0
Correspondence |

Response FREE TO VIEW

Emilio Bouza, MD, PhD; María Jesús Pérez, RN; Patricia Muñoz, MD, PhD; Cristina Rincón, RN; José María Barrio, MD; Javier Hortal, MD
Author and Funding Information

Hospital Gregorio Maranon Madrid, Spain

Correspondence to: Emilio Bouza, MD, PhD, Hospital Gregorio Maranon, Clinical Microbiology and Infectious Diseases, Dr Esquerdo 46, Madrid 28007, Spain; e-mail: ebouza@microb.net


The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/site/misc/reprints.xhtml).


© 2009 American College of Chest Physicians


Chest. 2009;136(1):322-323. doi:10.1378/chest.09-0770
Text Size: A A A
Published online

To the Editor:

We appreciate the interest of Tornero-Campello et al in our recent article in CHEST (November 2008)1 related to the value of continuous aspiration of subglottic secretions. They requested information regarding the use of thoracic epidural anesthesia (TEA), which they seem to consider a standard of care.

We did not use TEA in our daily practice because no evidence has suggested that TEA improves a patient's outcome, as has been concluded by two metaanalyses.2,3 TEA provides better analgesia and allows earlier tracheal extubation but does not reduce the length of hospital stay after coronary artery bypass surgery.46 TEA is probably not needed for pain control in patients undergoing cardiac surgery (which can be managed with conventional analgesia) or fast track (which can be achieved with short-acting IV or inhalational agents).7

TEA is a procedure that is usually applied during the initial 48 h after surgery, whereas ventilation-associated pneumonia (VAP) always occurs > 48 h after intubation. The clinical impact of a few hours delay in the time until extubation on a decrease in the incidence of VAP is far from proven. In our study, the greatest benefit of continuous aspiration of subglottic secretions was observed in the group of patients who received mechanical ventilation for longer than 48 h. Furthermore, the risk of epidural hematoma is a cause of concern, particularly in cardiac surgery patients, who frequently require anticoagulation.8

Finally, to our knowledge, no guidelines for the prevention of VAP have recommended TEA as a way to prevent VAP. For all of these reasons, TEA is not part of the standard of care in our cardiac surgery population.

Bouza E, Perez MJ, Munoz P, et al. Continuous aspiration of subglottic secretions in the prevention of ventilator-associated pneumonia in the postoperative period of major heart surgery. Chest. 2008;134:938-946. [PubMed] [CrossRef]
 
Liu SS, Block BM, Wu CL. Effects of perioperative central neuraxial analgesia on outcome after coronary artery bypass surgery: a meta-analysis. Anesthesiology. 2004;101:153-161. [PubMed]
 
Ronald A, Abdulaziz KA, Day TG, et al. In patients undergoing cardiac surgery, thoracic epidural analgesia combined with general anaesthesia results in faster recovery and fewer complications but does not affect length of hospital stay. Interact Cardiovasc Thorac Surg. 2006;5:207-216. [PubMed]
 
Priestley MC, Cope L, Halliwell R, et al. Thoracic epidural anesthesia for cardiac surgery: the effects on tracheal intubation time and length of hospital stay. Anesth Analg. 2002;94:275-282. [PubMed]
 
Royse C, Royse A, Soeding P, et al. Prospective randomized trial of high thoracic epidural analgesia for coronary artery bypass surgery. Ann Thorac Surg. 2003;75:93-100. [PubMed]
 
Tenling A, Joachimsson PO, Tyden H, et al. Thoracic epidural anesthesia as an adjunct to general anesthesia for cardiac surgery: effects on ventilation-perfusion relationships. J Cardiothorac Vasc Anesth. 1999;13:258-264. [PubMed]
 
Landoni G. Epidural anesthesia and analgesia in cardiac surgery. Minerva Anestesiol. 2008;74:617-618. [PubMed]
 
Ho AM, Chung DC, Joynt GM. Neuraxial blockade and hematoma in cardiac surgery: estimating the risk of a rare adverse event that has not (yet) occurred. Chest. 2000;117:551-555. [PubMed]
 

Figures

Tables

References

Bouza E, Perez MJ, Munoz P, et al. Continuous aspiration of subglottic secretions in the prevention of ventilator-associated pneumonia in the postoperative period of major heart surgery. Chest. 2008;134:938-946. [PubMed] [CrossRef]
 
Liu SS, Block BM, Wu CL. Effects of perioperative central neuraxial analgesia on outcome after coronary artery bypass surgery: a meta-analysis. Anesthesiology. 2004;101:153-161. [PubMed]
 
Ronald A, Abdulaziz KA, Day TG, et al. In patients undergoing cardiac surgery, thoracic epidural analgesia combined with general anaesthesia results in faster recovery and fewer complications but does not affect length of hospital stay. Interact Cardiovasc Thorac Surg. 2006;5:207-216. [PubMed]
 
Priestley MC, Cope L, Halliwell R, et al. Thoracic epidural anesthesia for cardiac surgery: the effects on tracheal intubation time and length of hospital stay. Anesth Analg. 2002;94:275-282. [PubMed]
 
Royse C, Royse A, Soeding P, et al. Prospective randomized trial of high thoracic epidural analgesia for coronary artery bypass surgery. Ann Thorac Surg. 2003;75:93-100. [PubMed]
 
Tenling A, Joachimsson PO, Tyden H, et al. Thoracic epidural anesthesia as an adjunct to general anesthesia for cardiac surgery: effects on ventilation-perfusion relationships. J Cardiothorac Vasc Anesth. 1999;13:258-264. [PubMed]
 
Landoni G. Epidural anesthesia and analgesia in cardiac surgery. Minerva Anestesiol. 2008;74:617-618. [PubMed]
 
Ho AM, Chung DC, Joynt GM. Neuraxial blockade and hematoma in cardiac surgery: estimating the risk of a rare adverse event that has not (yet) occurred. Chest. 2000;117:551-555. [PubMed]
 
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543