Related Experiment Videos
Postoperative myocardial ischemia: epidural versus intravenous patient-controlled analgesia. A pilot project
O A de Leon-Casasola1, M J Lema, D Karabella
1Department of Anesthesiology, Pain and Critical Care Medicine, Roswell Park Cancer Institute, Buffalo, New York 14263, USA.
Background And Objectives:
Continuous postoperative epidural analgesia with bupivacaine (BUP) and morphine (MS) may be associated with a decreased incidence of postoperative myocardial ischemia (ISCH) and infarction (MI). This study evaluated the incidence of ISCH and MI in patients with two or more risk factors for coronary artery disease (CAD) who were admitted to the ICU after upper abdominal surgery for cancer.
Methods:
During a 1-year period, 198 patients were studied for the incidence of ISCH and MI in a prospective, nonrandomized fashion. The epidural group (EPI, n = 110) received continuous epidural anesthesia by injection at the T7-9 interspaces with 0.5% BUP/0.013% MS and light general anesthesia followed by 0.1% BUP/0.01% MS epidural analgesia for 5-7 days. The general anesthesia group (GEN, n = 88) received a balanced technique followed by intravenous patient-controlled analgesia with 0.1% MS for 5-7 days. All patients had preoperative and postoperative 12 lead ECGs every 6 hours on the first 3 postoperative days. Patients with ECG changes consistent with myocardial ischemia had creatine kinase levels with isoenzymes drawn every 8 hours.
Results:
There were no differences in age, sex, number of cardiac risk factors, number taking anti-anginal medication, preoperative heart rate (75 +/- 5 [EPI] vs. 73 +/- 4 [GEN]), and incidence of preoperative or intraoperative ischemia between the two groups. All patients had adequate analgesia. Postoperatively, patients in the EPI group had a lower incidence of tachycardia (15 [14%] vs. 58 [65%], P < .00001), ischemia (5 [5%] vs. 15 [17%], P < .004), and infarction (0 vs. 3 [20% of patients with ischemia]). All episodes of ischemia were silent and occurred more frequently during the first 36 hours postoperatively (14 episodes or 72%). Overall 60% of the ISCH episodes were associated with tachycardia (5/5 in the EPI group and 7/15 in the GEN group). There were no deaths in either group.
Conclusions:
These preliminary results suggest that epidural anesthesia and analgesia may decrease the incidence of postoperative tachycardia, ischemia, and possibly infarction in patients undergoing upper abdominal procedures.
Insights
Continuous epidural analgesia with bupivacaine and morphine reduced postoperative myocardial ischemia and infarction in high-risk cancer patients undergoing abdominal surgery. This approach also decreased tachycardia incidence.
Area of Science:
- Anesthesiology
- Cardiology
- Oncology
Background:
- Patients with coronary artery disease (CAD) risk factors undergoing major abdominal surgery are susceptible to myocardial ischemia (ISCH) and infarction (MI).
- Continuous postoperative epidural analgesia with bupivacaine (BUP) and morphine (MS) is hypothesized to reduce ISCH and MI incidence.
Purpose of the Study:
- To evaluate the incidence of ISCH and MI in patients with at least two CAD risk factors after upper abdominal cancer surgery.
- To compare outcomes between continuous epidural analgesia and general anesthesia with intravenous patient-controlled analgesia.
Main Methods:
- A prospective, nonrandomized study of 198 patients over 1 year.
- Epidural group (n=110) received BUP/MS epidural anesthesia and analgesia.
- General anesthesia group (n=88) received balanced anesthesia and IV MS patient-controlled analgesia.
- Preoperative and postoperative ECGs and creatine kinase levels were monitored.
Main Results:
- No significant differences in patient demographics or preoperative conditions between groups.
- The epidural group showed significantly lower rates of postoperative tachycardia (14% vs. 65%) and ischemia (5% vs. 17%).
- No myocardial infarctions occurred in the epidural group, compared to 3 (20% of ischemic patients) in the general anesthesia group.
Conclusions:
- Continuous epidural anesthesia and analgesia may reduce the incidence of postoperative tachycardia, ischemia, and infarction in patients undergoing upper abdominal procedures.
- These findings suggest a potential benefit of epidural techniques for cardiac protection in high-risk surgical patients.