High Thoracic Epidural Anesthesia Research Articles

High thoracic epidural anesthesia for coronary artery bypass grafting using two different surgical approaches in conscious patients.

Recent developments in coronary artery bypass graft surgery (CABG) without cardiopulmonary bypass made the sole use of high thoracic epidural anesthesia (TEA) in conscious patients feasible. Previously, TEA has been reported only for single-vessel CABG via lateral thoracotomy. We investigated the feasibility and complications of sole TEA in 20 patients undergoing beating-heart arterial revascularization via partial lower sternotomy for single-vessel disease (minimally invasive direct coronary artery bypass grafting [MIDCAB] technique; n = 10) or complete median sternotomy for multivessel disease (off-pump coronary artery bypass grafting [OPCAB] technique; n = 10). An epidural catheter was inserted at the T1-2 or T2-3 interspace. An epidural infusion of ropivacaine 0.5% and sufentanil 1.66 micro g/mL was started to establish anesthetic levels at C5-6 for OPCAB and at T1-2 for MIDCAB. Nine OPCAB and eight MIDCAB procedures were completed while patients were awake and spontaneously breathing during the entire procedure. Because of surgical pneumothorax (OPCAB), insufficient anesthesia, or phrenic nerve palsy (both MIDCAB), three patients required intraoperative conversion to general anesthesia. The heart rate decreased significantly (P < 0.05) by 10%-15% in both groups during the procedure. Compared with baseline (B), mean arterial blood pressure (mm Hg) was decreased significantly only during coronary anastomosis (CA) (B(OPCAB), 95 +/- 11; CA(OPCAB), 68 +/- 9; B(MIDCAB), 86 +/- 10; CA(MIDCAB), 73 +/- 10; P not significant between groups). PaCO(2) increased from 42 +/- 2 mm Hg to 46 +/- 7 mm Hg (P < 0.05) throughout the perioperative course during OPCAB, whereas it remained almost unaltered during MIDCAB procedures. All patients rated TEA as "good" or "excellent." In conclusion, we demonstrated that the sole use of TEA for MIDCAB and OPCAB procedures was feasible and provided a high degree of patient satisfaction in our small and highly selected cohorts. IMPLICATIONS. The sole use of high thoracic epidural anesthesia was studied in 20 patients who underwent beating-heart coronary artery bypass grafting using either median or partial lower sternotomy while awake.

High Thoracic Epidural Anesthesia for Coronary Artery Bypass Grafting Using Two Different Surgical Approaches in Conscious Patients

Recent developments in coronary artery bypass graft surgery (CABG) without cardiopulmonary bypass made the sole use of high thoracic epidural anesthesia (TEA) in conscious patients feasible. Previously, TEA has been reported only for single-vessel CABG via lateral thoracotomy. We investigated the feasibility and complications of sole TEA in 20 patients undergoing beating-heart arterial revascularization via partial lower sternotomy for single-vessel disease (minimally invasive direct coronary artery bypass grafting [MIDCAB] technique;n = 10) or complete median sternotomy for multivessel disease (off-pump coronary artery bypass grafting [OPCAB] technique;n = 10). An epidural catheter was inserted at the T1-2 or T2-3 interspace. An epidural infusion of ropivacaine 0.5% and sufentanil 1.66 μg/mL was started to establish anesthetic levels at C5-6 for OPCAB and at T1-2 for MIDCAB. Nine OPCAB and eight MIDCAB procedures were completed while patients were awake and spontaneously breathing during the entire procedure. Because of surgical pneumothorax (OPCAB), insufficient anesthesia, or phrenic nerve palsy (both MIDCAB), three patients required intraoperative conversion to general anesthesia. The heart rate decreased significantly (P < 0.05) by 10%–15% in both groups during the procedure. Compared with baseline (B), mean arterial blood pressure (mm Hg) was decreased significantly only during coronary anastomosis (CA) (BOPCAB, 95 ± 11; CAOPCAB, 68 ± 9; BMIDCAB, 86 ± 10; CAMIDCAB, 73 ± 10;P not significant between groups). Paco2 increased from 42 ± 2 mm Hg to 46 ± 7 mm Hg (P < 0.05) throughout the perioperative course during OPCAB, whereas it remained almost unaltered during MIDCAB procedures. All patients rated TEA as “good” or “excellent.” In conclusion, we demonstrated that the sole use of TEA for MIDCAB and OPCAB procedures was feasible and provided a high degree of patient satisfaction in our small and highly selected cohorts.

