title: Immediate extubation after aortic valve surgery using high thoracic epidural analgesia or opioid-based analgesia.
abstract: OBJECTIVE
  Fast-track anesthesia has gained widespread use in cardiac centers around the world. No study has been published focusing on immediate extubation after aortic valve surgery. This study examines the feasibility and hemodynamic stability of immediate extubation after simple or combined aortic valve surgery using either thoracic epidural analgesia or opioid-based analgesia.
  
  
  METHODS
  Prospective audit, pilot study.
  
  
  METHODS
  Single-institution university medical center.
  
  
  METHODS
  Adult patients undergoing aortic valve replacement (N = 45).
  
  
  METHODS
  Forty-five patients undergoing aortic valve surgery with an ejection fraction of more than 30% were included in this prospective audit. Induction of anesthesia was done using fentanyl, 2 to 4 mug/kg, propofol, 1 to 2 mg/kg, and endotracheal intubation facilitated by rocuronium; anesthesia was maintained using sevoflurane titrated according to bispectral index (BIS [BIS target: 50]). Perioperative analgesia was provided by high thoracic epidural analgesia (TEA group, bupivacaine 0.125%, 6 to 14 mL/h) or fentanyl, up to 10 microg/kg, followed by patient-controlled analgesia with morphine (OPIOID group).
  
  
  RESULTS
  Success of extubation within 30 minutes after surgery was recorded. Hemodynamic data during surgery were compared by using an analysis of variance test; p < 0.05 was considered as showing a significant difference. Data presented as median (25th-75th percentile). In the TEA group, patients underwent simple aortic valve replacement (N = 21) or combined aortic valve surgery (N = 14), with additional coronary artery bypass grafting (N = 10) and replacement of the ascending aorta (Bentall, N = 4). In the OPIOID group, patients underwent simple aortic valve replacement (N = 5) or combined aortic valve surgery (N = 5), with additional aortocoronary bypass grafting (N = 2), replacement of the ascending aorta (Bentall, N = 2), and reconstruction of the mitral valve (N = 1). All 45 patients were extubated within 15 minutes after surgery. There was no need for reintubation; pain scores were lower in the TEA group than in the OPIOID group immediately after surgery and at 6 hours, 24 hours, and 48 hours after surgery. For the TEA group and OPIOID group, the pain scores were 0 (0-2), 0 (0-2), 0 (0-1.5), and 0 (0-0) and 5 (4-5.75), 4 (3-4.5), 4 (3.25-4), and 1 (0-2.5), respectively. During and up to 6 hours after surgery, there was no significant hemodynamic difference between the TEA and OPIOID groups. Eighteen of 45 patients needed temporary pacemaker activation. There were no epidural hematoma or neurologic complications related to TEA.
  
  
  CONCLUSIONS
  Immediate extubation is feasible after aortic valve surgery using either high thoracic epidural analgesia or opioid-based analgesia; both techniques maintain hemodynamic stability throughout surgery. TEA provides superior pain control.
authors.affiliation: Perioperative Cardiac Research Group (PeriCARG, Department of Anesthesiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada. thomashammerling@hotmail.com
authors.forename: Thomas M
authors.initials: TM
authors.lastname: Hemmerling
authors.forename: Nhiên
authors.initials: N
authors.lastname: Lê
authors.forename: Jean-François
authors.initials: JF
authors.lastname: Olivier
authors.forename: Jean-Luc
authors.initials: JL
authors.lastname: Choinière
authors.forename: Fadi
authors.initials: F
authors.lastname: Basile
authors.forename: Ignatio
authors.initials: I
authors.lastname: Prieto
mesh_terms: D000328:Adult; D000368:Aged; D015360:Analgesia, Epidural; D016058:Analgesia, Patient-Controlled; D000701:Analgesics, Opioid / Q000627:therapeutic use*; D000768:Anesthesia, General; D001021:Aortic Valve / Q000601:surgery*; D001794:Blood Pressure / Q000502:physiology; D006348:Cardiac Surgical Procedures; D002315:Cardiopulmonary Bypass; D005260:Female; D006439:Hemodynamics; D006801:Humans; D007442:Intubation, Intratracheal; D008297:Male; D008875:Middle Aged; D016343:Monitoring, Intraoperative; D010147:Pain Measurement / Q000187:drug effects; D010149:Postoperative Pain / Q000188:drug therapy; D010865:Pilot Projects; D011183:Postoperative Complications / Q000175:diagnosis / Q000503:physiopathology; D011446:Prospective Studies
chemical_list: D000701:Analgesics, Opioid