[Correlation of acute pain treatment to occurrence of chronic pain in tumor patients after thoracotomy]. Effects of thoracic epidural analgesia on pulmonary function after coronary artery bypass surgery. [Chronic postoperative pain after general anesthesia with or without a single-dose preincisional paravertebral nerve block in radical breast cancer surgery]. Thoracic epidural anesthesia improves early outcomes in patients undergoing off-pump coronary artery bypass surgery: a prospective, randomized, controlled trial. Preincisional paravertebral block reduces the prevalence of chronic pain after breast surgery. Pain outcomes after thoracotomy: lumbar epidural hydromorphone versus intrapleural bupivacaine. Multimodal analgesia before thoracic surgery does not reduce postoperative pain. Thoracic epidural anesthesia for cardiac surgery: a randomized trial. Thoracic epidural versus intravenous patient-controlled analgesia after cardiac surgery: a randomized controlled trial on length of hospital stay and patient-perceived quality of recovery. Thoracic epidural infusion for postoperative pain relief following abdominal aortic surgery: bupivacaine, fentanyl or a mixture of both? Thoracic epidural anesthesia as an adjunct to general anesthesia for cardiac surgery: effects on ventilation-perfusion relationships. Thoracic epidural anesthesia for cardiac surgery: the effects on tracheal intubation time and length of hospital stay. The effects of three different analgesia techniques on long-term postthoracotomy pain. Double-masked randomized trial comparing alternate combinations of intraoperative anesthesia and postoperative analgesia in abdominal aortic surgery. Comparison of epidural analgesia and intercostal nerve cryoanalgesia for post-thoracotomy pain control. To ventilate or not after minimally invasive direct coronary artery bypass surgery: the role of epidural anesthesia. Epidural anesthesia for coronary artery bypass surgery compared with general anesthesia alone does not reduce biochemical markers of myocardial damage. Design of the multicenter Australian study of epidural anesthesia and analgesia in major surgery: the MASTER trial. Myocardial, inflammatory, and stress responses in off-pump coronary artery bypass graft surgery with thoracic epidural anesthesia. High thoracic epidural blockade increases myocardial oxygen availability in coronary surgery patients.
Some researches found that the intensity, property and management of acute pain are associated with chronic pain in tumor patients after thoracotomy. Chronic pain may be transformed from acute pain. However, there are no routine or standard strategies to effectively prevent or relieve chronic pain in tumor patients after thoracotomy. This study was to explore the correlation of acute and chronic pain in tumor patients after thoracotomy.
                A total of 105 patients (American Society of Anesthesiologists physical status I-II) underwent thoracotomy were randomly divided into 3 groups: 36 received administration of ropivacaine and morphine through thoracic epidural preoperatively (group PE), 36 received the same treatment postoperatively (group E), and 33 received intravenous infusion of fentanyl postoperatively (group IV). VAS scores were recorded in the first 48 h after operation. The occurrence of chronic pain was observed at the first, second, third, sixth months after operation.
                VAS scores in the first 48h after operation were significantly lower in group PE and group E than that in group IV (P<0.05). VAS scores were significantly lower in group PE than in group E (P=0.004 at 4 h, P=0.013 at 8 h, P=0.035 at 24 h). The occurrence rate of pain after operation was significantly lower in group PE than in groups E and IV in the first and second months (Chi2=5.989, P=0.014; Chi2=7.603, P=0.006), and lower in groups PE and E than in group IV in the third and sixth months (Chi2=6.585, P=0.010; Chi2=8.661, P=0.003). The duration of pain was significantly shorter in group PE than in groups E and IV (P=0.027, P=0.009).
                Chronic pain after thoracotomy is associated with the intensity and management of acute pain after thoracotomy. The patients with intensive acute pain would experience intensive and long-term chronic pain. Preemptive administration with thoracic epidural ropivacaine and morphine can decrease the incidence and duration of chronic pain after operation. A substantial reduction in lung volumes and pulmonary function follows cardiac surgery. Pain may prevent effective breathing and coughing, and as thoracic epidural analgesia may reduce postoperative pain, we investigated the effect of epidural analgesia on pulmonary function.
