title: Ultra-fast-track anesthesia in off-pump coronary artery bypass grafting: a prospective audit comparing opioid-based anesthesia vs thoracic epidural-based anesthesia.
abstract: OBJECTIVE
  To examine the feasibility of immediate extubation after off-pump coronary artery bypass grafting (OPCAB) using opioid based analgesia or high thoracic epidural analgesia (TEA) and compare postoperative analgesia with continuous TEA vs patient-controlled analgesia (PCA).
  
  
  METHODS
  One hundred consecutive patients undergoing OPCAB were included in this prospective audit. After induction of anesthesia using fentanyl 2 to 5 microg.kg(-1), propofol 1 to 2 mg.kg(-1) and endotracheal intubation facilitated by rocuronium, anesthesia was maintained using sevoflurane titrated according to bispectral index monitoring. Perioperative analgesia was provided by TEA (n = 63) at the T3/T4 interspace or T4/T5 interspace using bupivacaine 0.125% 8 to 14 mL.hr(-1) and repetitive boluses of bupivacaine 0.25% during surgery. In patients who were fully anticoagulated or refused TEA, perioperative analgesia was achieved by i.v. fentanyl boluses (up to 15 microg.kg(-1)) and remifentanil 0.1 to 0.2 microg.kg(-1).min(-1), followed by morphine PCA after surgery (n = 37). Maintenance of body temperature was achieved by a heated operating room and forced-air warming blankets.
  
  
  RESULTS
  Ninety-five patients were extubated within 25 min after surgery (PCA, n = 33; TEA, n = 62). Five patients were not extubated immediately because their core temperature was lower than 35 degrees C. One patient was re-intubated because of agitation (TEA group); one was re-intubated because of severe pain and morphine-induced respiratory depression (PCA group). Pain scores were low after surgery, with pain scores in the TEA group being significantly lower immediately, at six hours, 24 hr and 48 hr after surgery (P < 0.05).
  
  
  CONCLUSIONS
  Immediate extubation is possible after OPCAB using either opioid-based analgesia or TEA. TEA provides significantly lower pain scores after surgery in comparison to morphine PCA.
authors.affiliation: Department of Anesthesiology, Centre hospitalier de l'université de Montréal, Hôtel-Dieu, Université de Montréal, Montréal, Québec, Canada. thomashemmerling@hotmail.com
authors.forename: Thomas M
authors.initials: TM
authors.lastname: Hemmerling
authors.forename: Ignatio
authors.initials: I
authors.lastname: Prieto
authors.forename: Jean-Luc
authors.initials: JL
authors.lastname: Choinière
authors.forename: Fadi
authors.initials: F
authors.lastname: Basile
authors.forename: Joanne D
authors.initials: JD
authors.lastname: Fortier
mesh_terms: D016058:Analgesia, Patient-Controlled / Q000379:methods; D000701:Analgesics, Opioid / Q000008:administration & dosage / Q000627:therapeutic use*; D000767:Anesthesia, Epidural / Q000379:methods*; D000779:Anesthetics, Local / Q000008:administration & dosage / Q000627:therapeutic use; D002045:Bupivacaine / Q000008:administration & dosage / Q000627:therapeutic use; D001026:Coronary Artery Bypass / Q000379:methods*; D005240:Feasibility Studies; D005260:Female; D005283:Fentanyl / Q000008:administration & dosage / Q000627:therapeutic use; D006801:Humans; D007442:Intubation, Intratracheal / Q000379:methods*; D008297:Male; D008875:Middle Aged; D009020:Morphine / Q000008:administration & dosage / Q000627:therapeutic use; D010147:Pain Measurement; D010149:Postoperative Pain / Q000517:prevention & control; D010880:Piperidines / Q000008:administration & dosage / Q000627:therapeutic use; D011446:Prospective Studies; D000077208:Remifentanil; D013997:Time Factors
chemical_list: D000701:Analgesics, Opioid; D000779:Anesthetics, Local; D010880:Piperidines; D009020:Morphine; D000077208:Remifentanil; D005283:Fentanyl; D002045:Bupivacaine