High thoracic epidural improves postoperative cardiac outcome in ischemic patients undergoing major abdominal surgery

Background

Postoperative cardiac morbidity (PCM) continues to pose considerable risks to surgical patients. High thoracic epidural analgesia (HTEA), with its selective blockade of cardiac sympathetic innervation, has been used for treatment of medically or surgically refractory angina pectoris. However, its use in patients with coronary artery disease (CAD) undergoing noncardiac surgery has not been adequately investigated.

Objective

To investigate the effect of HTEA on PCM in patients with established CAD undergoing major abdominal surgery as opposed to a comparable analgesic technique: low thoracic epidural analgesia (LTEA).

Method

After approval, 30 patients with CAD undergoing major abdominal surgery were included. Before general anesthesia, they were randomly allocated to receive HTEA or LTEA for both intraoperative and postoperative pain relief. In addition to haemodynamic measurements, PCM was investigated by comparing the preoperative ECG, echocardiography and troponin I with the postoperative ones done on the first, third and seventh days. Data are expressed as the mean (SE).

Results

Cardiac morbidity was only diagnosed in 13.3% of patients in the HTEA group (Group I). In the LTEA group (Group II), 53.3% were found to have new ischemic changes and 13.3% developed postoperative MI. There were no reported cases of cardiac mortality. The absolute risk reduction was 53.3% and the NNT was 2.

Conclusion

HTEA in patients with CAD undergoing noncardiac surgery has resulted in a reduced postoperative cardiac morbidity. It may be worthwhile establishing this technique, unless contra-indicated, in such patients.

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