                Fifty-four male patients, under 65 years and with an ejection fraction of more than 0.5, were randomized into two groups: a control group receiving high-dose fentanyl anaesthesia and an epidural group receiving low-dose fentanyl anaesthesia + thoracic epidural analgesia. Time to awakening and time to extubation were recorded. Further, spirometric data, arterial oxygenation, pulmonary shunt, haemodynamics, use of vasoactive drugs and fluid balance were followed for up to 6 days postoperatively.
                Patients with low-dose fentanyl and epidural analgesia awoke (1.6 vs 3.6 h) and were extubated (5.4 vs 10.8 h) significantly earlier than control group patients. A 50-70% reduction in forced vital capacity, forced expiratory volume in 1 s (FEV1.0) and peak expiratory flow rate (PEFR) was seen after surgery, but higher FEV1.0 and PEFR on days 2 and 3 were seen in the epidural group than in the control group. Pulmonary shunt and alveolo-arterial oxygen difference increased similarly in both groups, whereas oxygen delivery and mixed venous oxygen saturation were higher in the epidural group. Epidural analgesia gave better control of the postoperative hyperdynamic circulation.
                Thoracic epidural analgesia yields a slight, but significant, improvement in pulmonary function, most likely due to a more profound postoperative analgesia. Over 50% of patients still experience pain a year after mastectomy with or without lymphadenectomy. We aimed to determine the association between anesthetic technique, acute postoperative pain intensity, and the development of chronic postoperative pain. Patients and
                Forty patients were randomly assigned to receive general anesthesia with or without a paravertebral nerve block for modified radical mastectomy. Postoperative pain was assessed on a visual analog scale at 60 minutes and 24 hours; the patients were also asked to respond to a telephone questionnaire on chronic pain 4 to 5 months later.
                No significant differences in acute pain were observed. Twenty-nine responded to the telephone questionnaire. Only 1 patient in the paravertebral block group reported chronic neuropathic pain and none had phantom breast pain. Only 1 patient (6.7%) in the paravertebral block group reported chronic neuropathic pain and none had phantom breast pain. In the group that received general anesthesia alone, 1 patient reported phantom breast pain and 6 patients had neuropathic pain, associated with phantom breast pain in 2 cases (incidence of chronic pain 50%; P = .01, Fischer exact test; relative risk, 7.5, 95% confidence interval, 1.0-53.5). The incidences of myofascial pain (neck muscle tightness) were similar in the 2 groups.
                Four to 5 months after mastectomy, fewer cases of chronic pain developed in the group operated under general anesthesia with a preincisional paravertebral block than in the group that received only general anesthesia, with postoperative morphine chloride for analgesia. The aim of this two-center, open, randomized, controlled trial was to evaluate the impact of thoracic epidural anesthesia on early clinical outcomes in patients undergoing off-pump coronary artery bypass surgery.
                Two hundred and twenty-six patients were randomized to either general anesthesia plus epidural (GAE) (n = 109) or general anesthesia only (GA) (n = 117). The primary outcome was length of postoperative hospital stay. Secondary outcomes were: arrhythmia, inotropic support, intubation time, perioperative myocardial infarction, neurologic events, intensive care stay, pain scores, and analgesia requirement.
                Baseline characteristics were similar in the two groups. One patient died in the GAE group. Median postoperative stay was significantly reduced in the GAE, compared with the GA, group (5 days, interquartile range [5-6] vs. 6 days, interquartile range [5-7], hazard ratio = 1.39, 95% CI [1.06-1.82]; P = 0.017). The incidence of arrhythmias and the median intubation time were both significantly lower in the GAE, compared with the GA, group (odds ratio = 0.41, 95% CI [0.22-0.78], P = 0.006 and hazard ratio = 1.73, 95% CI [1.31-2.27], P < 0.001, respectively). Patients in the GAE group were more likely to need vasoconstrictors intraoperatively than in the GA group (odds ratio = 2.50, 95% CI [1.22-5.12]; P = 0.012). The GAE, compared with GA, group reported significantly lower levels of impairment for all pain domains and reduced morphine usage (odds ratio = 0.07, 95% CI [0.03-0.17]; P < 0.001).