Awake Coronary Artery Bypass Grafting Using a High Thoracic Epidural Anesthesia: A Viable Alternative in the Future?

Awake Coronary Artery Bypass Grafting Using a High Thoracic Epidural Anesthesia: A Viable Alternative in the Future?

High thoracic epidural anesthesia for coronary artery bypass graft surgery in a patient with severe obstructive lung disease

CHRONIC OBSTRUCTIVE zpulmonary disease (COPD) is well recognized as a major risk factor for perioperative morbidity and mortality in patients undergoing coronary artery bypass graft (CABG) surgery. Perioperative mortality may be 50% for elderly patients with severe COPD taking steroids who undergo CABG surgery. 1 Samuels LE Kaufman MS Morris RJ et al. Coronary artery bypass grafting in patients with COPD. Chest. 1998; 113: 878-882 Crossref PubMed Scopus (91) Google Scholar Nonsurgical therapy is recommended for this cohort. 1 Samuels LE Kaufman MS Morris RJ et al. Coronary artery bypass grafting in patients with COPD. Chest. 1998; 113: 878-882 Crossref PubMed Scopus (91) Google Scholar CABG surgery without cardiopulmonary bypass may have potential benefits for COPD patients. High thoracic epidural anesthesia (TEA) may further reduce postoperative complications. 2 Liem TH Hasenbos MAWM Booij LHDJ Gielen MJM Coronary artery bypass grafting using two different anesthestic techniques: Part 2. Postoperative outcome. J Cardiothorac Vasc Anesth. 1992; 6: 156-161 Abstract Full Text PDF PubMed Scopus (150) Google Scholar A case of a 77-year-old patient with severe COPD who successfully underwent off-pump CABG surgery, using high TEA, is presented.

High thoracic epidural anaesthesia in patients undergoing coronary artery bypass surgery

High thoracic epidural anaesthesia in patients undergoing coronary artery bypass surgery

Chronic Pain: Management Strategies That Work

Chronic Pain: Management Strategies That Work

Cardiovascular and pulmonary effects of epidural anaesthesia.

Epidural anaesthesia has been used since the early 1900s. Consequently the general characteristics of these procedures have been well defined. More studies have provided a better understanding of the cardiopulmonary changes produced by epidural anaesthesia. The cardiovascular effects observed with epidural anaesthesia are complex and variable, depending on a multitude of factors. The extent of sympathetic denervation, balance of sympathetic and parasympathetic activity, the pharmacological effect of systemically absorbed local anaesthetic agents, inclusion of adrenaline in the anaesthetic solution, the distribution of blood in relation to cardiac filling and cardiovascular function of the patient must be taken into account when considering the circulatory effects of epidural anaesthesia. Individual cardiovascular response to different levels of sympathetic blockade varies widely, depending on the degree of sympathetic tone before the block. Epidural anaesthesia that is restricted to the level of the low thoracic and lumbar region (T5-L4) results in a "peripheral" sympathetic blockade with vascular dilatation in the pelvis and lower limbs. High thoracic epidural anaesthesia, from the first to fifth thoracic, blocks the cardiac afferent and efferent sympathetic fibres with loss of chronotropic and inotropic drive to the myocardium. Thoracic epidural anaesthesia appears to at least partly reverse the diaphragmatic dysfunction that is a major determinant of the decrease in lung volumes observed after upper abdominal surgery. This article summarizes cardiovascular and pulmonary responses to epidural anaesthesia. Details of clinical management are not included in the review.

