Hemmerling Thomas M, Prieto Ignatio, Choinière Jean-Luc, Basile Fadi, Fortier Joanne D
Department of Anesthesiology, Centre hospitalier de l'université de Montréal, Hôtel-Dieu, Université de Montréal, Montréal, Québec, Canada.
Can J Anaesth. 2004 Feb;51(2):163-8. doi: 10.1007/BF03018777.
To examine the feasibility of immediate extubation after off-pump coronary artery bypass grafting (OPCAB) using opioid based analgesia or high thoracic epidural analgesia (TEA) and compare postoperative analgesia with continuous TEA vs patient-controlled analgesia (PCA).
One hundred consecutive patients undergoing OPCAB were included in this prospective audit. After induction of anesthesia using fentanyl 2 to 5 microg.kg(-1), propofol 1 to 2 mg.kg(-1) and endotracheal intubation facilitated by rocuronium, anesthesia was maintained using sevoflurane titrated according to bispectral index monitoring. Perioperative analgesia was provided by TEA (n = 63) at the T3/T4 interspace or T4/T5 interspace using bupivacaine 0.125% 8 to 14 mL.hr(-1) and repetitive boluses of bupivacaine 0.25% during surgery. In patients who were fully anticoagulated or refused TEA, perioperative analgesia was achieved by i.v. fentanyl boluses (up to 15 microg.kg(-1)) and remifentanil 0.1 to 0.2 microg.kg(-1).min(-1), followed by morphine PCA after surgery (n = 37). Maintenance of body temperature was achieved by a heated operating room and forced-air warming blankets.
Ninety-five patients were extubated within 25 min after surgery (PCA, n = 33; TEA, n = 62). Five patients were not extubated immediately because their core temperature was lower than 35 degrees C. One patient was re-intubated because of agitation (TEA group); one was re-intubated because of severe pain and morphine-induced respiratory depression (PCA group). Pain scores were low after surgery, with pain scores in the TEA group being significantly lower immediately, at six hours, 24 hr and 48 hr after surgery (P < 0.05).
Immediate extubation is possible after OPCAB using either opioid-based analgesia or TEA. TEA provides significantly lower pain scores after surgery in comparison to morphine PCA.
探讨在非体外循环冠状动脉旁路移植术（OPCAB）后使用阿片类镇痛或高位胸段硬膜外镇痛（TEA）进行即刻拔管的可行性，并比较持续TEA与患者自控镇痛（PCA）的术后镇痛效果。
本前瞻性审计纳入了连续100例行OPCAB的患者。使用2至5微克·千克⁻¹芬太尼、1至2毫克·千克⁻¹丙泊酚诱导麻醉并在罗库溴铵辅助下进行气管插管后，根据脑电双频指数监测滴定七氟醚维持麻醉。围手术期镇痛通过在T3/T4或T4/T5间隙置入TEA（n = 63），使用0.125%布比卡因8至14毫升·小时⁻¹，并在手术期间重复推注0.25%布比卡因。对于完全抗凝或拒绝TEA的患者，围手术期镇痛通过静脉推注芬太尼（最大剂量15微克·千克⁻¹）和瑞芬太尼0.1至0.2微克·千克⁻¹·分钟⁻¹实现，术后给予吗啡PCA（n = 37）。通过加热手术室和强制空气加温毯维持体温。
95例患者在术后25分钟内拔管（PCA组，n = 33；TEA组，n = 62）。5例患者因核心体温低于35摄氏度未即刻拔管。1例患者因躁动而复插管（TEA组）；1例因剧痛和吗啡诱导的呼吸抑制而复插管（PCA组）。术后疼痛评分较低，TEA组在术后即刻、6小时、24小时和48小时的疼痛评分显著更低（P < 0.05）。
在OPCAB后使用阿片类镇痛或TEA均可进行即刻拔管。与吗啡PCA相比，TEA术后疼痛评分显著更低。