                In patients undergoing off-pump coronary artery bypass surgery, the addition of thoracic epidural to general anesthesia significantly reduces the incidence of postoperative arrhythmias and improves pain control and overall quality of recovery, allowing earlier extubation and hospital discharge. We reported earlier that preincisional paravertebral block (PVB) provides significant immediate postoperative analgesia after breast cancer surgery. In the same patients (n = 60), a 1-yr follow-up was performed to find out whether PVB could also reduce the prevalence of postoperative chronic pain. The follow-up consisted of a 14-day symptom diary and telephone interviews 1, 6, and 12 mo after surgery. The 14-day consumption of analgesics was similar in the 30 PVB and the 30 control patients. However, 1 mo after surgery, the intensity of motion-related pain was lower (P = 0.005) in the PVB group. Six months after surgery, the prevalence of any pain symptoms (P = 0.029) was lower in the PVB group. Finally, at 12 mo after surgery, in addition to the prevalence of pain symptoms (P = 0.003) and the intensity of motion-related pain (P = 0.003), the intensity of pain at rest (P = 0.011) was lower in the PVB group. These findings were independent of whether or not axillary dissection had been performed. The incidence of neuropathic pain was low (two and three patients in the PVB and control groups, respectively). In addition to providing acute postoperative pain relief, preoperative PVB seems to reduce the prevalence of chronic pain 1 yr after breast cancer surgery. To evaluate postthoractomy analgesia in patients receiving lumbar epidural hydromorphone versus intrapleural bupivacaine.
                A randomized, prospective, double-blind study.
                A university-affiliated medical center.
                Twenty patients undergoing lateral thoracotomy for either pulmonary wedge resection, lobectomy, or pneumonectomy.
                Nine patients received epidural hydromorphone, and 11 patients received intrapleural bupivacaine in the postoperative period.
                Severity of pain was assessed using a visual analog pain scale (VAPS) (0 to 100 mm) at 1, 3, and 5 hours. Patients receiving epidural hydromorphone had a statistically significant improvement in VAPS scores. Patients who received intrapleural bupivacaine did not achieve a significant reduction in pain scores. Nine of 11 patients in the intrapleural bupivacaine group had "failed" postoperative analgesia as defined by a VAPS greater than 30. Only 3 of 9 patients in the continuous epidural hydromorphone group had "failed" analgesia.
                Epidural hydromorphone is superior to intrapleural bupivacaine in achieving satisfactory pain outcomes during the first 5 hours after thoracotomy. Several reports have suggested that preoperative nociceptive block may reduce postoperative pain, analgesic requirements, or both, beyond the anticipated duration of action of the analgesic agents. We have investigated, in a double-blind, placebo-controlled study, pre-emptive analgesia and the respiratory effects of preoperative administration of a multimodal antinociceptive regimen. Thirty patients undergoing thoracotomy were allocated randomly to two groups. Before surgery, the treatment group (n = 15) received morphine 0.15 mg kg-1 i.m. with perphenazine 0.03 mg kg-1 i.m. and a rectal suppository of indomethacin 100 mg, while the placebo group (n = 15) received midazolam 0.05 mg kg-1 i.m. and a placebo rectal suppository. After induction of anaesthesia, the treatment group received intercostal nerve block with 0.5% bupivacaine and adrenaline 1:200,000 (3 ml) in the interspace of the incision and in the two spaces above and two spaces below. The placebo group received identical injections but with normal saline only. The treatment group consumed significantly less morphine by patient-controlled analgesia in the first 6 h after operation, but the total dose of morphine consumed on days 2 and 3 after surgery was significantly greater in the treatment group. There were no differences between the groups in postoperative VAS scores (at rest or after movement), PaCO2 values or postoperative spirometry. However, pain thresholds to pressure applied at the side of the chest contralateral to the site of incision decreased significantly from preoperative values on days 1 and 2 after surgery in both groups. The results of this study do not support the preoperative use of this combined regimen for post-thoracotomy pain. The addition of thoracic epidural anesthesia (TEA) to general anesthesia (GA) during cardiac surgery may have a beneficial effect on clinical outcomes. TEA in cardiac surgery, however, is controversial because the insertion of an epidural catheter in patients requiring full heparinization for cardiopulmonary bypass may lead to an epidural hematoma. The clinical effects of fast-track GA plus TEA were compared with those of with fast-track GA alone.
