Anesth Analg 1991; 73:696-704
© 1991 International Anesthesia Research Society
Effects of Epidural Anesthesia and Analgesia on Coagulation and Outcome After Major Vascular Surgery
Kenneth J. Tuman, MD,
Robert J. McCarthy, PharMD,
Robert J. March, MD,
Giacomo A. DeLaria, MD,
Rajesh V. Patel, MD, and
Anthony D. Ivankovich, MD
Departments of Anesthesiology and Cardiovascular Surgery, Rush-Presbyterian-St. Luke's Medical Center, Chicago, Illinois
Abstract
To examine the interaction of epidural anesthesia, coagulation status, and outcome after lower extremity revascularization, 80 patients with atherosclerotic vascular disease were prospectively randomized to receive general anesthesia combined with postoperative epidural analgesia (GEN-EPI) or general anesthesia with on-demand narcotic analgesia (GEN). Demographics did not differ between groups except that the GEN-EPI group had a higher incidence of diabetes mellitus and of previous myocardial infarction. Coagulation status was monitored using thromboelastography. An additional 40 randomly selected patients without atherosclerotic vascular disease undergoing noncardiovascular procedures served as controls for coagulation status. Vascular surgical patients were hypercoagulable compared with control patients before operation and on the first postoperative day. Postoperatively, this hypercoagulability was attenuated in the GEN-EPI group and was associated with a lower incidence of thrombotic events (peripheral arterial graft, coronary artery or deep vein thromboses). The rates of cardiovascular, infectious, and overall postoperative complications, as well as duration of intensive care unit stay, were significantly reduced in the GEN-EPI group. Stepwise logistic regression demonstrated that the only significant predictors of postoperative cardiovascular complications were preoperative congestive heart failure and general anesthesia without epidural analgesia. We conclude that in patients with atherosclerotic vascular disease undergoing arterial reconstructive surgery (a) thromboelastographic evidence of increased platelet-fibrinogen interaction is associated with early postoperative thrombotic events, and (b) epidural anesthesia and analgesia is associated with beneficial effects on coagulation status and postoperative outcome compared with intermittent on-demand opioid analgesia.
This article has been cited by other articles:
|
|
|
|
 
American College of Cardiology Foundation, American Heart Association Task Force on Practice, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interve, Society for Vascular Medicine, Society for Vascular Surgery, L. A. Fleisher, et al.
2009 ACCF/AHA Focused Update on Perioperative Beta Blockade Incorporated Into the ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery
J. Am. Coll. Cardiol.,
November 2, 2009;
(2009)
j.jacc.2009.07.010v1.
[Full Text]
[PDF]
|
|
|
|
|
|
|
Y. Dai, A. Lee, L. A. H. Critchley, and P. F. White
Does Thromboelastography Predict Postoperative Thromboembolic Events? A Systematic Review of the Literature
Anesth. Analg.,
March 1, 2009;
108(3):
734 - 742.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
D. M. Popping, N. Elia, E. Marret, C. Remy, and M. R. Tramer
Protective Effects of Epidural Analgesia on Pulmonary Complications After Abdominal and Thoracic Surgery: A Meta-Analysis
Arch Surg,
October 1, 2008;
143(10):
990 - 999.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
R. Christopherson, K. E. James, M. Tableman, P. Marshall, and F. E. Johnson
Long-Term Survival After Colon Cancer Surgery: A Variation Associated with Choice of Anesthesia
Anesth. Analg.,
July 1, 2008;
107(1):
325 - 332.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
L. A. Fleisher, J. A. Beckman, K. A. Brown, H. Calkins, E. L. Chaikof, K. E. Fleischmann, W. K. Freeman, J. B. Froehlich, E. K. Kasper, J. R. Kersten, et al.
ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery) Developed in Collaboration With the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery
J. Am. Coll. Cardiol.,
October 23, 2007;
50(17):
e159 - e242.
[Full Text]
[PDF]
|
|
|
|
|
|
|
L. A. Fleisher, J. A. Beckman, K. A. Brown, H. Calkins, E. L. Chaikof, K. E. Fleischmann, W. K. Freeman, J. B. Froehlich, E. K. Kasper, J. R. Kersten, et al.
ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery)
Circulation,
October 23, 2007;
116(17):
e418 - e500.
[Full Text]
[PDF]
|
|
|
|
|
|
|
I. Cattabriga, D. Pacini, G. Lamazza, F. Talarico, R. Di Bartolomeo, G. Grillone, and L. Bacchi-Reggiani
Intravenous paracetamol as adjunctive treatment for postoperative pain after cardiac surgery: a double blind randomized controlled trial
Eur. J. Cardiothorac. Surg.,
September 1, 2007;
32(3):
527 - 531.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
D. L. Reich and G. W. Fischer
Perioperative Interventions to Modify Risk of Morbidity and Mortality
Seminars in Cardiothoracic and Vascular Anesthesia,
September 1, 2007;
11(3):
224 - 230.
