Thoracic epidural analgesia reduces myocardial injury in ischemic patients undergoing major abdominal cancer surgery

Mohamad Farouk Mohamad, Montaser A Mohammad, Diab F Hetta, Eman Hasan Ahmed, Ahmed A Obiedallah, Alaa Ali M Elzohry, Mohamad Farouk Mohamad, Montaser A Mohammad, Diab F Hetta, Eman Hasan Ahmed, Ahmed A Obiedallah, Alaa Ali M Elzohry

Abstract

Background and objectives: Major abdominal cancer surgeries are associated with significant perioperative mortality and morbidity due to myocardial ischemia and infarction. This study examined the effect of perioperative patient controlled epidural analgesia (PCEA) on occurrence of ischemic cardiac injury in ischemic patients undergoing major abdominal cancer surgery.

Patients and methods: One hundred and twenty patients (American Society of Anesthesiologists grade II and III) of either sex were scheduled for elective upper gastrointestinal cancer surgeries. Patients were allocated randomly into two groups (60 patients each) to receive, besides general anesthesia: continuous intra and postoperative intravenous (IV) infusion with fentanyl for 72 h postoperatively (patient controlled intravenous analgesia [PCIA] group) or continuous intra and postoperative epidural infusion with bupivacaine 0.125% and fentanyl (PCEA group) for 72 h postoperatively. Perioperative hemodynamics were recorded. Postoperative pain was assessed over 72 h using visual analog scale (VAS). All patients were screened for occurrence of myocardial injury (MI) by electrocardiography, echocardiography, and cardiac troponin I serum level. Other postoperative complications as arrhythmia, deep venous thrombosis (DVT), pulmonary embolism, pneumonia, and death were recorded.

Results: There was a significant reduction in overall adverse cardiac events (myocardial injury, arrhythmias, angina, heart failure and nonfatal cardiac arrest) in PCEA group in comparison to PCIA group. Also, there was a significant reduction in dynamic VAS pain score in group PCEA in comparison to PCIA at all measured time points. Regarding perioperative hemodynamics, there was a significant reduction in intra-operative mean arterial pressure (MAP); and heart rate in PCEA group in comparison to PCIA group at most of measured time points while there was not a significant reduction in postoperative MAP and heart rate in the second and third postoperative days. The incidence of other postoperative complications such as DVT, pneumonia and in hospital mortality were decreased in PCEA group.

Conclusion: Perioperative thoracic epidural analgesia in patients suffering from coronary artery disease subjected to major abdominal cancer surgery reduced significantly postoperative major adverse cardiac events with better pain control in comparison with perioperative IV analgesia.

Keywords: PCA; postoperative myocardial infarction; thoracic epidural analgesia.

Conflict of interest statement

Disclosure All authors are lecturers in South Egypt Cancer Institute, Assiut University. The authors report no other conflicts of interest in this work.

Figures

Figure 1
Figure 1
Flow diagram of patients. Abbreviations: PCIA, patient controlled intravenous analgesia; PCEA, patient controlled epidural analgesia.
Figure 2
Figure 2
Dynamic VAS pain score between groups. Note:P<0.05 is considered statistically significant. Abbreviations: VAS, visual analog scale; PCIA, patient controlled intravenous analgesia; PCEA, patient controlled epidural analgesia; h, hour interval.
Figure 3
Figure 3
Values of troponin I. Notes: Data are expressed as mean. P<0.05 is considered statistically significant. Abbreviations: PCIA, patient controlled intravenous analgesia; PCEA, patient controlled epidural analgesia.
Figure 4
Figure 4
Number of patients with troponin 1 elevation in each group. Abbreviations: PCEA, patient controlled epidural analgesia; PCIA, patient controlled intravenous analgesia.
Figure 5
Figure 5
Values of BNP levels in each group. Abbreviations: PCEA, patient controlled epidural analgesia; PCIA, patient controlled intravenous analgesia; BNP, B-type natriuretic peptide.

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