                A randomized controlled trial was conducted in 654 elective cardiac surgical patients who were randomly assigned to combined GA and TEA versus GA alone. Follow-up was at 30 days and 1 yr after surgery. The primary endpoint was 30-day survival free from myocardial infarction, pulmonary complications, renal failure, and stroke.
                Thirty-day survival free from myocardial infarction, pulmonary complications, renal failure, and stroke was 85.2% in the TEA group and 89.7% in the GA group (P = 0.23). At 1 yr follow-up, survival free from myocardial infarction, pulmonary complications, renal failure, and stroke was 84.6% in the TEA group and 87.2% in the GA group (P = 0.42). Postoperative pain scores were low in both groups.
                This study was unable to demonstrate a clinically relevant benefit of TEA on the frequency of major complications after elective cardiac surgery, compared with fast-track cardiac anesthesia without epidural anesthesia. Given the potentially devastating complications of an epidural hematoma after insertion of an epidural catheter, it is questionable whether this procedure should be applied routinely in cardiac surgical patients who require full heparinization. Perioperative thoracic epidural analgesia reduces stress response and pain scores and may improve outcome after cardiac surgery. This prospective, randomized trial was designed to compare the effectiveness of patient-controlled thoracic epidural analgesia with patient-controlled analgesia with intravenous morphine on postoperative hospital length of stay and patients' perception of their quality of recovery after cardiac surgery.
                One hundred thirteen patients undergoing elective cardiac surgery were randomly assigned to receive either combined thoracic epidural analgesia and general anesthesia followed by patient-controlled thoracic epidural analgesia or general anesthesia followed by to patient-controlled analgesia with intravenous morphine. Postoperative length of stay, time to eligibility for hospital discharge, pain and sedation scores, degree of ambulation, lung volumes, and organ morbidities were evaluated. A validated quality of recovery score was used to measure postoperative health status.
                Length of stay and time to eligibility for hospital discharge were similar between the groups. Study groups differed neither in postoperative global quality of recovery score nor in five dimensions of quality of recovery score. Time to extubation was shorter (P < 0.001) and consumption of anesthetics was lower in the patient-controlled thoracic epidural analgesia group. Pain relief, degree of sedation, ambulation, and lung volumes were similar between the study groups. There was a trend for lower incidences of pneumonia (P = 0.085) and confusion (P = 0.10) in the patient-controlled thoracic epidural analgesia group, whereas cardiac, renal, and neurologic outcomes were similar between the groups.
                In elective cardiac surgery, thoracic epidural analgesia combined with general anesthesia followed by patient-controlled thoracic epidural analgesia offers no major advantage with respect to hospital length of stay, quality of recovery, or morbidity when compared with general anesthesia alone followed by to patient-controlled analgesia with intravenous morphine. Thirty patients who had undergone elective abdominal aortic surgery were studied in a prospective, randomised double-blind comparison of thoracic epidural 0.2% bupivacaine alone, thoracic epidural fentanyl alone and thoracic epidural 0.2% bupivacaine combined with fentanyl. Pain relief, pulmonary function, cardiovascular stability and side effects were assessed. Pain relief was excellent in the combined bupivacaine-fentanyl series, being significantly better than the other groups (p less than 0.05) during the entire study period and was not accompanied by hypotension. Forced expiratory parameters were reduced in all groups throughout the study to 50-60% of the pre-operative values, but there were no significant differences between groups. The incidence of side effects attributable to either epidural bupivacaine or fentanyl was low. This study supports the increasing use of epidural infusion analgesia for postoperative pain management after abdominal surgery. To determine the effects of thoracic epidural anesthesia (TEA) on ventilation-perfusion (VA/Q) relationships, atelectasis, and oxygenation before and after coronary artery bypass graft surgery (CABG).