[Abstract]
[PDF]
|
|
|
|
|
|
|
M. A. Chaney
Intrathecal and Epidural Anesthesia and Analgesia for Cardiac Surgery
Anesth. Analg.,
January 1, 2006;
102(1):
45 - 64.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
E. R. Viscusi
Emerging Techniques in the Management of Acute Pain: Epidural Analgesia
Anesth. Analg.,
November 1, 2005;
101(5S_Suppl):
S23 - 29.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
R. Poston, J. Gu, J. Manchio, A. Lee, J. Brown, J. Gammie, C. White, and B. P. Griffith
Platelet function tests predict bleeding and thrombotic events after off-pump coronary bypass grafting
Eur. J. Cardiothorac. Surg.,
April 1, 2005;
27(4):
584 - 591.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. N. Ghansah and J. T. Murphy
Complications of Major Aortic and Lower Extremity Vascular Surgery
Seminars in Cardiothoracic and Vascular Anesthesia,
December 1, 2004;
8(4):
335 - 361.
[Abstract]
[PDF]
|
|
|
|
|
|
|
A. Kulik, M. Ruel, M. E. Bourke, L. Sawyer, J. Penning, H. J. Nathan, T. G. Mesana, and P. Bedard
Postoperative naproxen after coronary artery bypass surgery: a double-blind randomized controlled trial
Eur. J. Cardiothorac. Surg.,
October 1, 2004;
26(4):
694 - 700.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
B. A. Perler
A Comparison of Intrathecal Opioid and Intravenous Analgesia for the Incidence of Cardiovascular, Respiratory, and Renal Complications after Abdominal Aortic Surgery
Perspectives in Vascular Surgery and Endovascular Therapy,
June 1, 2004;
16(2):
146 - 147.
[Abstract]
[PDF]
|
|
|
|
|
|
|
T. T. Horlocker
Regional Anesthesia and Anticoagulation in Patients undergoing Cardiothoracic and Vascular Surgery
Seminars in Cardiothoracic and Vascular Anesthesia,
December 1, 2003;
7(4):
417 - 426.
[Abstract]
[PDF]
|
|
|
|
|
|
|
S. H. Wilson, P. Fasseas, J. L. Orford, R. J. Lennon, T. Horlocker, N. E. Charnoff, S. Melby, and P. B. Berger
Clinical outcome of patients undergoing non-cardiac surgery in the two months following coronary stenting
J. Am. Coll. Cardiol.,
July 16, 2003;
42(2):
234 - 240.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
M.-H. Fleron, R. B. Weiskopf, M. Bertrand, S. Mouren, D. Eyraud, G. Godet, B. Riou, E. Kieffer, and P. Coriat
A Comparison of Intrathecal Opioid and Intravenous Analgesia for the Incidence of Cardiovascular, Respiratory, and Renal Complications After Abdominal Aortic Surgery
Anesth. Analg.,
July 1, 2003;
97(1):
2 - 12.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
D. J. Cook and G. A. Rooke
Priorities in Perioperative Geriatrics
Anesth. Analg.,
June 1, 2003;
96(6):
1823 - 1836.
[Full Text]
[PDF]
|
|
|
|
|
|
|
R. Schumann, S. Shikora, J. M. Weiss, H. Wurm, S. Strassels, and D. B. Carr
A Comparison of Multimodal Perioperative Analgesia to Epidural Pain Management After Gastric Bypass Surgery
Anesth. Analg.,
February 1, 2003;
96(2):
469 - 474.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
M. S. Kashyap, S. S. Ahn, W. J. Quinones-Baldrich, B.-U. Choi, F. Dorey, T. D. Reil, J. A. Freischlag, and W. S. Moore
Infrapopliteal-Lower Extremity Revascularization with Prosthetic Conduit: A 20-Year Experience
Vascular and Endovascular Surgery,
July 1, 2002;
36(4):
255 - 262.
[Abstract]
[PDF]
|
|
|
|
|
|
|
K. Hahnenkamp, G. Theilmeier, H. K. Van Aken, and C. W. Hoenemann
The Effects of Local Anesthetics on Perioperative Coagulation, Inflammation, and Microcirculation
Anesth. Analg.,
June 1, 2002;
94(6):
1441 - 1447.
[Full Text]
[PDF]
|
|
|
|
|
|
|
R. Ehlers, T. W. Felbinger, H. K. Eltzschig, L. A. Fleisher, and K. A. Eagle
Lowering Cardiac Risk in Noncardiac Surgery
N. Engl. J. Med.,
April 4, 2002;
346(14):
1096 - 1097.
[Full Text]
[PDF]
|
|
|
|
|
|
|
W. S. Beattie, N. H. Badner, and P. Choi
Epidural Analgesia Reduces Postoperative Myocardial Infarction: A Meta-Analysis
Anesth. Analg.,
October 1, 2001;
93(4):
853 - 858.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. Boldt, I. Huttner, St. Suttner, B. Kumle, S. N. Piper, and G. Berchthold
Changes of haemostasis in patients undergoing major abdominal surgery--is there a difference between elderly and younger patients?
