Canadian Journal of Anaesthesia

, Volume 40, Issue 6, pp 532–541

Epidural morphine reduces the riskof postoperative myocardial ischaemia in patients with cardiac risk factors

  • Wm. Scott Beattie
  • D. Norman Buckley
  • James B. Forrest
Anaesthetic Techniques

Abstract

Perioperative myocardial ischaemia is a predictor of postoperative cardiac morbidity (PCM). Epidural anaesthesia and adequate perioperative analgesia have been shown to improve myocardial oxygen dynamics due to interruption of pain and sympathetic pathways. The aim of the present study was to compare the incidence of ischaemia after either general anaesthesia followed by parenteral analgesia with morphine or combined epidural/general anaesthesia followed by analgesia with epidural morphine. In a prospective observer-blinded analysis of the occurrence of ischaemia, 55 patients (epidural = 29/ parenteral = 26) scheduled for elective surgery with defined risks for ischaemic cardiac disease were entered and followed for 24 hr after surgery with two-lead continuous Hotter monitoring. Groups were similar with respect to age, weight, modified Goldman (Detsky) risk classification and the use of cardiac medications. Fewer patients receiving the epidural anaesthesia/ analgesia had ischaemic episodes (17.2 vs 50.0%, P = 0.01), and tachyarrhythmias (20.7 vs 50.0%, P < 0.05). Epidural patients had a four-fold reduction of the relative risk for either event (P < 0.001). All ischaemic events were asymptomatic and unrecognized (silent). All major morbid events (n = 5) (MI, congestive heart failure and death) occurred in patients who had perioperative episodes of ischaemia. There were three distinct peaks in onset of ischaemia, at 1–4 hr, 9–12 hr and 22–24 hr postoperatively. One third of postoperative ischaemic events occurred within the first four hours after operation and lasted from 1 to 31 min. Forty-two percent of ischaemic episodes were associated with a heart rate > 100 bpm, or an increase of 20% over the baseline heart rate. We conclude that epidural anaesthesia/analgesia reduces but does not eliminate the risk of myocardial ischaemia and tachyarrhythmia. We were unable to determine any associated reduction in the risk of PCM.

Key words

analgesia: postoperative, epidural complications: myocardial ischaemia 

Résumé

L’ischémie myocardique périopératoire a une bonne valeur pronostique sur la morbidité cardiaque postopératoire (MCP). II a été démontré que l’anesthésie et l’analgésie post-opératoire épidurales favorisaient l’oxygénation myocardique par interruption des voies de conductions algiques et sympathiques. L’objectif de la présente étude est de comparer l’incidence de l’ischémie après l’anesthésie générale suivie d’analgésie parentérale à la morphine à l’association anesthésie générale-épidurale suivie d’analgésie à la morphine épidurale. Sont inclus dans cette étude prospective, à l’insu de l’observateur, 55 patients (29 dans le group épidural, 26 dans le groupe parentéral) programmés pour une chirurgie réglée et présentant des risques définis de maladie cardiaque ischémique. Les patients sont monitorés continuellement pendant 24 heures après la chirurgie avec un Hotter à deux dérivations. Il n’y a pas de différence entre les deux groupes pour l’âge, le poids, l’échelle de risque de Goldman (Detsky) et la médication cardiaque. Moins de patients du groupe anesthésie générale-épidurale souffrent d’épisodes ischémiques (17,2 vs 50%, P = 0,01), et de tachyarythmies (20,7 vs 50%, P < 0,05). Les patients du groupe épidural courent un risque quatre fois moins élevé de souffrir de l’une ou de l’autre complication (P < 0,001). Tous les épisodes ischémiques ont été asymptomatiques et sont passés inaperçus. Toutes les complications (n = 5) (infarctus du myocarde, défaillance cardiaque et décès) sont survenus chez des patients qui avaient présenté de l’ischémie périopératoire. On a identifié trois pointes d’incidence ischémiques postopératoires: à 1–4 hres, 9–12 hres et 22–24 hres. Un tiers des épisodes ischemiques est survenu en-deçà de quatre heures après l’opération et a duré de 1 à 31 min. Quarante-deux pourcent de ces épisodes étaient associés à une fréquence de plus de cent b · min−1 ou à une augmentation de 20% du niveau de base. Nous concluons que l’anesthésie / analgésie épidurale diminue mais n’élimine pas le risque d’ischémie cardiaque et de tachyarythmies. Nous n’avons pas démontré une réduction associée de la MCP.

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Copyright information

© Canadian Anesthesiologists 1993

Authors and Affiliations

  • Wm. Scott Beattie
    • 1
  • D. Norman Buckley
    • 1
  • James B. Forrest
    • 1
  1. 1.Department of AnaesthesiaMcMaster UniversityHamilton

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