                Prospective, controlled, unblinded, randomized trial.
                Cardiothoracic clinic at a major university referral center.
                Twenty-eight patients undergoing elective CABG.
                Perioperative and postoperative TEA was added to general anesthesia (GA) in 14 patients, and 14 patients receiving GA alone served as controls.
                VA/Q relationships were measured by the multiple inert gas elimination technique, and, 20 hours postoperatively, atelectasis was assessed by computerized tomographic scans. Arterial and mixed venous blood gases and hemodynamic variables were measured by standard techniques. TEA per se caused no change in shunt, VA/Q matching, or oxygenation. Induction of GA in the control group and induction of TEA caused similar reductions in mean arterial pressure. The TEA patients needed less morphine analgesia postoperatively and were extubated earlier. Extubation caused significant improvement in VA/Q matching. On the first postoperative day, a slight reduction in PaCO2 was seen in the TEA group, but no differences in shunt, VA/Q matching, or oxygenation compared with the GA group. Both groups showed extensive bilateral atelectasis.
                TEA can reduce respirator time and the need for morphine analgesics after CABG without negative effects on VA/Q matching, oxygenation, or atelectasis formation. Improvements in analgesia after major surgery may allow a more rapid recovery and shorter hospital stay. We performed a prospective randomized trial to study the effects of epidural analgesia on the length of hospital stay after coronary artery surgery. The anesthetic technique and postoperative mobilization were altered to facilitate early intensive care discharge and hospital discharge. Fifty patients received high (T1 to T4) thoracic epidural anesthesia (TEA) with ropivacaine 1% (4-mL bolus, 3-5 mL/h infusion), with fentanyl (100-microg bolus, 15-25 microg/h infusion) and a propofol infusion (6 mg x kg(-1) x h(-1)). Another 50 patients (the General Anesthesia group) received fentanyl 15 microg/kg and propofol (5 mg x kg(-1) x h(-1)), followed by IV morphine patient-controlled analgesia. The TEA group had lower visual analog scores with coughing postextubation (median, 0 vs 26 mm; P < 0.0001) and were extubated earlier (median hours [interquartile range], 3.2 [2.1-4.6] vs 6.7 [3.3-13.2]; P < 0.0001). More than half of all patients were discharged home on Postoperative Day 4 (24%) or 5 (33%), but there was no difference in the length of stay between the TEA group (median [interquartile range], Day 5 [5-6]) and the General Anesthesia group (median [interquartile range], Day 5 [4-7]). There were no differences in postoperative spirometry or chest radiograph changes or in markers for postoperative myocardial ischemia or infarction. No significant TEA-related complications occurred. In summary, TEA provided better analgesia and allowed earlier tracheal extubation but did not reduce the length of hospital stay after coronary artery surgery.
