A comparison of high thoracic epidural anaesthesia versus conventional intravenous opioids in pediatric patients undergoing corrective open heart surgery for ventricular septal defect
Keywords:HTEA, Epidural anaesthesia, ScvO2, Bupivacaine, CPB
Background: We compared high thoracic epidural anaesthesia with a combination of morphine and bupivacaine versus IV fentanyl as an alternative for perioperative pain management.
Methods: Group-E: Injection Morphine 75-100 mcg/kg and Injection 0.25 % Bupivacaine 0.5 ml/kg was given via epidural catheter at insertion, Injection 0.25% Bupivacaine 0.5 ml/kg just before skin incision, and continuous infusion of Injection 0.125% Bupivacaine at 0.2 ml/kg/hr intra-operatively. Post-operative 0.1 ml/kg/hr infusion. Group F- intravenous fentanyl 2-3 mcg/Kg IV bolus given just before skin incision, followed by 1-2 mcg/Kg/hr IV fentanyl started after weaning from cardiopulmonary bypass.
Results: The mean ScvO2 was comparable between the two groups during induction period but became higher in group E during bypass and post bypass period intraoperatively, and the difference in rise in ScvO2 is statistically significant with a p<0.05. The mean rSo2- C was comparable between the two groups in the first postoperative hour but group F shows higher rSo2-C postoperatively which was statistically significant. The postoperative pain was significantly lower in group E in the postoperative period (except for 4,5,6 and 40 and 48th hour).
Conclusions: HTEA to paediatric patients prior to sternotomy for cardiac surgeries resulted in a much better control of haemodynamic parameters. Produces better central venous and regional tissue oxygenation during bypass and post bypass intraoperatively as compared to the patients that received only intravenous fentanyl. There was lower amount of postoperative bleeding in the HTEA group with significant reduction in requirement of post-operative ventilation and time to extubation after surgery, better post-operative pain control and overall outcome.
Nygren A, Sunnegårdh J, Berggren H. Preoperative evaluation and surgery in isolated ventricular septal defects: a 21 year perspective. Heart. 2000;83(2):198-204.
Bhatt M, Roth SJ, Kumar RK, Gauvreau K, Nair SG, Chengode S, et al. Management of infants with large, unrepaired ventricular septal defects and respiratory infection requiring mechanical ventilation. The Journal of thoracic and cardiovascular surgery. 2004;127(5):1466-73.
Imani F. Postoperative pain management. Anesthesiology and pain medicine. 2011;1(1):6-7.
Ziyaeifard M, Azarfarin R, Golzari SEJ. A Review of Current Analgesic Techniques in Cardiac Surgery. Is Epidural Worth it? Journal of Cardiovascular and Thoracic Research. 2014;6(3):133-40.
Zawar BP, Mehta Y, Juneja R, Arora D, Raizada A, Trehan N. Nonanalgesic benefits of combined thoracic epidural analgesia with general anesthesia in high risk elderly off pump coronary artery bypass patients. Annals of cardiac anaesthesia. 2015;18(3):385.
Bakhtiary F, Therapidis P, Dzemali O, Ak K, Ackermann H, Meininger D, et al. Impact of high thoracic epidural anesthesia on incidence of perioperative atrial fibrillation in off-pump coronary bypass grafting: a prospective randomized study. The Journal of thoracic and cardiovascular surgery. 2007;134(2):460-4.
Salvi L, Sisillo E, Brambillasca C, Juliano G, Salis S, Marino MR. High thoracic epidural anesthesia for off-pump coronary artery bypass surgery. Journal of cardiothoracic and vascular anesthesia. 2004;18(3):256-62.
Bignami E, Landoni G, Biondi-Zoccai GG, Boroli F, Messina M, Dedola E, et al. Epidural analgesia improves outcome in cardiac surgery: a meta-analysis of randomized controlled trials. Journal of cardiothoracic and vascular anesthesia. 2010;24(4):586-97.
Wijeysundera DN, Beattie WS, Austin PC, Hux JE, Laupacis A. Epidural anaesthesia and survival after intermediate-to-high risk non-cardiac surgery: a population-based cohort study. The Lancet. 2008;372(9638):562-9.
Schmidt C, Hinder F, Van Aken H, Theilmeier G, Bruch C, Wirtz SP, et al. The effect of high thoracic epidural anesthesia on systolic and diastolic left ventricular function in patients with coronary artery disease. Anesthesia & Analgesia. 2005;100(6):1561-9.
Jakobsen CJ, Nygaard E, Norrild K, Kirkegaard H, Nielsen J, Torp P, et al. High thoracic epidural analgesia improves left ventricular function in patients with ischemic heart. Acta Anaesthesiologica Scandinavica. 2009;53(5): 559-64.
Beattie WS, Badner NH, Choi P. Epidural analgesia reduces postoperative myocardial infarction: a meta-analysis. Anesthesia & Analgesia. 2001;93(4):853-8.
Clemente A, Carli F. The physiological effects of thoracic epidural anesthesia and analgesia on the cardiovascular, respiratory and gastrointestinal systems. Minerva Anestesiol. 2008;74(10):549-63.
Lattermann R, Wykes L, Eberhart L, Carli F, Meterissian S, Schricker T. A randomized controlled trial of the anticatabolic effect of epidural analgesia and hypocaloric glucose. Regional anesthesia and pain medicine. 2007;32(3): 227-32.
Schricker T, Meterissian S, Wykes L, Eberhart L, Lattermann R, Carli F. Postoperative protein sparing with epidural analgesia and hypocaloric dextrose. Annals of surgery. 2004;240(5):916.
Salomäki T, Leppäluoto J, Laitinen J, Vuolteenaho O, Nuutinen LS. Epidural versus intravenous fentanyl for reducing hormonal, metabolic, and physiologic responses after thoracotomy. Anesthesiology. 1993;79(4):672-9.
Shayevitz JR, Merkel S, O'Kelly SW, Reynolds PI, Gutstein HB. Lumbar epidural morphine infusions for children undergoing cardiac surgery. Journal of cardiothoracic and vascular anesthesia. 1996;10(2):217-24.