Original article
Epidural Analgesia Improves Outcome in Cardiac Surgery: A Meta-analysis of Randomized Controlled Trials

https://doi.org/10.1053/j.jvca.2009.09.015Get rights and content

Objective

The authors conducted a review of randomized studies to determine whether there were any advantages for clinically relevant outcomes by adding epidural analgesia in patients undergoing cardiac surgery under general anesthesia.

Design

Meta-analysis.

Setting

Hospitals.

Participants

A total of 2366 patients from 33 randomized trials.

Interventions

None.

Measurements and Main Results

Data sources and study selection: PubMed, BioMedCentral, CENTRAL, EMBASE, Cochrane Central Register of Controlled Trials, and conference proceedings were searched (updated January 2008) for randomized trials that compared general anesthesia with an anesthetic plan including general anesthesia and epidural analgesia in cardiac surgery. Two independent reviewers appraised study quality, with divergences resolved by consensus. Overall analysis showed that epidural analgesia reduced the risk of the composite endpoint mortality and myocardial infarction (30/1125 [2.7%] in the epidural group v 64/1241 [5.2%] in the control arm, odds ratio [OR] = 0.61 [0.40-0.95], p = 0.03 number needed to treat [NNT] = 40), the risk of acute renal failure (35/590 [5.9%] in the epidural group v 54/618 [8.7%] in the control arm, OR = 0.56 [0.34-0.93], p = 0.02, NNT = 36), and the time of mechanical ventilation (weighted mean differences = −2.48 hours [−2.64, −2.32], p < 0.001).

Conclusions

This analysis suggested that epidural analgesia on top of general anesthesia reduced the incidence of perioperative acute renal failure, the time on mechanical ventilation, and the composite endpoint of mortality and myocardial infarction in patients undergoing cardiac surgery.

Section snippets

Data Sources and Searches

Pertinent studies were independently searched in the Cochrane Central Register of Controlled Trials, BioMedCentral, CENTRAL, EMBASE, and PubMed (updated January 1, 2008) by 4 trained investigators. The full PubMed search strategy was developed according to Biondi-Zoccai et al40 and is available in their appendix. Further hand or computerized searches involved the recent (2005-2008) conference proceedings from the European Association of Cardiothoracic Anaesthesiologists, International

Results

Database searches, snowballing, and contacts with experts yielded a total of 691 citations (Fig 1). Excluding 643 nonpertinent titles or abstracts, the authors retrieved 48 studies in complete form and assessed according to the selection criteria. A total of 15 studies were further excluded because of their nonexperimental design, including the use of historic controls, or because of duplicate publication. Specifically, 10 studies were excluded because of duplicate publication,44, 45, 46, 47, 48

Discussion

The authors performed a meta-analysis of pooled data from several small, underpowered studies and showed that TEA does not decrease the rate of mortality or the rate of myocardial infarction after cardiac surgery even if it reduced the rate of acute renal failure, the time of mechanical ventilation, and the composite endpoint death/myocardial infarction. This is the first time that TEA has been shown to have an impact on clinically relevant endpoints in cardiac surgery. Given the low incidence

Conclusions

An anesthetic regimen including TEA does not appear to reduce mortality or myocardial infarction after cardiac surgery, but there is evidence of reductions in renal impairment, duration of postoperative ventilation, and the composite endpoint myocardial infarction/death. In view of the potential risks of epidural hematoma and paraplegia, while waiting for the realization of a large multicenter RCT powered to clinically relevant endpoints, TEA only should be used after careful consideration and

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