Effects of Thoracic Epidural Anesthesia on Outcome after Coronary Artery Bypass Surgery: A Systematic Review_Chinese Journal of Evidence-Based Medicine

Authors：

FANG Bo , CHEN Jie , LI Xiaoqian ,  MA Hong

Department of Anesthesiology, The First Affiliated Hospital of China Medical University, Shenyang 110001, China;

Corresponding author：

MA Hong, Email: mahong5466@yahoo.com

Keywords：

Thoracic epidural anesthesia; Coronary artery bypass; Meta-analysis; Systematic review

DOI：

10.7507/1672-2531.20100522

Video：

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Objective ?To systematically evaluate the effects of thoracic epidural anesthesia on outcome after coronary artery bypass surgery.
Methods ?We searched PubMed, EBSCO, Springer, Ovid, and CNKI databases from 1990 through Oct. 2009 to identify randomized controlled trials (RCTs) about thoracic epidural anesthesia combined with general anesthesia versus general anesthesia alone on outcome after coronary artery bypass surgery. The methodological quality of the included RCTs was assessed and the data was extracted according to the Cochrane Reviewer’s Handbook. The homogeneous RCTs were pooled using RavMan 4.2.10 software.
Results ?Sixteen RCTs involving 1 316 patients met the inclusion criteria. The results of meta-analyses showed that thoracic epidural anesthesia significantly reduced time to tracheal extubation (MD= –332.43, 95%CI –640.19 to –24.68, P=0.03), visual analog scale (VAS) scores at rest on postoperation day 1 (MD= –1.23, 95%CI –2.19 to –0.27, P=0.01), VAS scores with movement on postoperation day 1 (MD= –2.52, 95%CI –4.65 to –0.39, P=0.02) and day 2 (MD= –1.5, 95%CI –2.56 to –0.43, P=0.006), and incidences of myocardial ischemia (RR=0.53, 95%CI 0.29 to 0.97, P=0.04). There were no significant differences between the two groups in postoperative pulmonary function, incidences of myocardial infarction, atrial fibrillation, and mortality.
Conclusions ?Thoracic epidural anesthesia could reduce postoperative time to tracheal extubation, VAS score, and incidences of myocardial ischemia, but it does not affect postoperative pulmonary function, incidences of myocardial infarction, atrial fibrillation, and mortality. More high-quality RCTs are required.

Citation： FANG Bo,CHEN Jie,LI Xiaoqian,MA Hong. Effects of Thoracic Epidural Anesthesia on Outcome after Coronary Artery Bypass Surgery: A Systematic Review. Chinese Journal of Evidence-Based Medicine, 2010, 10(8): 932-938. doi: 10.7507/1672-2531.20100522 Copy

