Thoracolumbar epidural blockade as adjunct to high dose fentanyl/midazolam anesthesia in coronary surgery: effects of sternotomy.
The present study tests the hypothesis that the changes in myocardial lactate metabolism in the early period of coronary surgery are caused by raised adrenergic activity, and that these are preventable by the addition of thoracolumbar epidural blockade to high dose fentanyl/midazolam anesthesia. Twenty-seven male beta 1-blocked patients undergoing coronary surgery were included in a prospective, controlled, randomized study. High dose fentanyl/midazolam anesthesia alone (control) or supplemented with thoracolumbar epidural blockade (treatment) was used. Measurements were performed before the induction of anesthesia and after sternotomy. After sternotomy adrenaline (A) and noradrenaline (NA) had decreased and were both in the low range, especially in the epidural group (P < 0.01). Arterial pressures decreased in both groups, especially in the epidural group, where coronary perfusion pressure (CPP) decreased from 61 (42-88) to 48 (33-64) mm Hg; Systemic vascular resistance (SVR) decreased with 30% in the epidural group (P < 0.01), but not significantly in the control group. The myocardial fractional extraction of lactate decreased in both groups, 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 concluded that high dose fentanyl/midazolam anesthesia prevents hyperadrenergic activity in the early phase of coronary surgery, but cannot eliminate changes in myocardial lactate metabolism. The addition of the thoracolumbar epidural blockade to high dose fentanyl/midazolam anesthesia offers no obvious benefits in the early phase of coronary surgery.
Department of Thoracic and Cardiovascular Surgery, University Hospital, Uppsala, Sweden.
J
J
Thorelius
R
R
Ekroth
S
S
Hallhagen
P O
PO
Joachimsson
J
J
von der Linden
H
H
Tyden
O
O
Wesslén
D000767:Anesthesia, Epidural / Q000379:methods*; D018686:Anesthetics, Intravenous / Q000627:therapeutic use*; D002395:Catecholamines / Q000378:metabolism; D003327:Coronary Disease / Q000378:metabolism / Q000601:surgery*; D004359:Drug Therapy, Combination; D005283:Fentanyl / Q000627:therapeutic use*; D006439:Hemodynamics / Q000187:drug effects; D006801:Humans; D019344:Lactic Acid / Q000378:metabolism; D008297:Male; D008874:Midazolam / Q000627:therapeutic use*; D008875:Middle Aged; D009206:Myocardium / Q000378:metabolism; D011446:Prospective Studies; D013249:Sternum / Q000601:surgery*
D018686:Anesthetics, Intravenous; D002395:Catecholamines; D019344:Lactic Acid; D008874:Midazolam; D005283:Fentanyl