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Ultra-fast-track anesthesia in off-pump coronary artery bypass grafting: a prospective audit comparing opioid-based anesthesia vs thoracic epiduralbased anesthesia

Un mode anesthésique ultrarapide pendant le pontage aortocoronarien à cœur battant : un audit prospectif comparant l’anesthésie avec opioïdes et l’anesthésie péridurale thoracique

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Abstract

Purpose

To examine the feasibility of immediate extubation after off-pump coronary artery bypass grafting (OPCAB) using opioid based analgesia or high thoracic epidural analgesia (TEA) and compare postoperative analgesia with continuous TEA vs patient-controlled analgesia (PCA).

Methods

One hundred consecutive patients undergoing OPCAB were included in this prospective audit. After induction of anesthesia using fentanyl 2 to 5 μg·kg−1, propofol 1 to 2 mg·kg−1 and endotracheal intubation facilitated by rocuronium, anesthesia was maintained using sevoflurane titrated according to bispectral index monitoring. Perioperative analgesia was provided by TEA (n = 63) at the T3/T4 interspace or T4/T5 interspace using bupivacaine 0.125% 8 to 14 mL·hr−1 and repetitive boluses of bupivacaine 0.25% during surgery. In patients who were fully anticoagulated or refused TEA, perioperative analgesia was achieved by iv fentanyl boluses (up to 15 μg·kg−1) and remifentanil 0.1 to 0.2 μg·kg−1·min−1, followed by morphine PCA after surgery (n = 37). Maintenance of body temperature was achieved by a heated operating room and forced-air warming blankets.

Results

Ninety-five patients were extubated within 25 min after surgery (PCA,n = 33; TEA,n = 62). Five patients were not extubated immediately because their core temperature was lower than 35°C. One patient was re-intubated because of agitation (TEA group); one was re-intubated because of severe pain and morphine-induced respiratory depression (PCA group). Pain scores were low after surgery, with pain scores in the TEA group being significantly lower immediately, at six hours, 24 hr and 48 hr after surgery (P < 0.05).

Conclusion

Immediate extubation is possible after OPCAB using either opioid-based analgesia or TEA. TEA provides significantly lower pain scores after surgery in comparison to morphine PCA.

Résumé

Objectif

Vérifier la faisabilité de l’extubation immédiatement après un pontage aortocoronarien à cœur battant (PACCB) en utilisant une analgésie avec opioïdes ou une analgésie péridurale thoracique (APT), et comparer l’analgésie postopératoire avec APT continue ou analgésie auto-contrôlée (AAC).

Méthode

Cent patients consécutifs devant subir un PACCB ont été inclus dans un audit prospectif. Après l’induction de l’anesthésie avec 2 à 5 μg·kg−1 de fentanyl, 1 à 2 mg·kg−1 de propofol et l’intubation endotrachéale facilitée par du rocuronium, l’anesthésie a été maintenue avec du sévoflurane ajusté selon le monitorage de l’index bispectral. L’analgésie périopératoire a été fournie par l’APT (n = 63) dans l’espace intervertébral T3/T4 ou T4/T5 avec de la bupivacaïne à 0,125 % à raison de 8 à 14 mL·h−1 et de bolus répétés de bupivacaïne à 0,25 % pendant l’opération. Chez les patients traités aux anticoagulants ou qui refusaient l’APT, l’analgésie périopératoire a été réalisée par des bolus iv de fentanyl (jusqu’à 15 μg·kg−1) et de 0,1 à 0,2 μg·kg−1 ·min−1 de rémifentanil, suivi de morphine en AAC postopératoire (n = 37). La température corporelle a été maintenue dans une salle d’opération chauffée et par des couvertures chauffantes à air forcé.

Résultats

On a pu extuber 95 patients pendant les 25 premières minutes postopératoires (AAC, n = 33; APT, n = 62). Cinq patients n’ont pu être extubés immédiatement, étant donné leur température centrale plus basse que 35 °C. Deux patients ont été ré-intubés : l’un, du groupe d’APT, pour agitation, l’autre, du groupe d’AAC, à cause de douleurs intenses et de dépression respiratoire induite par la morphine. Les scores de douleur postopératoires ont été faibles, ceux du groupe d’APT étant significativement plus bas immédiatement après, puis à 6, 24 et 48 h postopératoire (P < 0,05).

Conclusion

L’extubation immédiate est possible après le PACCB en utilisant soit une analgésie avec opioïdes, soit une APT. L’APT, comparée à l’AAC avec morphine, produit des scores de douleurs postopératoires significativement plus bas.

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Correspondence to Thomas M. Hemmerling.

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Hemmerling, T.M., Prieto, I., Choinière, J. et al. Ultra-fast-track anesthesia in off-pump coronary artery bypass grafting: a prospective audit comparing opioid-based anesthesia vs thoracic epiduralbased anesthesia. Can J Anesth 51, 163 (2004). https://doi.org/10.1007/BF03018777

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Keywords

  • Morphine
  • Bupivacaine
  • Remifentanil
  • Rocuronium
  • Thoracic Epidural Anesthesia