                We found that epidural analgesia was more effective than IV morphine for cardiac surgery. Epidural anesthesia also allowed earlier weaning from mechanical ventilation, but it did not affect hospital discharge time. In this clinical, randomized, prospective study, we compared the effects of three different analgesia techniques (thoracic epidural analgesia [TEA] with and without preoperative initiation and IV patient-controlled analgesia [IV-PCA]) on postthoracotomy pain in 69 patients. In two groups, a thoracic epidural catheter was inserted preoperatively. Group Pre-TEA had bupivacaine and morphine solution preoperatively and intraoperatively. Postoperative analgesia was maintained with epidural PCA with a similar solution. Group Post-TEA, with no intraoperative medication, had the same postoperative analgesia as Group Pre-TEA plus the bolus dose. Group IV-PCA received only IV-PCA with morphine for postoperative analgesia. Pain was evaluated every 4 h during the first 48 h at rest, cough, and movement. Pre-TEA was associated with decreased pain compared with the other groups. Six months later, the patients were asked about their pain. The incidence and the intensity of pain were most frequent in Group IV-PCA (78%) and were the least in Group Pre-TEA (45%) (Group Pre-TEA versus Group IV-PCA, P = 0.0233; Group Pre-TEA versus Group IV-PCA, P = 0.014). Patients having pain on the second postoperative day had 83% chronic pain. TEA with preoperative initiation is a preferable method in preventing acute and long-term thoracotomy pain.
                Preoperatively initiated thoracic epidural analgesia has the most satisfying results in controlling postthoracotomy pain in the acute and long-term period, and it is associated with a decreased incidence (and intensity) of chronic pain compared with postoperative (epidural or IV) analgesia. Chronic pain has an incidence of 62%. Improvement in patient outcome and reduced use of medical resources may result from using epidural anesthesia and analgesia as compared with general anesthesia and intravenous opioids, although the relative importance of intraoperative versus postoperative technique has not been studied. This prospective, double-masked, randomized clinical trial was designed to compare alternate combinations of intraoperative anesthesia and postoperative analgesia with respect to postoperative outcomes in patients undergoing surgery of the abdominal aorta.
                One hundred sixty-eight patients undergoing surgery of the abdominal aorta were randomly assigned to receive either thoracic epidural anesthesia combined with a light general anesthesia or general anesthesia alone intraoperatively and either intravenous or epidural patient-controlled analgesia postoperatively (four treatment groups). Patient-controlled analgesia was continued for at least 72 h. Protocols were used to standardize perioperative medical management and to preserve masking intraoperatively and postoperatively. A uniform surveillance strategy was used for the identification of prospectively defined postoperative complications. Outcome evaluation included postoperative hospital length of stay, direct medical costs, selected postoperative morbidities, and postoperative recovery milestones.
                Length of stay and direct medical costs for patients surviving to discharge were similar among the four treatment groups. Postoperative outcomes were similar among the four treatment groups with respect to death, myocardial infarction, myocardial ischemia, reoperation, pneumonia, and renal failure. Epidural patient-controlled analgesia was associated with a significantly shorter time to extubation (P = 0.002). Times to intensive care unit discharge, ward admission, first bowel sounds, first flatus, tolerating clear liquids, tolerating regular diet, and independent ambulation were similar among the four treatment groups. Postoperative pain scores were also similar among the four treatment groups.
                In patients undergoing surgery of the abdominal aorta, thoracic epidural anesthesia combined with a light general anesthesia and followed by either intravenous or epidural patient-controlled analgesia, offers no major advantage or disadvantage when compared with general anesthesia alone followed by either intravenous or epidural patient-controlled analgesia. Epidural analgesia is regarded as the gold method for controlling post-thoracotomy pain. Intercostal nerve cryoanalgesia can also produce satisfactory analgesic effects, but is suspected to increase the incidence of chronic pain. However, randomized controlled trials comparing these two methods for post-thoracotomy acute pain analgesic effects and chronic pain incidents have not been conducted previously. We studied 107 adult patients, allocated randomly to thoracic epidural bupivacaine and morphine or intercostal nerve cryoanalgesia. Acute pain scores and opioid-related side effects were evaluated for three postoperative days. Chronic pain information, including the incidence, severity, and allodynia-like pain, was acquired on the first, third, sixth and twelfth months postoperatively. There was no significant difference on numeral rating scales (NRS) at rest or on motion between the two groups during the three postoperative days. The patient satisfaction results were also similar between the groups. The side effects, especially mild pruritus, were reported more often in the epidural group. Both groups showed high incidence of chronic pain (42.1-72.1%), and no significance between the groups. The incidence of allodynia-like pain reported in cryo group was higher than that in Epidural group on any postoperative month, with significance on the sixth and the twelfth months postoperatively (P<0.05). More patients rated their chronic pain intensity on moderate and severe in cryo group and interfered with daily life (P<0.05). Both thoracic epidural analgesia and intercostal nerve cryoanalgesia showed satisfactory analgesia for post-thoracotomy acute pain. The incidence of post-thoracotomy chronic pain is high. Cryoanalgesia may be a factor that increases the incidence of neuropathic pain. To evaluate the effect of immediate postoperative extubation and postoperative ventilation after minimally invasive direct coronary artery bypass (MIDCAB) surgery and to assess the role of epidural anesthesia.
