title: Epidural analgesia and intravenous patient-controlled analgesia result in similar rates of postoperative myocardial ischemia after aortic surgery.
abstract: To assess the role of postoperative analgesia on myocardial ischemia after aortic surgery, we compared intravenous patient-controlled analgesia (PCA) with thoracic epidural analgesia (TEA). One hundred twenty-four patients were prospectively randomized to the PCA or TEA group. In the TEA group, a T6-7 or T7-8 epidural catheter was inserted before the induction of general anesthesia. Within 1 h of the end of surgery, analgesia and 24-h two-channel Holter monitoring were begun. Myocardial ischemia was defined as ST segment depression > or = 1 mm, 0.06 s after the J point, and lasting for more than 1 min. In the PCA group, a bolus of morphine, 0.05 mg/kg, was given, followed by 0.02 mg/kg of morphine on demand every 10 min. Bupivacaine 0.125% and fentanyl 10 microg/mL was used in the TEA group. Analgesics were titrated to maintain a visual analog scale score < or = 3. The overall incidence of myocardial ischemia was 18.4%-18.2% for TEA and 18.6% for PCA (P = not significant). There were no differences between the groups in the total duration of ischemia per patient (22.2 +/- 119.8 min for TEA and 20.5 +/- 99 min for PCA) and the number of episodes per patient (0.69 +/- 2.1 for TEA and 1.2 +/- 4.9 for PCA). Twenty-three patients had an adverse cardiac outcome, although there were no differences between the groups. The postoperative pain control was superior with TEA. In these patients undergoing elective aortic surgery, the use of postoperative TEA did not result in a lower incidence of early myocardial ischemia compared with intravenous PCA with morphine, despite better analgesia with TEA.
  
  
  CONCLUSIONS
  Postoperative myocardial ischemia is associated with adverse cardiac outcome. Using Holter monitoring after aortic surgery, this study shows that the use of thoracic epidural analgesia with bupivacaine and fentanyl did not result in a lower incidence of myocardial ischemia compared with intravenous patient-controlled analgesia with morphine.
authors.affiliation: Department of Anesthesiology, Université de Montréal, Hôpital Notre-Dame, Québec, Canada.
authors.forename: S
authors.initials: S
authors.lastname: Bois
authors.forename: P
authors.initials: P
authors.lastname: Couture
authors.forename: D
authors.initials: D
authors.lastname: Boudreault
authors.forename: P
authors.initials: P
authors.lastname: Lacombe
authors.forename: F
authors.initials: F
authors.lastname: Fugère
authors.forename: D
authors.initials: D
authors.lastname: Girard
authors.forename: N
authors.initials: N
authors.lastname: Nadeau
mesh_terms: D000368:Aged; D015360:Analgesia, Epidural; D016058:Analgesia, Patient-Controlled; D000701:Analgesics, Opioid / Q000008:administration & dosage; D000779:Anesthetics, Local / Q000008:administration & dosage; D001012:Aorta, Abdominal / Q000601:surgery*; D002045:Bupivacaine / Q000008:administration & dosage; D015716:Electrocardiography, Ambulatory; D005260:Female; D005283:Fentanyl / Q000008:administration & dosage; D006801:Humans; D008297:Male; D009020:Morphine / Q000008:administration & dosage; D017202:Myocardial Ischemia / Q000175:diagnosis / Q000209:etiology*; D010147:Pain Measurement; D010149:Postoperative Pain / Q000188:drug therapy; D011183:Postoperative Complications; D011446:Prospective Studies
chemical_list: D000701:Analgesics, Opioid; D000779:Anesthetics, Local; D009020:Morphine; D005283:Fentanyl; D002045:Bupivacaine