High thoracic epidural anaesthesia for coronary artery bypass surgery (CABG): A prospective randomized study - preliminary results

High thoracic epidural anaesthesia for coronary artery bypass surgery (CABG): A prospective randomized study - preliminary results

Towards pain free cardiac surgery - high thoracic epidural analgesia

Abstract Epidural analgesia is a well-established analgesic technique, providing complete or near complete perioperative analgesia for major surgery. Epidural analgesia may also confer additional benefits during the perioperative period, including attenuation of the stress response, reduction in procoagulation tendency, and reduction in myocardial ischaemia and infective complications. These additional benefits are an advantage in patients with ischaemic heart disease. We discuss the use of high thoracic epidural anaesthesia in cardiac surgery, outlining potential benefits and risks. Our experience with epidural analgesia in over 300 patients undergoing cardiac surgery is briefly described.

Hypotension during thoracic surgery under combined general and high thoracic epidural anesthesia

High thoracic epidural anesthesia (TEA) is increasingly often used in combination with general anesthesia for major thoracic and abdominal surgery. TEA leads to sympatholysis of cardiac efferences leading to improved myocardial oxygen balance, which is in part due to vasodilation of atherosclerotic coronary vessels. To provide the full benefit of TEA, it is important to extend it as patient-controlled epidural analgesia in the postoperative period. If adequate vascular volume is maintained, hypotension is less frequent after TEA than after lumbar epidural anesthesia. However, in combination with general anesthesia, it may be more frequent and more severe. Treatment of hypotension is sometimes difficult and may require the use of nonadrenergic vasoconstrictors (eg, vasopressin). Copyright © 2000 by W.B. Saunders Company

Room 301, 10/17/2000 9: 00 AM - 10: 30 AM (PD) Effect of High Thoracic Epidural Anesthesia (TEA) on Global Left Ventricular (LV) Function in Patients with Coronary Artery Disease (CAD)

Room 301, 10/17/2000 9: 00 AM - 10: 30 AM (PD) Effect of High Thoracic Epidural Anesthesia (TEA) on Global Left Ventricular (LV) Function in Patients with Coronary Artery Disease (CAD)

Measurement of Sympathetic Blockade: Effect of Epidural and Spinal Anesthesia

Consultant in Anesthesiology Akureyri Central HospitalAkureyri, IcelandDirectorklaus.kirno@medfak.gu.seProfessorDepartment of Cardiothoracic Anesthesiology and Intensive CareAssociate ProfessorDepartment of Clinical NeurophysiologySahlgrenska University HospitalUniversity of GöteborgGöteborg, SwedenIn Reply:—We appreciate the interest and comments expressed by Drs. Introna, Blair, Martin, and Yodlowski. We fully agree that indirect methods of measuring sympathetic nerve activity can provide useful, qualitative information. Quantification of sympathetic nerve activity, however, is difficult with these techniques.The main issue raised by Introna et al. is whether a high thoracic epidural anesthesia (TEA) completely inhibits cardiac sympathetic activity. Based on studies measuring heart rate variability, these authors are convinced that TEA with T1–T5 sensory blockade does not result in complete cardiac sympathetic blockade. However, a comparative study of heart rate variability, cardiac norepinephrine spillover, and muscle sympathetic nerve activity in humans by Kingwell et al. 1invites some caution because it showed heart rate variability to be dependent on multiple factors in addition to cardiac sympathetic nerve activity and not directly related to cardiac norepinephrine spillover.The degree of thoracic sympathetic blockade was not specifically addressed in our recent study, 2which was primarily aimed at evaluating sympathetic function caudal to the TEA-induced sensory blockade and showed no sign of sympathetic blockade. However, previous microneurographic studies of lumbar epidural and spinal anesthesia have shown a fairly close relation between the extent of sensory and sympathetic blockade. 3,4Because the nerves to internal organs are not accessible to microneurographic recording in humans, we previously used biochemical measurements of nerve transmitter release to quantify cardiac sympathetic nerve activity. 5We used an isotope dilution technique with radiolabeled norepinephrine to demonstrate that TEA prevented the sympathetically mediated surgical stress response during coronary artery bypass surgery. Although this finding could be explained by an afferent nociceptive blockade or an efferent blockade of cardiac sympathetic nerve fibers, supportive evidence for the existence of a cardiac sympathetic blockade after TEA has been provided by Taniguchi et al. , 6who directly measured efferent cardiac sympathetic nerve activity after TEA in an experimental study on cats. Our recent finding 2that vasomotor and sudomotor reflexes were abolished in the hands but remained in the feet after TEA also suggests a thoracic sympathetic blockade. Therefore, although we agree with Introna et al. that “sympathetic fibers above and below the segment of epidural anesthesia could travel cephalad or caudad within the sympathetic chain” and “continue to innervate the heart,” we remain convinced that TEA can abolish sympathetic reflexes within thoracic segments.

