Effects of intrathecal opioid on extubation time, analgesia, and intensive care unit stay following coronary artery bypass grafting

doi:10.1016/S0952-8180(97)00081-0

Journal of Clinical Anesthesia

Volume 9, Issue 5, August 1997, Pages 415-419

https://doi.org/10.1016/S0952-8180(97)00081-0 Get rights and content

Abstract

Study Objective: To determine if intrathecal opioid decreases time to extubation after coronary artery bypass surgery without compromising postoperative analgesia.

Design: Prospective randomized trial.

Setting: Veterans Affairs Hospital.

Patients: 21 ASA physical status III and IV men scheduled for elective coronary bypass surgery, who had not received medications that would impair anticoagulation at the time of surgery.

Interventions: Patients were randomized to receive 10 μg/kg morphine and 25 μg fentanyl intrathecally preoperatively (n = 12) or no intrathecal opioid (n = 9). The latter group received 25 to 50 μg/kg fentanyl and 0.05 to 0.1 mg/kg midazolam intraoperatively, whereas the intrathecal opioid group received intravenous (IV) fentanyl and midazolam only as needed. Both groups were administered IV morphine and midazolam postoperatively as needed by intensive care unit (ICU) personnel who were blinded to the treatment group.

Measurements and Main Results: For the first 24 hours postoperatively, pain levels (0 = none, to 10 = most severe) and sedation levels (1 = none, to 5 = unconscious) were measured hourly. The time to extubation and discharge from the ICU was recorded. ECG evidence of myocardial ischemia was noted. Pain scores were low for both groups (1.5), but the intrathecal opioid subjects exhibited less sedation than the high-dose fentanyl subjects [means ± standard deviation (SD) of 2.3 ± 0.4 vs. 2.8 ± 0.5, p = 0.03]. Extubation time was 12 hours shorter in the intrathecal opioid group (2.9 ± 5.3 vs. 14.7 ± 6.8, p = 0.001). The five subjects with a one day ICU stay were all in the intrathecal opioid group (p = 0.04). The incidence of myocardial ischemia did not differ between the two groups.

Conclusions: Intrathecal opioid can facilitate early extubation and discharge from the ICU without compromising analgesia or increasing myocardial ischemia.

References (18)

DC Cheng
Pro: early extubation after cardiac surgery decreases intensive care unit stay and cost
J Cardiothorac Vasc Anesth
(1995)
KV Arom et al.
Cost-effectiveness and predictors of early extubation
Ann Thorac Surg
(1995)
ET Mathews et al.
Intrathecal morphine in open heart surgery [Letter]
Lancet
(1980)
GJ Fitzpatrick et al.
Intrathecal morphine in the management of pain following cardiac surgery. A comparison with morphine iv
Br J Anaesth
(1988)
WF Casey et al.
The role of intrathecal morphine in the anesthetic management of patients undergoing coronary artery bypass surgery
J Cardiothorac Anesth
(1987)
N Rawal et al.
Present state of extradural and intrathecal opioid analgesia in Sweden. A nation-wide follow-up survey
Br J Anaesth
(1987)
DC Cheng et al.
Cost analysis of early vs. conventional extubation post coronary artery bypass graft (CABG) surgery: a prospective randomized controlled study [Abstract]
Anesth Analg
(1995)
DC Cheng et al.
Cardiovascular intensive care unit (CVICU) utilization and service cost following early tracheal extubation practice post cardiac surgery [Abstract]
Anesth Analg
(1995)
FT Velasco et al.
Economic rationale for early extubation
J Cardiotharac Vasc Anesth
(1995)

There are more references available in the full text version of this article.

Cited by (32)