1.	Gramling-Babb PM, Zile MR, Reeves ST. Preliminary report on high thoracic epidural analgesia: Relationship between its therapeutic effects and myocardial blood flow as assessed by stress thallium distribution. J Cardiovasc Vasc Anesth, 2000, 14(6): 657-661.
2.	Chaney MA. Intrathecal and epidural anesthesia and analgesia for cardiac surgery. Anesth Analg, 1997, 84(6): 1211-1221.
3.	Grass JA. The role of epidural anesthesia and analgesia in postoperative outcome. Anesthesiol Clin North Am, 2000, 18(2): 407–428, viii.
4.	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(3): 528-535.
5.	Berendes E, Schmidt C, Van Aken H, et al. Reversible Cardiac sympathectomy by high thoracic epidural anesthesia improves regional left ventricular function in patients undergoing coronary artery bypass grafting. Arch Surgm, 2003, 138(12): 1283-1290.
6.	Fillinger MP, Yeager MP, Dodds TM, et al. Epidural anesthesia and analgesia: Effects on recovery from cardiac surgery. J Cardiothorac Vasc Anesth, 2002, 16(1):15-20.
7.	Jideus L, Joachimsson PO, Stridsberg M, et al. Thoracic epidural anesthesia does not influence the occurrence of postoperative sustained atrial fibrillation. Ann Tho- rac Surg, 2001, 72(1): 65-71.
8.	Priestley MC, Cope L, Halliwell R, et al. Thoracic epidural anesthesia for cardiac surgery: The effects on tracheal intubation time and length of hospital stay. Anesth Analg, 2002, 94(2): 275-282.
9.	Kirno K, Friberg P, Grzegorczyk A, et al. Thoracic epidural anesthesia during coronary artery bypass surgery: effects on cardiac sympathetic activity, myocardial blood flow and metabolism, and central hemodynamics. Anesth Analg, 1994, 79(6): 1075-1081.
10.	Liem TH, Hasenbos MA, Booij LH, et al. Coronary artery bypass grafting using two different anesthetic techniques: II. Postoperative outcome. J Cardiothorac Vasc Anesth, 1992, 6(2): 156-161.
11.	Barrington MJ, Kluger R, Watson, R, et al. Epidural anesthesia for coronary artery bypass surgery compared with general anesthesia alone does not reduce biochemical markers of myocardial damage. Anesth Analg, 2005, 100(4): 921-928.
12.	Nygård E, Sørensen LH, Hviid LB. Effects of amiodarone and thoracic epidural analgesia on atrial fibrillation after coronary artery bypass grafting. J Cardiothorac Vasc Anesth, 2004, 18(6 ): 709-714.
13.	Tenenbein PK, Debrouwere R, Maguire D, et al. Thoracic epidural analgesia improves pulmonary function in patients undergoing cardiac surgery. Can J Anesth, 2008, 55(6): 344-350.
14.	Royse C, Royse A, Soeding P, et al. Prospective randomized trial of high thoracic epidural analgesia for coronary artery bypass surgery. Ann Thorac Surg, 2003, 75(1): 93-100.
15.	Tenling A, Joachimsson PO, Tyden H, et al. Thoracic epidural analgesiaas an adjunct to general anesthesia for cardiac surgery: Effects on pulmonary mechanics. Acta Anaesthesiol Scand, 2000, 44(9): 1071-1076.
16.	Fawcett WJ, Edwards RE, Quinn AC, et al. Thoracic epidural analgesia started after cardiopulmonary bypass. Anaesth, 1997, 52(4): 294-299.
17.	Loick HM, Schmidt C, Van Aken H, et al. 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(4): 701–709.
18.	Rodriguez MAP, Gonzalo LS, Villaralvarez F, et al. Thoracic epidural anesthesia decrease C-reactive protein levels in patients undergoing elective coronary artery bypass raft surgery with cardiopulmonary bypass. Minerva Anesthesiol, 2008, 74(11): 619-626.
19.	Tenling A, Joachimsson PO, Tyden H, et al. Thoracic epidural anesthesia as an adjunct to general anesthesia for cardiac surgery: effects on ventilation-perfusion relationships. J Cardiothorac Vasc Anesth, 1999, 13(3): 258-264.
20.	Moore CM, Cross MH, Desborough JP, et al. Hormonal effects of thoracic extradural analgesia for cardiac surgery. Br J Anaesth, 1995, 75(4): 387-393.
21.	Buggy DJ, Smith G. Epidural anaesthesia and analgesia:better outcome after major surgery? Growing evidence suggests so. BMJ, 1999, 319(7209): 531-532.
22.	Blomberg S, Emanuelsson H, Kvist H, et al. Effects of thoracic epidural anesthesia on coronary arteries and arterioles in patients with coronary artery disease. Anesthesiology, 1990, 73(5): 840-847.
23.	Blomberg S, Emanuelsson H, Ricksten SE. Thoracic epidural anesthesia and central hemodynamics in patients with unstableangina pectoris. Anesth Analg, 1989, 69(5): 558-562.
24.	Meissner A, Rolf N, Van Aken H. Thoracic epidural anesthesia and the patient with heart disease: Benefits, risks, and controversies. Anesth Analg, 1997, 85(3): 517-528.
25.	Hogue CW, Hyder ML. Atrial ?brillation after cardiac operation: Risks, mechanisms, and treatment. Ann Thorac Surg, 2000, 69(1): 300-306.

