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Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet]. Chichester, UK: John Wiley & Sons, Ltd; 2003-. doi: 10.1002/14651858.CD006715.pub2

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet].

Epidural analgesia for heart surgery

First published: June 6, 2013.

Link to full article: [Cochrane Library]

Plain language summary

The use of thoracic epidural analgesia (TEA) in heart surgery is controversial. TEA produces a high level of pain relief and may reduce some of the adverse effects that are associated with heart surgery. Along with these potential benefits of TEA there is a widespread fear that TEA could cause bleeding into the epidural space (haematoma). We have conducted a review of medical trials to compare the effect of general anaesthesia (GA) alone with GA in combination with epidural analgesia on major complications in patients undergoing elective heart surgery. We identified 5035 titles of which 31 publications met all the inclusion criteria. These 31 publications reported on a total of 3047 patients, 1578 patients with GA and 1469 patients with TEA as well as GA. The risks of death, heart attack and stroke were not statistically significant, however our analysis showed statistically significant reductions in the risk of arrhythmias and pulmonary complications. Despite this, our findings must be viewed with caution. Epidural analgesia in heart surgery remains controversial in the absence of a sufficiently large and statistical significant effect on mortality, stroke, or myocardial infarction and while the risks are unclear.

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.

Objectives: 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.

Search 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).

Selection criteria: We included randomized controlled trials comparing outcomes in adult patients undergoing cardiac surgery with either GA alone or GA in combination with TEA.

Data collection and analysis: 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.

Main 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.

Authors' 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.

Editorial Group: Cochrane Anaesthesia, Critical and Emergency Care Group.

Publication status: Edited (no change to conclusions).

Citation: Svircevic V, Passier MM, Nierich AP, van Dijk D, Kalkman CJ, van der Heijden GJ. Epidural analgesia for cardiac surgery. Cochrane Database of Systematic Reviews 2013, Issue 6. Art. No.: CD006715. DOI: 10.1002/14651858.CD006715.pub2. Link to Cochrane Library. [PubMed: 23740694]

Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

PMID: 23740694

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