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

LOICK, HEINZ MICHAEL; SCHMIDT, CHRISTOPH; VAN AKEN, HUGO; JUNKER, RALF; ERREN, MICHAEL; BERENDES, ELMAR; ROLF, NORBERT; MEISSNER, ANDREAS; SCHMID, CHRISTOPH; SCHELD, HANS HEINRICH; MÖLLHOFF, THOMAS Author Information

Effects of high thoracic epidural anesthesia and local anesthetics on bronchial hyperreactivity.

Bronchial hyperreactivity can cause life threatening bronchospasm after airway irritation. Therefore, endotracheal intubation is avoided in asthmatics when feasible. High thoracic epidural anesthesia can be used to avoid endotracheal intubation and offers less postoperative pulmonary complications when compared to systemic postoperative analgesia. However, there are concerns that it might also cause impaired ventilation by extended motor blockade, increased airway resistance, and increased bronchial reactivity because of pulmonary sympathicolysis. Nevertheless, high thoracic epidural anesthesia causes only a slight decrease in vital capacity and neither an increase in airway resistance nor increased bronchial reactivity. In fact, it causes a decrease in bronchial reactivity in patients with bronchial hyperreactivity mostly due to the systemic effect of the local anesthetic. The attenuation of bronchial hyperreactivity can be shown as a dose dependent effect of lidocaine and bupivacaine. The intravenous effect of lidocaine is comparable to the effect of a moderate dose of salbutamol and leads to an additive effect when both drugs are used in combination. Overall, high thoracic epidural anesthesia can be used safely in patients with bronchial hyperreactivity and intravenous administration of lidocaine (1.5-2.0 mg x kg(-1)) can be used as a prophylactic treatment prior to airway instrumentation.

Paravertebral Blockade for Modified Radical Mastectomy in a Pregnant Patient

Paravertebral Blockade for Modified Radical Mastectomy in a Pregnant Patient

Embracing the heart: Perioperative management of patients undergoing off-pump coronary artery bypass grafting using the octopus tissue stabilizer

Objective: To describe hemodynamic alterations during coronary artery bypass grafting (CABG) without extracorporeal circulation using the Octopus Tissue Stabilizer, and to describe the two anesthetic management protocols based on either general anesthesia with opioids (34 patients) or general anesthesia with high thoracic epidural anesthesia (TEA; 66 patients). Design: A prospective observational report. Setting: An academic university heart center. Participants: First 100 patients undergoing CABG using the Octopus Tissue Stabilizer. Interventions: None. Main Results: Current management provided satisfactory results in preventing hypoperfusion of the heart and inadequate systemic circulation without the use of major pharmacologic interventions. Movement of the heart to reach the target site of anastomosis caused hemodynamic alterations. These could easily be corrected by anesthetic interventions, such as fluid load and low doses of inotropes. High TEA allows earlier extubation compared with the opioid anesthesia technique (0.9 v 4.5 hours). Perioperative management and the incidence of postoperative complications did not differ between anesthetic techniques. Major complications, such as death, intraoperative myocardial infarction, and stroke, did not occur. Conclusion: Both anesthetic protocols are safe and effective in handling these patients. Off-pump CABG surgery requires anesthetic interventions because hemodynamic alterations are caused by the presentation of the heart to the surgeon. The complication rate is low but needs to be evaluated, compared with conventional CABG, in a prospective randomized study. High thoracic epidural anesthesia allows early recovery, but improved outcome could not be proved in this patient group.

