Thoracolumbar epidural blockade as adjunct to high dose fentanyl/midazolam anesthesia in coronary surgery: effects of sternotomy

• Published in: European journal of cardio-thoracic surgery 1996, Vol.10 (9), p.754-762
• Main Authors: THORELIUS, J, EKROTH, R, HALLHAGEN, S, JOACHIMSSON, P.-O, VON DER LINDEN, J, TYDEN, H, WESSLEN, Ö
• Format: Article
• Language: English
• Subjects: Anesthesia, Epidural - methods; Anesthetics, Intravenous - therapeutic use; Anesthetics. Neuromuscular blocking agents; Biological and medical sciences; Catecholamines - metabolism; Coronary Disease - metabolism; Coronary Disease - surgery; Drug Therapy, Combination; Fentanyl - therapeutic use; Hemodynamics - drug effects; Humans; Lactic Acid - metabolism; Male; Medical sciences; Midazolam - therapeutic use; Middle Aged; Myocardium - metabolism; Neuropharmacology; Pharmacology. Drug treatments; Prospective Studies; Sternum - surgery
• ISSN: 1010-7940; 1873-734X
• DOI: 10.1016/S1010-7940(96)80336-8

The present study tests the hypothesis that the changes in myocardiallactate metabolism in the early period of coronary surgery are caused byraised adrenergic activity, and that these are preventable by the additionof thoracolumbar epidural blockade to high dose fentanyl/midazolamanesthesia. Twenty-seven male beta 1-blocked patients undergoing coronarysurgery were included in a prospective, controlled, randomized study. Highdose fentanyl/midazolam anesthesia alone (control) or supplemented withthoracolumbar epidural blockade (treatment) was used. Measurements wereperformed before the induction of anesthesia and after sternotomy. Aftersternotomy adrenaline (A) and noradrenaline (NA) had decreased and wereboth in the low range, especially in the epidural group (P < 0.01).Arterial pressures decreased in both groups, especially in the epiduralgroup, where coronary perfusion pressure (CPP) decreased from 61 (42-88) to48 (33- 64) mm Hg; Systemic vascular resistance (SVR) decreased with 30% inthe epidural group (P < 0.01), but not significantly in the controlgroup. The myocardial fractional extraction of lactate decreased in bothgroups, from 33 (10-45) to 13 (0-42)% in the control group (P < 0.01),and from 36 (19-43) to 10 (2-20)% in the epidural group. It is concludedthat high dose fentanyl/midazolam anesthesia prevents hyperadrenergicactivity in the early phase of coronary surgery, but cannot eliminatechanges in myocardial lactate metabolism. The addition of the thoracolumbarepidural blockade to high dose fentanyl/midazolam anesthesia offers noobvious benefits in the early phase of coronary surgery.