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Anesth Analg 2006;103:1592
© 2006 International Anesthesia Research Society
doi: 10.1213/01.ane.0000246290.57890.d0

LETTER TO THE EDITOR

Editor-in-Chief Steven L. Shafer

The Use of Epidural Analgesia in Cardiac Surgery Should Be Encouraged

Thomas M. Hemmerling, MD, DEAA, George Djaiani, MD, Patricia Babb, and John P. Williams, MD

Department of Anesthesiology; Montreal General Hospital; McGill University; Montreal, Canada; thomashemmerling{at}hotmail.com (Hemmerling) Department of Anesthesiology; University of Toronto; Toronto, Ontario, Canada (Djaiani) University of Chicago; Chicago, IL (Babb) Department of Anesthesiology; University of Pittsburgh; Pittsburgh, PA (Williams)

To the Editor:

We read Chaney’s (1) review of regional techniques in cardiac surgery. The risk of hematoma formation as a result of using epidural catheters in cardiac surgery is theoretical, calculated to be in the range of 1:1500 (2) to fewer than 1 in 10,000 procedures (3). At the time of this calculation about 7% of cardiac anesthesiologists used epidural anesthesia in cardiac surgery (4). Since then, epidural analgesia has become more popular in cardiac surgery with more than 10,000 cases reported in the literature. There have been no reported cases of epidural hematoma due to full systemic intraoperative heparinization. The advantages of epidural anesthesia, compared with conventional anesthesia techniques, include better pain control, fewer pulmonary and renal complications, and fewer arrhythmias (5–8). Some authors have even recommended regional anesthesia as a technique of choice in cardiac surgery (8).

The case of epidural hematoma cited in Chaney’s review has been discussed before (9). The hematoma was due not to intraoperative systemic heparinization, but rather to the combination of administration of full systemic heparin, administration of IV alteplase, and removal of the catheter despite a greatly increased prothrombin time (10). Consequently, this case report should not discourage anesthesiologists from using epidural anesthesia and analgesia in cardiac surgery, provided that strict guidelines for regional techniques are followed (11).

The three other cases of "disastrous epidural hematomas" anecdotally reported by Chaney (1,12) have not been published. As a result, the circumstances under which they occurred cannot be judged.

Recent meta-analyses have strongly supported using epidural anesthesia in cardiac surgery (6–8), as long as strict guidelines are followed (13). In one of these authors’ hospital settings (Hemmerling), more than 500 epidural catheters have been placed for different cardiac surgical procedures with zero incidence of epidural hematoma. The key to avoiding epidural hematoma is an environment in which all members of the health care team are aware of the inherent risk of hematoma formation, maintain good communication, and judiciously follow the guidelines for insertion and removal of epidural catheters.

In conclusion, we believe three key factors are important:

  1. The establishment of an international registry for epidural hematomas in cardiac surgery,
  2. A large multicenter, controlled, clinical trial to investigate whether epidural analgesia can indeed reduce morbidity and mortality after cardiac surgery, and
  3. Awareness that the practice of epidural analgesia in cardiac surgery requires a vigilant environment in which possible complications are readily recognized and appropriately managed.

REFERENCES

  1. Chaney MA. Intrathecal and epidural anesthesia and analgesia for cardiac surgery. Anesth Analg 2006;102:45–64.[Abstract/Free Full Text]
  2. Ho AM, Chung DC, Joynt GM. Neuraxial blockade and hematoma in cardiac surgery: estimating the risk of a rare adverse event that has not (yet) occurred. Chest 2000;117:551–5.[Medline]
  3. Horlocker TT, Wedel DJ, Schroeder DR, et al. Preoperative antiplatelet therapy does not increase the risk of spinal hematoma associated with regional anesthesia. Anesth Analg 1995;80:303–9.[Abstract]
  4. Goldstein S, Dean D, Kim SJ, et al. A survey of spinal and epidural techniques in adult cardiac surgery. J Cardiothorac Vasc Anesth 2001;15:158–68.[ISI][Medline]
  5. Alvarez J, Hernandez B, Atanassoff PG. High thoracic epidural anesthesia and coronary artery disease in surgical and non-surgical patients. Curr Opin Anaesthesiol 2005;18:501–6.[Medline]
  6. Liu SS, Block BM, Wu CL. Effects of perioperative central neuraxial analgesia on outcome after coronary artery bypass surgery: a meta-analysis. Anesthesiology 2004;101:153–61.[ISI][Medline]
  7. Djaiani G, Fedorko L, Beattie WS. Regional anesthesia in cardiac surgery: a friend or a foe? Semin Cardiothorac Vasc Anesth 2005;9:87–104.[Abstract/Free Full Text]
  8. Ronald A, Abdul Aziz KA, Day TG, Scott M. In patients undergoing cardiac surgery, thoracic epidural analgesia combined with general anesthesia results in faster recovery and fewer complications but does not affect length of hospital stay. Interact Cardiovasc Thorac Surg 2006;5: 207. doi: 10.1510/icvts. 2005.125054.
  9. Hemmerling TM, Olivier JF, Basile F, Prieto I. Epidural hematoma after anticoagulation with a thoracic epidural catheter in place: a mere coincidence? Anesth Analg 2004;99:1267–8.[Free Full Text]
  10. Rosen DA, Hawkinberry DW II, Rosen KR, et al. An epidural hematoma in an adolescent patient after cardiac surgery. Anesth Analg 2004;98:966–9.[Abstract/Free Full Text]
  11. Horlocker TT, Wedel DJ, Benzon H, et al. Regional anesthesia in the anticoagulated patient: defining the risks (the second ASRA Consensus Conference on Neuraxial Anesthesia and Anticoagulation). Reg Anesth Pain Med 2003;28: 172–97.[ISI][Medline]
  12. Chaney MA. Cardiac surgery and intrathecal/epidural techniques: at the crossroads? Can J Anaesth 2005;52: 783–8.[Free Full Text]
  13. Williams JP. Thoracic epidural anesthesia for cardiac surgery. Can J Anaesth 2002;49:R1–6.[Free Full Text]



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Lippincott, Williams & Wilkins Anesthesia & Analgesia® is published for the International Anesthesia Research Society® by Lippincott Williams & Wilkins with the assistance of Stanford University Libraries' HighWire Press®. Copyright 2006 by the International Anesthesia Research Society. Online ISSN: 1526-7598   Print ISSN: 0003-2999 HighWire Press