Physiology and pathophysiology of thoracic sympathetic blockade

Sympathetic innervation of the heart and lung is mediated by fibres originating from the thoracic segments T1–4. Sympathetic stimulation in healthy subjects causes coronary vasodilation, whereas stenotic coronary arteries show vasoconstriction in response to sympathetic stimulation. Thus, in patients at risk of ischaemia, high thoracic epidural anaesthesia (TEA) should dilate constricted coronary vessels, decrease heart rate and myocardial metabolism, and improve cardiac function by reducing pre- and afterload and optimizing oxygen availability. The pulmonary effects include an improved postoperative diaphragmatic function in lambs and humans and enhanced respiratory function parameters. Hypoxic pulmonary vasoconstriction, an important mechanism for the maintenance of adequate oxygenation after induction of general anaesthesia, is not affected by TEA in dogs. Beneficial effects of epidural sympathetic blockade on myocardial perfusion and function, and on pulmonary parameters, can only be achieved by a thoracic blockade, whereas lumbar epidural anaesthesia may exert adverse effects due to a compensatory increase of thoracic sympathetic activity.

Thoracic epidural anaesthesia for treatment of refractory angina pectoris

Unstable angina is a dangerous condition with a high risk of developing myocardial infarction. The atherosclerotic plaque is exceedingly inflammatory and the unstable condition is due to a plaque rupture changing the anatomic configuration and associated with activation of the sympathetic nervous system and stenotic vasoconstriction and thrombosis. In spite of nitrates, β-blockers, calcium blockers and anti-platelet and anti-thrombotic drugs, there is refractory angina in about 10% of cases. These patients may successfully be treated with high thoracic epidural anaesthesia (HTEA), which is anti-anginal and anti-ischemic; if they are inoperable they can be discharged for long-term home self-treatment with tunnelled or inplantable HTEA devices. These have a low cost and are simple to insert and easy to handle, with a low risk for complications. There is also a decreasing need for injections with time, which may be explained by less tissue damage or intimal hyperplasia due to the sympathetic blockade.

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

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

Minimally invasive direct coronary artery bypass procedure using a high thoracic epidural plus general anesthetic technique

A NEW SURGICAL approach to coronary artery revascularization that avoids the use of extracorporeal circulation (ECC) is now available: minimally invasive direct coronary artery bypass (MIDCAB). The procedure is limited to patients with one-vessel or two-vessel coronary artery disease (CAD), and allows the heart to continue beating throughout surgery. 1,2 An additional advantage is that the size of the incision is reduced to a small submammary area (keyhole incision). However, the combination of the beating heart and the keyhole incision make this surgical approach more difficult for the surgeon. The increase in postoperative pain and the need for one-lung ventilation during the anastomosis are additional disadvantages of this technique. Incisional pain after the snbmammary incision is greater (especially during the postoperative period) than that associated with a median sternotomy. 3 There are also selected patient characteristics that exclude candidates for MIDCAB, such as severe chronic obstructive pulmonary disease (FEV 1 < 1,500 mL) and coagulation disorders (especially when epidural anesthesia will be used). In contrast to these problems, however, are the many beneficial effects, which include lack of ECC and, therefore, a decreased inflammatory reaction, faster patient recovery, and shorter hospital stay. Beginning in 1990 at Nijmegen University Hospital (The Netherlands), a combined anesthetic technique (high thoracic epidural plus general anesthesia [HTE/GA]) has been used for the patients undergoing coronary artery bypass grafting (CABG) surgery. The authors previously described and reported the beneficial effects of the HTE/GA technique compared with a general anesthetic. 4-6