American Society of Regional Anesthesia and Pain Medicine November 2017 - 48
Table 1: Recent meta-analyses of neuraxial analgesia in cardiac surgery.7,10,11
Author, year
No. of studies/patients
Intervention
Significant findings
↓ARF
Bignami et al, 2010
33/2,366
GA versus GA+TEA
↓Mechanical ventilation time
↓Composite mortality/MI
Svircevic et al, 2011
28/2,731
GA versus GA+TEA
↓SVT
↓Respiratory complications
↓SVT
Zhang et al, 2015
25/3,062
GA versus GA+TEA
↓Respiratory complications
↓Intubation time
↓ICU time
No effect
↔Mortality
↔MI
↔Mortality
↔MI
↔Stroke
↔Mortality
↔MI
↔Stroke
Abbreviations: ARF, acute renal failure; GA, general anesthesia; ICU, intensive care unit; MI, myocardial infarction; SVT, supraventricular tachyarrhythmia;
TEA, thoracic epidural analgesia
epidural anesthesia could be extended inferiorly to cover incisions
for gastroepiploic artery harvesting. The avoidance of general
anesthesia certainly has the potential to enhance recovery and
improve outcomes after cardiac surgery.
In recent years, multiple meta-analyses assessing the efficacy of
TEA in cardiac surgery have been published (Table 1), as well as a
large Cochrane review.7,10,11,15 No clear mortality benefit has been
shown, but other endpoints demonstrate advantages associated
with the application of TEA for cardiac surgery. For example, a
meta-analysis by Bignami et al11 found that TEA with GA compared
favorably with GA alone and resulted in a reduced incidence of
acute renal failure and duration of mechanical ventilation. Notably,
the composite endpoint of mortality and myocardial infarction
(MI) was reduced, but the study was underpowered to detect a
benefit when these endpoints were considered individually. More
recently, Zhang et al10 published a meta-analysis showing that the
addition of TEA over GA alone decreased the risk of respiratory
complications, SVT, time to extubation, and length of stay in the
intensive care unit (ICU).
With respect to spinal analgesia for cardiac surgery, a metaanalysis by Zangrillo et al16 found no difference in outcomes,
including mortality, perioperative MI, and length of hospital
stay. However, only 1 of the 25 studies used local anesthetic in
the intrathecal dosing regimen. The other studies administered
intrathecal opioid alone or in combination with clonidine.
48
Despite growing evidence for the efficacy of neuraxial analgesia,
many anesthesiologists remain hesitant to use these approaches
based on some unique considerations in the cardiac surgery
population. In particular, full heparinization generates increased
concerns about epidural hematoma and the devastating possibility
of paraplegia. Additional complicating factors include the risk of
post-CPB coagulopathy and the fact that medical management
for many of those patients includes antiplatelet therapy. In fact,
concurrent aspirin use with systemic heparinization is a known
risk factor for epidural hematoma after neuraxial instrumentation.17
The actual risk of epidural hematoma in this setting is difficult to
assess because it is a relatively rare event. From 1966-2012, 3
of 16,477 patients who received TEA for cardiac surgery suffered
catheter-related epidural hematomas.18 Based on these data,
the estimated risk of epidural hematoma is 1 in 5,493 cases. A
different approach applied mathematical models to estimate the
frequency of a rare event that has never occurred, estimating the
risk of epidural hematoma in this context to be roughly 1/1,528 and
1/3,610 for epidural and spinal techniques, respectively.19
Given the paucity of data to estimate risk of hematoma formation,
many anesthesiologists who currently place epidural catheters
for cardiac surgery remain abundantly cautious. Typical
recommendation for initiating systemic heparin regimens after
neuraxial instrumentation is to delay at least 1 hour after the
procedure.17 In contrast, considering the full anticoagulation
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