title: Epidural analgesia for cardiac surgery.
abstract: BACKGROUND
  A combination of general anaesthesia (GA) with thoracic epidural analgesia (TEA) may have a beneficial effect on clinical outcomes by reducing the risk of perioperative complications after cardiac surgery.
  
  
  OBJECTIVE
  The objective of this review was to determine the impact of perioperative epidural analgesia in cardiac surgery on perioperative mortality and cardiac, pulmonary or neurological morbidity. We performed a meta-analysis to compare the risk of adverse events and mortality in patients undergoing cardiac surgery under general anaesthesia with and without epidural analgesia.
  
  
  METHODS
  We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2012, Issue 12) in The Cochrane Library; MEDLINE (PubMed) (1966 to November 2012); EMBASE (1989 to November 2012); CINHAL (1982 to November 2012) and the Science Citation Index (1988 to November 2012).
  
  
  METHODS
  We included randomized controlled trials comparing outcomes in adult patients undergoing cardiac surgery with either GA alone or GA in combination with TEA.
  
  
  METHODS
  All publications found during the search were manually and independently reviewed by the two authors. We identified 5035 titles, of which 4990 studies did not satisfy the selection criteria or were duplicate publications, that were retrieved from the five different databases. We performed a full review on 45 studies, of which 31 publications met all inclusion criteria. These 31 publications reported on a total of 3047 patients, 1578 patients with GA and 1469 patients with GA plus TEA.
  
  
  RESULTS
  Through our search (November 2012) we have identified 5035 titles, of which 31 publications met our inclusion criteria and reported on a total of 3047 patients. Compared with GA alone, the pooled risk ratio (RR) for patients receiving GA with TEA showed an odds ratio (OR) of 0.84 (95% CI 0.33 to 2.13, 31 studies) for mortality; 0.76 (95% CI 0.49 to 1.19, 17 studies) for myocardial infarction; and 0.50 (95% CI 0.21 to 1.18, 10 studies) for stroke. The relative risks (RR) for respiratory complications and supraventricular arrhythmias were 0.68 (95% CI 0.54 to 0.86, 14 studies) and 0.65 (95% CI 0.50 to 0.86, 15 studies) respectively.
  
  
  CONCLUSIONS
  This meta-analysis of studies, identified to 2010, showed that the use of TEA in patients undergoing coronary artery bypass graft surgery may reduce the risk of postoperative supraventricular arrhythmias and respiratory complications. There were no effects of TEA with GA on the risk of mortality, myocardial infarction or neurological complications compared with GA alone.
authors.affiliation: Department of Perioperative Care and Emergency Medicine, University Medical Center Utrecht, Utrecht, Netherlands. vesnasvircevic@hotmail.com
authors.forename: Vesna
authors.initials: V
authors.lastname: Svircevic
authors.forename: Martijn M
authors.initials: MM
authors.lastname: Passier
authors.forename: Arno P
authors.initials: AP
authors.lastname: Nierich
authors.forename: Diederik
authors.initials: D
authors.lastname: van Dijk
authors.forename: Cor J
authors.initials: CJ
authors.lastname: Kalkman
authors.forename: Geert J
authors.initials: GJ
authors.lastname: van der Heijden
mesh_terms: D000328:Adult; D015360:Analgesia, Epidural / Q000009:adverse effects* / Q000379:methods / Q000401:mortality; D000768:Anesthesia, General / Q000009:adverse effects* / Q000379:methods / Q000401:mortality; D001145:Arrhythmias, Cardiac / Q000517:prevention & control; D006348:Cardiac Surgical Procedures / Q000009:adverse effects / Q000401:mortality; D001026:Coronary Artery Bypass / Q000009:adverse effects / Q000401:mortality; D006801:Humans; D009203:Myocardial Infarction / Q000209:etiology*; D016032:Randomized Controlled Trials as Topic; D012120:Respiration Disorders / Q000209:etiology; D020521:Stroke / Q000209:etiology*