-281.[Abstract/Free Full Text]
  68. Albright GA. Cardiac arrest following regional anesthesia with etidocaine and bupivicaine. Anesthesiology 1979;51:285-287.[CrossRef][Medline]
  69. Auroy Y, Narchi P, Messiah A, Litt L, Rouvier B, Sannii K. Serious complications related to regional anesthesia: results of a prospective survey in France. Anesthesiology 1997;87:479-486.[CrossRef][Medline]
  70. Horlocker TT. Regional anesthesia: complications of spinal and epidural anesthesia. Anesthesiol Clin North Am 2000;18:461-485.[CrossRef][Medline]
  71. Borghi B, Casati A, Iuorio S, Celleno D, Michael M, Serafini P, Pusceddu P, Fanelli G, on behalf of the Study Group on Orthopedic Anesthesia of the Italian Society of Anesthesia, Analgesia and Intensive care (SIAARTI) Frequency of hypotension and bradycardia during general anesthesia, epidural anesthesia, or integrated epidural-general anesthesia for total hip replacement. J Clin Anesth 2002;14:102-106.[CrossRef][Medline]
  72. Sidiropoulou T, Pompeo E, Bozzao A, Lunardi P, Dauri M. Epidural hematoma after thoracic epidural catheter removal in the absence of risk factors. Reg Anesth Pain Med 2003;28:531-534.[CrossRef][Medline]
  73. Gibson P. Spinal cord damage following thoracic epidural anaesthesia. Anaesth Intensive Care 2004;32:596-597.[Medline]
  74. Kehlet H, Dahl JB. The value of multi-modal or balanced analgesia in postoperative pain relief. Anesth Analg 1993;77:1048-1056.[Free Full Text]
  75. Tanaka K, Watanabe R, Harada T, Daer K. Extensive applications of epidural anesthesia and analgesia in a university hospital: incidence of complications related to technique. Reg Anesth 1993;18:34-38.[Medline]
  76. Stride PC, Cooper GM. Dural taps revisited: a 20 year survey from Birmingham Maternity Hospital. Anaesthesia 1993;48:247-255.[Medline]
  77. Neal JM. Management of postdural puncture headache, epidural and spinal analgesia and anesthesia: contemporary issues. In: Benumof JL, Bantra MS, editors. Anesthesiology clinics of North America. Philadelphia: WB Saunders; 1993. pp. 163-178.
  78. 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;117:551-555.[CrossRef][Medline]
  79. Renck H. Neurological complications of central nerve blocks. Acta Anaesthesiol Scand 1995;39:859-868.[Medline]
  80. Hearn M. Epidural abscess complicating insertion of epidural catheters. Br J Anaesth 2003;90:706-707.[Free Full Text]
  81. Govasi C, Bland D, Poddar R, Horst C. Epidural abscess complicating insertion of epidural catheters. Br J Anaesth 2004;92:294-295.[Free Full Text]
  82. Jack ES, Scott NB. The risk of vertebral canal complications in 2837 cardiac surgery patients with thoracic epidurals. Acta Anaesthesiol Scand 2006[Epub ahead of print].
  83. Ruppen W, Derry S, McQuay HJ, Moore A. Incidence of epidural haematoma and neurological injury in cardiovascular patients with epidural analgesia/anesthesia: systematic review and meta-analysis. BMC Anesthesiol 2006;6:10.[CrossRef][Medline]
  84. Kessler P, Neidhart G, Bremerich DH, Aybek T, Dogan S, Lischke V, Byhahn C. High thoracic epidural anesthesia for coronary artery bypass grafting using two different surgical approaches in conscious patients. Anesth Analg 2002;95:791-797.[Abstract/Free Full Text]



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