Vojislava Nesković1, Predrag Milojević. 1. Institut za kardiovaskularne bolesti Dedinje, 11040 Beograd, Milana Tepića 1. vojka_n@hotmail.com
Abstract
INTRODUCTION: High thoracic epidural anesthesia and analgesia are being increasingly used for coronary artery bypass graft surgery. The reasons for this include excellent perioperative pain control with advantage of early tracheal extubation, improved postoperative pulmonary function, and cardiac protection due to sympthatetic blockade. EFFECTS OF HIGH THORACIC EPIDURAL ANESTHESIA: Cardiac protection is the consequence of decreased heart rate, myocardial contractility and arterial blood pressure, without changes in coronary perfusion pressure. Therefore, high thoracic epidural analgesia beneficially alters major determinants of myocardial oxygen consumption, without jeopardizing coronary perfusion pressure. In addition, decrease of functional residual capacity, may reduce postoperative pulmonary morbidity. RESULTS OF CLINICAL STUDIES: Patients with high thoracic epidural anesthesia revealed a more favourable perioperative hemodynamic profile, lower incidence of ischemia and better response to perioperative stress. HIGH THORACIC EPIDURAL ANESTHESIA TECHNIQUE: The epidural catheter should be placed at the Th2/Th3 interspace at least one hour before administration of heparin. After local anesthetic bolus dose, a continuous epidural infusion is recommended. CONCLUSION: There is strong evidence for beneficial effects of high thoracic epidural anesthesia in patients undergoing surgical myocardial revascularization. However, it is still underutilized in current clinical practice.
INTRODUCTION: High thoracic epidural anesthesia and analgesia are being increasingly used for coronary artery bypass graft surgery. The reasons for this include excellent perioperative pain control with advantage of early tracheal extubation, improved postoperative pulmonary function, and cardiac protection due to sympthatetic blockade. EFFECTS OF HIGH THORACIC EPIDURAL ANESTHESIA: Cardiac protection is the consequence of decreased heart rate, myocardial contractility and arterial blood pressure, without changes in coronary perfusion pressure. Therefore, high thoracic epidural analgesia beneficially alters major determinants of myocardial oxygen consumption, without jeopardizing coronary perfusion pressure. In addition, decrease of functional residual capacity, may reduce postoperative pulmonary morbidity. RESULTS OF CLINICAL STUDIES: Patients with high thoracic epidural anesthesia revealed a more favourable perioperative hemodynamic profile, lower incidence of ischemia and better response to perioperative stress. HIGH THORACIC EPIDURAL ANESTHESIA TECHNIQUE: The epidural catheter should be placed at the Th2/Th3 interspace at least one hour before administration of heparin. After local anesthetic bolus dose, a continuous epidural infusion is recommended. CONCLUSION: There is strong evidence for beneficial effects of high thoracic epidural anesthesia in patients undergoing surgical myocardial revascularization. However, it is still underutilized in current clinical practice.