Effectiveness of combined regional-general anesthesia for reducing mortality in coronary artery bypass: Meta-analysis
2016, Brazilian Journal of Anesthesiology
A anestesia neuroaxial (AN) vem sendo utilizada em associação com a anestesia geral (AG) para revascularização miocárdica, entretanto a anticoagulação durante a cirurgia torna questionável a viabilidade dos benefícios mediante o risco de hematoma de espaço peridural. O objetivo deste estudo foi executar metanálises analisando a efetividade da AN associada à AG comparada à AG isolada para a cirurgia de revascularização miocárdica relativa à redução da mortalidade.
Foram analisados mortalidade, arritmias, acidente vascular cerebral (AVC), infarto miocárdico (IM), tempo de internação hospitalar (TIH), tempo de internação em unidade de terapia intensiva (TUTI), reoperações, transfusão sanguínea (TS), qualidade de vida, grau de satisfação e disfunção cognitiva pós‐opertória. A diferença média (DM) ponderada foi estimada para as variáveis contínuas e risco relativo (RR) e a diferença de risco (DR) para variáveis categóricas.
Analisados 17 artigos originais. Metanálise da mortalidade (DR = –0,01; IC 95% = –0,03 a 0,01), AVC (RR = 0,79; IC 95% = 0,32 a 1,95), IM (RR = 0,96; IC 95% = 0,52 a 1,79) e TIH (DM = –1,94; IC 95% = –3,99 a 0,12) não demonstraram significância estatística. Arritmia foi menos frequente com AN (RR = 0,68; IC 95% = 0,50 a 0,93). O TUTI foi menor no com AN (DM = –2,09; IC 95% = –2,92 a –1,26).
Não se observaram diferenças estatisticamente significantes quanto a mortalidade. A combinação de AN e AG mostrou menor incidência de arritmias e menor TUTI.
Neuraxial anesthesia (NA) has been used in association with general anesthesia (GA) for coronary artery bypass; however, anticoagulation during surgery makes us question the viability of benefits by the risk of epidural hematoma. The aim of this study was to perform a meta‐analyzes examining the efficacy of NA associated with GA compared to GA alone for coronary artery bypass on mortality reduction.
Mortality, arrhythmias, cerebrovascular accident (CVA), myocardial infarction (MI), length of hospital stay (LHS), length of ICU stay (ICUS), reoperations, blood transfusion (BT), quality of life, satisfaction degree, and postoperative cognitive dysfunction were analyzed. The weighted mean difference (MD) was estimated for continuous variables, and relative risk (RR) and risk difference (RD) for categorical variables.
17 original articles analyzed. Meta‐analysis of mortality (RD = –0.01, 95% CI = –0.03 to 0.01), CVA (RR = 0.79, 95% CI = 0.32 to 1.95), MI (RR = 0.96, 95% CI = 0.52 to 1.79) and LHS (MD = –1.94, 95% CI = –3.99 to 0.12) were not statistically significant. Arrhythmia was less frequent with NA (RR = 0.68, 95% CI = 0.50 to 0.93). ICUS was lower in NA (MD = –2.09, 95% CI = –2.92 to –1.26).
There was no significant difference in mortality. Combined NA and GA showed lower incidence of arrhythmias and lower ICUS.
Should Thoracic Epidural/Spinal Analgesia be Used for Coronary Artery Bypass Grafting?
2013, Evidence-Based Practice of Anesthesiology
Spinal Analgesia in Cardiac Surgery: A Meta-analysis of Randomized Controlled Trials
2009, Journal of Cardiothoracic and Vascular Anesthesia
Controversial results exist on the effects of spinal analgesia in cardiac surgery. The authors conducted a review of randomized studies to show whether there are any advantages in clinically relevant outcomes using spinal analgesia in patients undergoing cardiac surgery.
Meta-analysis.
Multiple hospitals.
A total of 1,106 patients from 25 randomized trials.
None.
PubMed, BioMedCentral, CENTRAL, EMBASE, Cochrane Central Register of Controlled Trials, and conference proceedings were searched (updated January 2009) for randomized trials that compared general anesthesia with an anesthetic plan including spinal analgesia in cardiac surgery. Four independent reviewers performed data extraction, with divergences resolved by consensus. A total of 1,106 patients from 25 randomized studies were included in the analysis. Overall analysis showed that there were no differences in terms of mortality (2/562 [0.4%] in the spinal group v 2/514 [0.4%] in the control arm [risk difference (RD) = 0.00 [−0.02, +0.02], p = 1.0), perioperative myocardial infarction (9/421 [2.1%] in the spinal group v 11/407 [2.7%] in the control arm [RD = 0.00, −(0.03, +0.02), p = 0.77), and the length of hospital stay (WMD = −0.28 days [−0.68, −0.13], p = 0.18, with 419 included patients).
This analysis indicated that spinal analgesia does not improve clinically relevant outcomes in patients undergoing cardiac surgery, discouraging further randomized controlled trials on this topic even if changes in techniques, devices, and drugs could modify the outlook of the comparison between spinal and standard anesthesia in this setting.
Analgesia Best Practice After Cardiac Surgery
2008, Anesthesiology Clinics
Citation Excerpt :
Intrathecal morphine is a potentially simple technique that can provide prolonged analgesia with a single injection. Many studies have examined the use of intrathecal opioid analgesia, describing doses of morphine ranging from 70 to 600 microgram per kilogram [58–66]. There is consistent agreement regarding the potential for intrathecal morphine to attenuate stress responses and provide quality analgesia, but there is much debate about the correct dose that can facilitate early extubation.
