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Prospective randomized trial of high thoracic epidural analgesia for coronary artery bypass surgery
Colin Royse1, Alistair Royse, Paul Soeding
1Department of Anaesthesia and Pain Management,The Royal Melbourne Hospital, Melbourne, Victoria, Australia. colin.royse@mh.org.au
Insights
High thoracic epidural analgesia (HTEA) significantly reduces postoperative pain and psychological distress after coronary artery bypass surgery. This intense analgesia also improves patient cooperation with physiotherapy and leads to earlier extubation.
Area of Science:
- Cardiovascular Surgery
- Pain Management
- Anesthesiology
Background:
- Coronary artery bypass surgery (CABG) can result in severe postoperative pain.
- High thoracic epidural analgesia (HTEA) is an effective method for managing intense pain.
Purpose of the Study:
- To compare the efficacy of HTEA versus intravenous morphine for analgesia after CABG.
- To assess the impact of HTEA on pain scores, psychological morbidity, and other clinical outcomes.
Main Methods:
- Eighty patients undergoing CABG were randomized to receive either HTEA or intravenous morphine.
- Pain was assessed using a visual analogue scale; psychological morbidity, hemodynamics, lung function, and physiotherapy cooperation were also evaluated.
- Analgesia methods were discontinued on postoperative day 3, with only oral medications used thereafter.
Main Results:
- HTEA significantly reduced pain scores at rest and with coughing on postoperative days 1 and 2 compared to morphine.
- Patients receiving HTEA exhibited lower scores for postoperative depression and posttraumatic stress.
- Earlier extubation, improved physiotherapy cooperation, and better lung function (arterial oxygen tension, peak expiratory flow rate) were observed with HTEA.
Conclusions:
- High thoracic epidural analgesia is effective in reducing postoperative pain following coronary artery bypass surgery.
- HTEA is associated with significant benefits including improved physiotherapy cooperation, earlier extubation, and reduced psychological distress.
- The findings support the use of HTEA for enhanced recovery after cardiac surgery.
Background:
Postoperative pain may be severe after coronary artery bypass surgery. High thoracic epidural analgesia (HTEA) provides intense analgesia.
Methods:
Eighty patients were randomized to HTEA or intravenous morphine analgesia (control). Patients received coronary artery bypass surgery (CABG) with cardiopulmonary bypass. Pain was measured by visual analogue scale 0 to 10. Psychologic morbidity, intraoperative hemodynamics, ventricular function, lung function, and physiotherapy cooperation were also assessed. On the third postoperative day HTEA and morphine were ceased and only oral medications were used. Acetaminophen, indomethacin, and tramadol were allowed as supplemental analgesics in both groups.
Results:
The primary endpoint of pain scores was significantly less with HTEA on postoperative days 1 and 2 at rest, 0.02 +/- 0.2 versus 0.8 +/- 1.8 (p = 0.008) and 0.1 +/- 0.4 versus 1.2 +/- 2.7 (p = 0.022), respectively, and with coughing 1.2 +/- 1.7 versus 4.4 +/- 3.1 (p < 0.001) and 1.5 +/- 2.0 versus 3.6 +/- 3.1 (p = 0.001), respectively. When HTEA and morphine were ceased on day 3, there were no significant differences. The secondary endpoints of postoperative depression (p = 0.033) and posttraumatic stress subscales (p = 0.021) of the Minnesota Multiphasic Personality Inventory were lower with HTEA. Extubation occurred earlier with HTEA, 2.6 versus 5.4 hours (p < 0.001). HTEA showed improved physiotherapy cooperation (p < 0.001), arterial oxygen tension (p = 0.041), and peak expiratory flow rate (p = 0.001). Mean arterial pressure was lower with HTEA (p = 0.036), otherwise there were no differences in intraoperative hemodynamics or ventricular function.
Conclusions:
Epidural analgesia reduces pain after coronary operation and is associated with improved physiotherapy cooperation, earlier extubation, and reduced risk of depression and posttraumatic stress.
