Anderson Mark B, Kwong King F, Furst Alex J, Salerno Tomas A
Division of Cardiothoracic Surgery, UMDNJ/Robert Wood Johnson School of Medicine, New Brunswick, NJ 08903, USA.
Heart Surg Forum. 2002;5(2):105-8.
Cardiac surgery is perceived to be maximally invasive and fraught with complications. In response to this perception, cardiothoracic surgeons have been refining traditional techniques to minimize their invasive nature. Epidural anesthesia has been used safely and effectively for numerous surgical procedures to reduce morbidity associated with general anesthesia. In hopes of achieving a similar result, we set out to determine the feasibility of using thoracic epidural anesthesia for limited cardiac surgery through a left anterior thoracotomy for patients who were awake and spontaneously breathing.
A high thoracic epidural technique was used in all cases. In each instance, the chest was entered through a small left anterior thoracotomy. The procedures included minimally invasive direct coronary artery bypass (MIDCAB) and transmyocardial revascularization (TMR). These procedures were performed in routine fashion using standard techniques. Pulmonary function tests were performed preoperatively, and the adequacy of respiratory function was serially monitored throughout each operation. The epidural catheters were left in place for 24 hours after operation for pain control.
A total of 10 operations were performed. These included 7 MIDCAB, 2 TMR and 1 MIDCAB/TMR hybrid. The mean preoperative forced expiratory volume for one second (FEV1) was 1.9 liters. Significant intra-operative hypoxia or hypercarbia was not seen. One patient required intubation during the procedure for restlessness not associated with hypoxia. Two others required brief periods of assisted ventilation. All procedures were completed without incident. The mean operating time and length of stay were 70 minutes and 4.7 days. Postoperative pain control and patient satisfaction were excellent.
Thoracic epidural anesthesia for limited cardiac surgical procedures by means of a left anterior thoracotomy is feasible, even in patients with diminished pulmonary function. Furthermore, this method offered no significant technical hurdles. Nevertheless, the applicability of this technique to other procedures remains unclear. We believe that these results warrant controlled comparison of regional versus general anesthesia for limited cardiac surgery.
心脏手术被认为具有极大的侵入性且充满并发症。针对这种看法，心胸外科医生一直在改进传统技术以尽量减少其侵入性。硬膜外麻醉已被安全有效地用于众多外科手术，以降低与全身麻醉相关的发病率。为了达到类似的效果，我们着手确定对于清醒且自主呼吸的患者，通过左前开胸术进行有限心脏手术时使用胸段硬膜外麻醉的可行性。
所有病例均采用高位胸段硬膜外技术。在每种情况下，通过小的左前开胸术进入胸腔。手术包括微创直接冠状动脉旁路移植术（MIDCAB）和心肌血运重建术（TMR）。这些手术采用标准技术以常规方式进行。术前进行肺功能测试，并在每次手术过程中连续监测呼吸功能是否充足。硬膜外导管在术后留置24小时用于控制疼痛。
共进行了10例手术。其中包括7例MIDCAB、2例TMR和1例MIDCAB/TMR联合手术。术前一秒用力呼气量（FEV1）的平均值为1.9升。术中未出现明显的低氧血症或高碳酸血症。1例患者在手术过程中因与低氧血症无关的烦躁不安需要插管。另外2例患者需要短时间的辅助通气。所有手术均顺利完成。平均手术时间和住院时间分别为70分钟和4.7天。术后疼痛控制良好，患者满意度高。
通过左前开胸术对有限心脏手术采用胸段硬膜外麻醉是可行的，即使是肺功能减退的患者。此外，该方法没有明显的技术障碍。然而，该技术在其他手术中的适用性仍不清楚。我们认为这些结果值得对有限心脏手术的区域麻醉与全身麻醉进行对照比较。