Sources of pain after cardiac surgery include sternotomy, rib retraction, conduit harvest, and drain tubes sites. An analgesic regimen should consider individual patient characteristics, including age, preoperative history of pain and response to analgesics, comorbidities, and psychologic state. Intraoperative and postoperatively administered opioids remain the mainstay of therapy, but adjunctive analgesics such as paracetamol, nonsteroidal anti-inflammatory drugs and tramadol, and regional techniques, can reduce opioid consumption and opioid-induced respiratory depression. This may facilitate earlier tracheal extubation, mobilization, and recovery.
Emerging Nurse-Sensitive Outcomes and Evidence-Based Practice in Postoperative Cardiac Patients
2007, Critical Care Nursing Clinics of North America
Outcomes continue to be one of the most powerful measures of quality care in all health care settings for all caregivers. Nurse-sensitive outcome measurement is one of the most promising strategies that can enhance patient care and satisfaction of patients, families, and caregivers. The purpose of this article is to assist intensive care unit nurses with identification and implementation of current evidence-based nursing interventions for the critically ill patients undergoing cardiac surgery.
A combination of intrathecal morphine and remifentanil anesthesia for fast-track cardiac anesthesia and surgery
2002, Journal of Cardiothoracic and Vascular Anesthesia
Citation Excerpt :
In this study, the authors used 2 mg of intrathecal morphine to ensure adequate postoperative analgesia, provided that early tracheal extubation would not be compromised. These findings are consistent with a study by Shroff et al,23 who reported that extubation times were significantly shorter with intrathecal anesthesia compared with high-dose fentanyl technique. Shroff et al23 showed that the intrathecal technique permitted tracheal extubation on average within 3 hours after surgery.
Objective: To determine if the combined remifentanil and intrathecal morphine (RITM) anesthetic technique facilitates early extubation in patients undergoing coronary artery bypass graft (CABG) surgery. Design: Prospective, randomized, controlled clinical trial. Setting: Referral center for cardiothoracic surgery at a university hospital. Participants: Patients (n = 24) undergoing first-time elective CABG surgery. Interventions: Two groups represented RITM (n = 12) and fentanyl-based (controls, n = 12) anesthesia. Premedication was standardized to temazepam, 0.4 mg/kg, and anesthesia was induced with etomidate, 0.3 mg/kg, in both groups. The RITM group received remifentanil, 1 μg/kg bolus followed by 0.25 to 1 μg/kg/min infusion, and intrathecal morphine, 2 mg. The control group received fentanyl, 12 μg/kg in 3 divided doses. Anesthesia was maintained with isoflurane and pancuronium in both groups. After completion of surgery, the remifentanil infusion was stopped. Complete reversal of muscle relaxation was ensured with a nerve stimulator, and a propofol infusion, 0.5 to 3 mg/kg/h, was started in both groups. All patients were transferred to the intensive care unit (ICU) to receive standardized postoperative care. Intensivists and ICU nurses were blinded to the group assignment. Propofol infusion was stopped, and the tracheal extubation was accomplished when extubation criteria were fulfilled. Measurements and Main Results: Both groups were similar with respect to demographic data and surgical characteristics. Extubation times were 156 ± 82 minutes and 258 ± 91 minutes in the RITM and control groups (p = 0.012). Patients in the RITM group exhibited lower visual analog scale pain scores during the first 2 hours after extubation (p < 0.04). Morphine requirements during the 24 hours after extubation were 2.5 ± 3 mg in the RITM group and 16 ± 11 mg in the control group (p = 0.0018). Sedation scores were lower in the RITM group during the first 3 hours after extubation (p < 0.03). Pulmonary function tests as assessed by spirometry were better in the RITM group at 6 and 12 hours after extubation (p < 0.04). There were no significant differences in PaO₂ and PaCO₂ after extubation between the 2 groups. None of the patients had episodes of apnea during the immediate 24-hour postextubation period. Two patients from the RITM group required reintubation on the second and sixth postoperative days. There were no differences in ICU and hospital length of stay between the 2 groups. Conclusion: Implementation of the RITM technique provided earlier tracheal extubation, decreased level of sedation, excellent analgesia, and improved spirometry in the early postoperative period. The impact of RITM on ICU and hospital length of stay and potential cost benefits require further evaluation. Copyright 2002, Elsevier Science (USA). All rights reserved.

View all citing articles on Scopus

^☆: Supported by the Office of Research and Development, Department of Veterans Affairs, Washington, D.C.

^∗: Acting Assistant Professor of Anesthesiology.

^†: Associate Professor of Anesthesiology.

View full text

Original contributionEffects of intrathecal opioid on extubation time, analgesia, and intensive care unit stay following coronary artery bypass grafting☆

Abstract

J Cardiothorac Vasc Anesth

Ann Thorac Surg

Lancet

Br J Anaesth

J Cardiothorac Anesth

Br J Anaesth

Cost analysis of early vs. conventional extubation post coronary artery bypass graft (CABG) surgery: a prospective randomized controlled study [Abstract]

Anesth Analg

Cardiovascular intensive care unit (CVICU) utilization and service cost following early tracheal extubation practice post cardiac surgery [Abstract]

Anesth Analg

Economic rationale for early extubation

J Cardiotharac Vasc Anesth

Original contribution
Effects of intrathecal opioid on extubation time, analgesia, and intensive care unit stay following coronary artery bypass grafting☆