Perioperative ischaemia in aortic surgery: Combined epidural/general anaesthesia and epidural analgesia vs general anaesthesia and iv analgesia

Purpose: The goal of this randomized study was to determine whether combined general and epidural anaesthesia with postoperative epidural analgesia compared with general anaesthesia and postoperative intravenous analgesia, reduced the incidence of perioperative myocardial ischaemia in patients undergoing elective aortic surgery. Method: Patients were randomly assigned to one of two groups. One group (EPI, n = 48) received combined general and epidural anaesthesia and postoperative epidural analgesia for 48 hrs. The other group (GA, n = 51) received general anaesthesia followed by postoperative intravenous analgesia. Anaesthetic goals were to maintain haemodynamic stability (+/-20% of preoperative values), and a stroke volume >1 ml . kg(-1). A Holter monitor was attached to each patient the day before surgery. Leads 11, V-2, and V-5 were monitored. Myocardial ischaemia was defined as ST segment depression >1 mm measured at 80 millisec beyond the J point or an elevation of 2 mm 60 millisec beyond the J point which lasted >60 sec. An event that lasted >60 sec but returned to the baseline for >60 sec and then recurred was counted as two separate events. The Holter tapes were reviewed by a cardiologist blind to the patient's group. Results: There were no demographic differences between the two groups. Myocardial ischaemia was common; it occurred in 55% of patients. In hospital, preoperative ischaemia was uncommon (GA = 3, EPI = 8). Intraoperative ischaemia was common (GA = 18, EPI = 25). Mesenteric traction produced the largest number of ischaemic (GA = 11, EPI = 11) events. Postoperative ischaemia was most common on the day of surgery Termination of epidural analgesia produced a burst of ischaemia (60 events in 9 patients) Conclusion: Combined general and epidural anaesthesia and postoperative epidural analgesia do not reduce the incidence of myocardial ischaemia or morbidity compared with general anaesthesia and postoperative intravenous analgesia.