                Randomized prospective study.
                University hospital, single institution.
                Patients (n = 90) scheduled for elective MIDCAB surgery.
                Patients were divided into 3 groups: 30 patients had general anesthesia and were extubated immediately after surgery (extubated group), 30 patients had a thoracic epidural and general anesthesia and were extubated immediately after surgery (epidural group), and 30 patients had general anesthesia and were ventilated after surgery (intubated group).
                With a similar cardiac index and less vasoactive medication, mean arterial blood pressure (77 plus minus 8 mmHg [mean plus minus SD]) and heart rate (76 plus minus 10 beats/min) in the epidural group were lower on the first postoperative day than in the intubated group (83 plus minus 10 mmHg and 81 plus minus 13 beats/min) and the extubated group (86 plus minus 10 mmHg and 83 plus minus 13) (p = 0.01 and p = 0.09). Oxygenation on the first postoperative day was better in the epidural group than in the intubated group (14.8 plus minus 3.8 kPa v 12.6 plus minus 3.2 kPa; p = 0.05). The epidural group and the extubated group had a transient respiratory acidosis postoperatively. Pain score in the epidural group was lower on the first postoperative day than in the extubated group with general anesthesia (3.0 plus minus 1.6 visual analog scale v 4.6 plus minus 1.8 visual analog scale; p = 0.01). Hospital stay was shorter in the epidural group than in the ventilated group (5.9 plus minus 2.4 days v 8.1 plus minus 5.3 days; p = 0.05)
                Immediate postoperative extubation in patients with thoracic epidural anesthesia and supplemental general anesthesia provides the most favorable clinical circumstances after MIDCAB surgery.
                Copyright 2002, Elsevier Science (USA). All rights reserved. High thoracic epidural anesthesia/analgesia (HTEA) for coronary artery bypass grafting (CABG) surgery may have myocardial protective effects. In this prospective randomized controlled study, we investigated the effect of HTEA for elective CABG surgery on the release of troponin I, time to tracheal extubation, and analgesia. One-hundred-twenty patients were randomized to a general anesthesia (GA) group or a GA plus HTEA group. The GA group received fentanyl (7-15 microg/kg) and a morphine infusion. The HTEA group received fentanyl (5-7 microg/kg) and an epidural infusion of ropivacaine 0.2% and fentanyl 2 microg/mL until postoperative Day 3. There were no differences in troponin I levels between study groups. The time to tracheal extubation [median (interquartile range)] in the HTEA group was 15 min (10-320 min), compared with 430 min (284-590 min) in the GA group (P < 0.0001). Analgesia was improved in the HTEA group compared with the GA group. Mean arterial blood pressure poststernotomy and systemic vascular resistance in the intensive care unit were lower in the HTEA group. We conclude that HTEA for CABG surgery had no effect on troponin release but improved postoperative analgesia and was associated with a reduced time to extubation. The Multicenter Australian Study of Epidural Anesthesia and Analgesia in Major Surgery (The MASTER Trial) was designed to evaluate the possible benefit of epidural block in improving outcome in high-risk patients. The trial began in 1995 and is scheduled to reach the planned sample size of 900 during 2001. This paper describes the trial design and presents data comparing 455 patients randomized in 21 institutions in Australia, Hong Kong, and Malaysia, with 237 patients from the same hospitals who were eligible but not randomized. Nine categories of high-risk patients were defined as entry criteria for the trial. Protocols for ethical review, informed consent, randomization, clinical anesthesia and analgesia, and perioperative management were determined following extensive consultation with anesthesiologists throughout Australia. Clinical and research information was collected in participating hospitals by research staff who may not have been blind to allocation. Decisions about the presence or absence of endpoints were made primarily by a computer algorithm, supplemented by blinded clinical experts. Without unblinding the trial, comparison of eligibility criteria and incidence of endpoints between randomized and nonrandomized patients showed only small differences. We conclude that there is no strong evidence of important demographic or clinical differences between randomized and nonrandomized patients eligible for the MASTER Trial. Thus, the trial results are likely to be broadly generalizable. Epidural anesthesia has been suggested to exert a protective effect against the inflammatory and stress responses associated with surgery. The aim of this study was to evaluate the impact of thoracic epidural anesthesia on myocardial cell damage, inflammatory, and stress responses in patients undergoing off-pump coronary artery bypass graft (OPCABG) surgery.