Br. J. Anaesth.,
September 1, 2001;
87(3):
435 - 440.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
C. J. O'Connor and K. J. Tuman
Epidural Anesthesia and Analgesia for Coronary Artery Bypass Graft Surgery: Still Forbidden Territory?
Anesth. Analg.,
September 1, 2001;
93(3):
523 - 525.
[Full Text]
[PDF]
|
|
|
|
|
|
|
H. Kehlet and K. Holte
Effect of postoperative analgesia on surgical outcome
Br. J. Anaesth.,
July 1, 2001;
87(1):
62 - 72.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
C. M. Samama
Thromboelastography: The Next Step
Anesth. Analg.,
March 1, 2001;
92(3):
563 - 564.
[Full Text]
[PDF]
|
|
|
|
|
|
|
E. Mahla, T. Lang, M. N. Vicenzi, G. Werkgartner, R. Maier, C. Probst, and H. Metzler
Thromboelastography for Monitoring Prolonged Hypercoagulability After Major Abdominal Surgery
Anesth. Analg.,
March 1, 2001;
92(3):
572 - 577.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
S. A. Bew, A. E. Bryant, J. P. Desborough, and G. M. Hall
Epidural analgesia and arterial reconstructive surgery to the leg: effects on fibrinolysis and platelet degranulation
Br. J. Anaesth.,
February 1, 2001;
86(2):
230 - 235.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. Rodgers, N. Walker, S Schug, A McKee, H Kehlet, A van Zundert, D Sage, M Futter, G Saville, T Clark, et al.
Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials
BMJ,
December 16, 2000;
321(7275):
1493 - 1493.
[Abstract]
[Full Text]
|
|
|
|
|
|
|
S. Mantha
Rational Cardiac Risk Stratification Before Peripheral Vascular Surgery: Application of Evidence-Based Medicine and Bayesian Analysis
Seminars in Cardiothoracic and Vascular Anesthesia,
November 1, 2000;
4(4):
198 - 212.
[PDF]
|
|
|
|
|
|
|
C. L. Wu and L. A. Fleisher
Outcomes Research in Regional Anesthesia and Analgesia
Anesth. Analg.,
October 1, 2000;
91(5):
1232 - 1242.
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. P. Desborough
The stress response to trauma and surgery
Br. J. Anaesth.,
July 1, 2000;
85(1):
109 - 117.
[Full Text]
[PDF]
|
|
|
|
|
|
|
M. K. Urban, S. M. Markowitz, M. A. Gordon, B. L. Urquhart, and P. Kligfield
Postoperative Prophylactic Administration of {beta}-Adrenergic Blockers in Patients at Risk for Myocardial Ischemia
Anesth. Analg.,
June 1, 2000;
90(6):
1257 - 1261.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
G. B. Hammer, K. Ngo, and A. Macario
A Retrospective Examination of Regional Plus General Anesthesia in Children Undergoing Open Heart Surgery
Anesth. Analg.,
May 1, 2000;
90(5):
1020 - 1024.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
K. J. Tuman
Cardiovascular Anesthesiology in the 1990s and Beyond
Anesth. Analg.,
May 1, 2000;
90(5):
1229 - 1231.
[Full Text]
[PDF]
|
|
|
|
|
|
|
R. A. Kahn
Pain Management After Vascular Surgery
Seminars in Cardiothoracic and Vascular Anesthesia,
September 1, 1999;
3(3):
177 - 181.
[Abstract]
[PDF]
|
|
|
|
|
|
|
S. Datta and S. Jain
Pain Management
Seminars in Cardiothoracic and Vascular Anesthesia,
September 1, 1997;
1(3):
264 - 277.
[Abstract]
[PDF]
|
|
|
|
|
|
|
S. Howell and P. Foex
Stratifying patients by perioperative risk is equivalent to screening
BMJ,
September 21, 1996;
313(7059):
750a - 750.
[Full Text]
|
|
|
|
|
|
|
D. A. O'Hara and L. G. Kushins
Preoperative Prediction of Postoperative Delirium
JAMA,
May 25, 1994;
271(20):
1573 - 1573.
[Abstract]
[PDF]
|
|
|
|
|
|
|
H. W. Hopf and S. Weitz
Postoperative Pain Management
Arch Surg,
February 1, 1994;
129(2):
128 - 132.
[Abstract]
[PDF]
|
|
|
|
|
|
|
Q. Hogan
The Cardiac Risks of Noncardiac Surgery
JAMA,
April 28, 1993;
269(16):
2083 - 2083.
[Abstract]
[PDF]
|
|
|
|
|
|
|
P. Barash
Anesthesiology
JAMA,
July 15, 1992;
268(3):
335 - 337.
[Abstract]
[PDF]
|
|
|
|
