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Editorials |

Epidural Analgesia and Cardiac Surgery : Worth the Risk?

John M. Castellano, MD; Charles G. Durbin, Jr., MD
Author and Funding Information

Affiliations: Charlottesville, VA 
 ,  Dr. Castellano is Assistant Professor of Anesthesiology, Acute Pain Service, and Dr. Durbin is Medical Director, Respiratory Care, Department of Anesthesiology, University of Virginia Health System, Charlottesville, VA.

Correspondence to: Charles G. Durbin, Jr, MD, Department of Anesthesiology, University of Virginia Health Science Center, Box 100710, Charlottesville, VA 22908–0710; e-mail: CGD8V@virginia.edu



Chest. 2000;117(2):305-307. doi:10.1378/chest.117.2.305
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Extract

Pain following surgery remains a significant clinical problem. Frequently, systemic opioids are used in inadequate doses due to severe side effects and fear of respiratory depression. Patients undergoing intrathoracic procedures are especially at risk of inadequate analgesia. The consequences of persistent pain include hypertension, sympathetic hyperactivity, poor pulmonary toilet, atelectasis, and pneumonia. Recently, interest has emerged in the use of epidural infusions of local anesthetics and narcotics to improve analgesia in high-risk patients following thoracic surgery. With every intervention, there is a series of risks that must be weighed against the potential for a desired outcome. Inadequate or spotty analgesia, nerve or spinal cord injury, back pain, local infection, epidural abscess, inadvertent subarachnoid injection, respiratory arrest, and spinal cord compression from epidural hematoma are possible complications from epidural analgesia. Most of these are rare, reversible, or insignificant. Spinal cord compression from a hematoma or abscess is frequently not reversible. Systemic anticoagulation is presumed to increase the incidence of developing an epidural hematoma related to the epidural catheter; however, there is little objective evidence to quantitate the magnitude of this increased risk. In fact, there are no published reports of epidural hematomas complicating thoracic epidural analgesia in patients following cardiac surgery employing cardiopulmonary bypass and systemic anticoagulation. In this issue of CHEST (see page 551), the article by Ho et al is a mathematical attempt to bracket the upper and lower likelihood of this potentially catastrophic event occurring. While interesting, the analysis by Ho et al provides little evidence to reassure the prudent clinician that epidural placement is safe in cardiac surgery patients who have undergone anticoagulation.


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