                Seventy-four patients (66 male [89%], mean age 65.2 years [SD 9.6]) undergoing OPCABG surgery were randomly assigned to receive either general anesthesia plus epidural (GAE [n = 36]) or general anesthesia only (GA [n = 38]). Troponin I, 8-isoprostane, cortisol, C3alpha, interleukin (IL)-6, IL-8, and IL-10 were measured preoperatively, at 30 minutes, and 4, 12, 24, and 48 hours postoperatively.
                Baseline characteristics were similar in the two groups. One patient died in the GAE group, but no other major postoperative complications were recorded in either group. The IL-6 and IL-8 levels were lower in the GAE group (ratio 0.83, 95% confidence interval: 0.68 to 1.02; p = 0.070) than in the GA group (ratio 0.90, 95% confidence interval: 0.78 to 1.02; p = 0.090). The difference in levels of IL-10 between the GAE and GA groups varied over time (p greater, similar 0.001). The C3alpha, troponin I, 8-isoprostane, and cortisol release was similar in the two groups throughout (p > or = 0.12).
                Thoracic epidural anesthesia does not provide any additional benefits in terms of reducing myocardial damage, inflammatory, and stress response compared with general anesthesia only in patients undergoing OPCABG surgery. High thoracic epidural techniques are increasingly being used in patients scheduled for cardiothoracic surgery, including coronary artery bypass grafting. In the present study, we evaluated the acute effects of the epidural blockade on myocardial oxygen availability by means of tissue oxygen pressure monitoring in patients submitted for surgical revascularization.
                Fifty adult patients were included in a prospective, randomized, double-blind study. After placement of an epidural catheter in thoracic space T1-T2, and under general anesthesia, 5-10 ml of either normal saline or 0.3% ropivacaine was injected through the epidural catheter. Hemodynamic parameters and the intramyocardial oxygen partial pressure were recorded before and 20 min after the epidural injection.
                There were no demographic or hemodynamic differences between the groups before intervention. A significant increase in intramyocardial partial oxygen pressure was observed in the ropivacaine group (14.6 mmHg vs. 25.1 mmHg, P < 0.0005).
                High thoracic epidural blockade with 5-10 ml of 0.3% ropivacaine increases myocardial oxygen availability in coronary diseased patients prior to surgical revascularization without deleterious hemodynamic disturbances.
Epidural anaesthesia may reduce the risk of developing chronic pain after thoracotomy in about one patient out of every four patients treated. Paravertebral block may reduce the risk of chronic pain after breast cancer surgery in about one out of every five women treated. Our conclusions are significantly weakened by performance bias, shortcomings in allocation concealment, considerable attrition and incomplete outcome data. We caution that our evidence synthesis is based on only a few, small studies. More studies with high methodological quality, addressing various types of surgery and different age groups, including children, are needed.