PEDIATRIC ANESTHESIA: Letters to the Editor
Thoracic epidural anesthesia (TEA) combined with general anesthesia may facilitate early extubation and hemodynamic stability in patients undergoing coronary artery bypass graft (CABG) surgery (1,2). However, TEA is generally avoided in CABG surgery because of the perceived risk of epidural hematoma formation with heparinization. Several studies have shown epidural catheter placement to be safe in patients undergoing major vascular surgery with various degrees of heparinization (3,4), but to our knowledge no large study has evaluated the risk of epidural hematoma formation with TEA in fully heparinized patients undergoing CABG surgery.
After institutional review board approval, we retrospectively examined the perioperative course of 278 patients who underwent CABG surgery with TEA as part of their routine management at a local community hospital. Epidural catheters were inserted no less than 1 h before anticoagulation. In the event of a bloody tap, surgery was delayed for 24 h. Postoperatively, catheters were not removed if the international normalized ratio was greater than 1.5.
We found no evidence of clinically significant epidural hematoma formation in any patient.
We believe this is the largest group of patients reported to have undergone CABG surgery with TEA as part of their anesthetic management. There appears to be minimal risk associated with placement of thoracic epidural catheters 1 h before anticoagulation in patients undergoing CABG surgery. However, the retrospective nature of this review seriously limits the conclusions that can be drawn from this group of patients.
We believe TEA in CABG surgery warrants prospective study to further evaluate the potential risks and benefits.
David Warters MD
Stephen M. Koch MD, FCCM, FCCP
Susan Luehr MD
William Knight MD
1. Liem TH, Booij LHDJ, Hasenbos MAWM, Gielen MJM. Coronary artery bypass grafting using two different anesthetic techniques. Part 1. Hemodynamic results. J Cardiothorac Vasc Anesth 1992; 6:148–55.
2. Joachimsson PO, Nystrom SO, Tyden FL. Early extubation after coronary artery surgery in sufficiently re-warmed patients: a postoperative comparison of opioid anesthesia versus inhalational anesthesia and thoracic epidural anesthesia. J Cardiothorac Anesth 1989; 3:444–54.
3. Baron HC, LaRaja RD, Rossi G, Atkinson D. Continuous epidural analgesia in the heparinized vascular surgical patient: a retrospective review of 912 patients. J Vasc Surg 1987; 6:144–6.
4. Odoom JA, Sih IL. Epidural analgesia and anticoagulant therapy: experience with one thousand cases of continuous epidurals. Anaesthesia 1983; 38:254–9.