1. Gramling-Babb PM, Zile MR, Reeves ST. Preliminary report on high thoracic epidural analgesia: Relationship between its therapeutic effects and myocardial blood flow as assessed by stress thallium distribution. J Cardiovasc Vasc Anesth, 2000, 14(6): 657-661.
2. Chaney MA. Intrathecal and epidural anesthesia and analgesia for cardiac surgery. Anesth Analg, 1997, 84(6): 1211-1221.
3. Grass JA. The role of epidural anesthesia and analgesia in postoperative outcome. Anesthesiol Clin North Am, 2000, 18(2): 407–428, viii.
4. 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(3): 528-535.
5. Berendes E, Schmidt C, Van Aken H, et al. Reversible Cardiac sympathectomy by high thoracic epidural anesthesia improves regional left ventricular function in patients undergoing coronary artery bypass grafting. Arch Surgm, 2003, 138(12): 1283-1290.
6. Fillinger MP, Yeager MP, Dodds TM, et al. Epidural anesthesia and analgesia: Effects on recovery from cardiac surgery. J Cardiothorac Vasc Anesth, 2002, 16(1):15-20.
7. Jideus L, Joachimsson PO, Stridsberg M, et al. Thoracic epidural anesthesia does not influence the occurrence of postoperative sustained atrial fibrillation. Ann Tho- rac Surg, 2001, 72(1): 65-71.
8. Priestley MC, Cope L, Halliwell R, et al. Thoracic epidural anesthesia for cardiac surgery: The effects on tracheal intubation time and length of hospital stay. Anesth Analg, 2002, 94(2): 275-282.
9. Kirno K, Friberg P, Grzegorczyk A, et al. Thoracic epidural anesthesia during coronary artery bypass surgery: effects on cardiac sympathetic activity, myocardial blood flow and metabolism, and central hemodynamics. Anesth Analg, 1994, 79(6): 1075-1081.
10. Liem TH, Hasenbos MA, Booij LH, et al. Coronary artery bypass grafting using two different anesthetic techniques: II. Postoperative outcome. J Cardiothorac Vasc Anesth, 1992, 6(2): 156-161.
11. Barrington MJ, Kluger R, Watson, R, et al. Epidural anesthesia for coronary artery bypass surgery compared with general anesthesia alone does not reduce biochemical markers of myocardial damage. Anesth Analg, 2005, 100(4): 921-928.
12. Nygård E, Sørensen LH, Hviid LB. Effects of amiodarone and thoracic epidural analgesia on atrial fibrillation after coronary artery bypass grafting. J Cardiothorac Vasc Anesth, 2004, 18(6 ): 709-714.
13. Tenenbein PK, Debrouwere R, Maguire D, et al. Thoracic epidural analgesia improves pulmonary function in patients undergoing cardiac surgery. Can J Anesth, 2008, 55(6): 344-350.
14. Royse C, Royse A, Soeding P, et al. Prospective randomized trial of high thoracic epidural analgesia for coronary artery bypass surgery. Ann Thorac Surg, 2003, 75(1): 93-100.
15. Tenling A, Joachimsson PO, Tyden H, et al. Thoracic epidural analgesiaas an adjunct to general anesthesia for cardiac surgery: Effects on pulmonary mechanics. Acta Anaesthesiol Scand, 2000, 44(9): 1071-1076.
16. Fawcett WJ, Edwards RE, Quinn AC, et al. Thoracic epidural analgesia started after cardiopulmonary bypass. Anaesth, 1997, 52(4): 294-299.
17. Loick HM, Schmidt C, Van Aken H, et al. 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(4): 701–709.
18. Rodriguez MAP, Gonzalo LS, Villaralvarez F, et al. Thoracic epidural anesthesia decrease C-reactive protein levels in patients undergoing elective coronary artery bypass raft surgery with cardiopulmonary bypass. Minerva Anesthesiol, 2008, 74(11): 619-626.
19. Tenling A, Joachimsson PO, Tyden H, et al. Thoracic epidural anesthesia as an adjunct to general anesthesia for cardiac surgery: effects on ventilation-perfusion relationships. J Cardiothorac Vasc Anesth, 1999, 13(3): 258-264.
20. Moore CM, Cross MH, Desborough JP, et al. Hormonal effects of thoracic extradural analgesia for cardiac surgery. Br J Anaesth, 1995, 75(4): 387-393.
21. Buggy DJ, Smith G. Epidural anaesthesia and analgesia:better outcome after major surgery? Growing evidence suggests so. BMJ, 1999, 319(7209): 531-532.
22. Blomberg S, Emanuelsson H, Kvist H, et al. Effects of thoracic epidural anesthesia on coronary arteries and arterioles in patients with coronary artery disease. Anesthesiology, 1990, 73(5): 840-847.
23. Blomberg S, Emanuelsson H, Ricksten SE. Thoracic epidural anesthesia and central hemodynamics in patients with unstableangina pectoris. Anesth Analg, 1989, 69(5): 558-562.
24. Meissner A, Rolf N, Van Aken H. Thoracic epidural anesthesia and the patient with heart disease: Benefits, risks, and controversies. Anesth Analg, 1997, 85(3): 517-528.
25. Hogue CW, Hyder ML. Atrial ?brillation after cardiac operation: Risks, mechanisms, and treatment. Ann Thorac Surg, 2000, 69(1): 300-306.

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Effects of Thoracic Epidural Anesthesia on Outcome after Coronary Artery Bypass Surgery: A Systematic Review

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