Jean-François Olivier

A novel approach for pain management in cardiac surgery via median sternotomy: bilateral single-shot paravertebral blocks.

Regional analgesia has entered cardiac anesthesia in the form of spinal or epidural analgesia. However, the risk of spinal or epidural hematoma is a constant worry. Alternative regional techniques might be applicable in cardiac surgery. The purpose of this study is to present a novel technique of bilateral single-shot paravertebral blocks (BSS-PVB) for cardiac surgery via median sternotomy and compare its efficacy versus high thoracic epidural analgesia (TEA). Fifty-two patients were compared in this prospective cohort audit. In 26 patients, cardiac surgery was performed using low-dose fentanyl/BSS-PVB (bilateral blocks of 3 mL bupivacaine 0.5% each, T1-7) and general anesthesia; in another 26 patients, TEA (bupivacaine 0.125% at 10 mL/hour) and general anesthesia were used. Patients were assigned to cohorts according to their preoperative data and types of surgery. All patient data are shown as mean +/- SD; pain scores were compared between groups using the t test immediately, 6 hours, and 24 hours after surgery (P < .05). In the BSS-PVB-group (19 men, 7 women), mean age was 65 +/- 11 years, weight 74 +/- 16 kg, ejection fraction 59% +/- 12%, and duration of surgery 130 +/- 27 minutes; in the TEA-group (17 men, 9 women), mean age was 63 +/- 10 years, weight 75 +/- 16 kg, ejection fraction 58% +/- 12%, and duration of surgery 113 +/- 27 minutes. These data and preoperative comorbidity variables were not significantly different between the two groups. In each group, 18 patients underwent off-pump coronary artery bypass grafting, 3 on-pump and 5 mitral valve replacements. All patients were successfully immediately extubated. Postoperative pain scores were at any point significantly lower with TEA, immediately at 2.4 +/- 2.2 versus 3.7 +/- 2.6, at 6 hours at 1.1 +/- 1.5 versus 2.4 +/- 1.8, and at 24 hours at 1.0 +/- 1.4 versus 2.3 +/- 1.6 (0 = no pain, 10 = maximum pain). There was no complications related to epidural catheter placement or BSS-PVB. Using both techniques, immediate extubation after cardiac surgery is feasible; TEA provides better pain relief after cardiac surgery than BSS-PVB.

Comparison of Three Different Epidural Solutions in Cardiac Surgery for Stress Protection

Background: Different solutions are possible for thoracic epidural analgesia in cardiac surgery. So far, local an- esthetics alone or in combination with either clonidine or opioids have been used. Aims: To determine the stress protection provided by different epidural solutions throughout cardiac surgery. Study Design: A randomized, prospective, double blind study in patients undergoing off-pump coronary artery bypass grafting (OPCAB), randomized in three different groups. Thoracic epidural analgesia was installed more than 1 h before application of heparin at levels of T2 to T4; analgesia was provided by 8 ml of bupivacaine 0.25% 15 min prior to surgery and extubation, and 10 ml/h during and up to 72 h after surgery using one of the following regimens: bupivacaine 0.125% solely, bupivacaine 0.125% with fentanyl 3 � g/mL or bupivacaine 0.125% with clonidine 0.6 � g/mL. Patients were block- randomized for one of the three treatments. Cortisol and glucose values were determined before surgery, at extubation and 1h and 3h after surgery. Pain scores were assessed up to 48 h after surgery. Hemodynamic stability was also recorded in form of heart rate, systolic and diastolic blood pressure. Multi-comparison ANOVA and Chi-square test were used to compare the data, presented as mean (SD) or median (25 th and 75 th percentile), P < 0.05. Study Setting: A cardiac surgery unit at a tertiary university hospital. Participants: Forty-two patients undergoing OPCAB were enrolled. Main Results: All patient data as well hemodynamic stability were not different between the three groups. All patients were successfully extubated in theatre immediately after surgery. Pain control was good and not significantly different be- tween the groups. Mean glucose concentrations ± SD before surgery and (significantly higher) 3h after surgery were 5.4 ± 1.0 mmol l -1 and 8.4 ± 1.6 mmol l -1 for bupivacaine alone, 5.2 ± 0.5 mmol l -1 and 8.5 ± 2.2 mmol l -1 for bupivacaine plus fentanyl and 5.5 ± 1.6 mmol l -1 and 9.5 ± 2.1mmol l -1 for bupivacaine and clonidine, respectively. The mean cortisol val- ues ± SD in the pre-operative period and 3h after surgery were 413 ± 162 nmol l -1 and 562 ± 173 nmol l -1 for bupivacaine alone, 393 ± 107 nmol l -1 and 581 ± 265 nmol l -1 for bupivacaine and fentanyl and 409 ± 159 nmol l -1 and 570 ± 160 nmol l -1 for bupivacaine and clonidine, respectively. There were no significant differences between the groups. Conclusions: We conclude that short-term stress protection with TEA is equally effective with solely bupivacaine, bupivacaine with fentanyl or clonidine.

Para-vertebral block versus epidural anesthesia in ultra fast track cardiac surgery

INTRODUCTION: Epidural anesthesia provides superior analgesia, better respiratory outcome and myocardial protection after cardiac surgery (1,2) but is at risk of epidural hematoma. Paravertebral block related hematoma may have less consequences and anesthesiologists may feel more comfortable with this technique. The aim of this study is to compare the analgesia provided by high thoracic epidural analgesia (Epidural group) versus single-shot para-vertebral blocks (PVB group) after cardiac surgery using an ultra-fast track strategy.

Stress protection of different solutions of thoracic epidural anesthesia for immediate extubation after off-pump cardiac surgery (OPCAB)

METHODS: Forty-two non-diabetic patients undergoing OPCAB were enrolled in this study. TEA was installed more than 1 h before application of heparine at levels of T2 to T4; analgesia was provided by 8 ml of bupivacaine 0.25% 15 min prior to surgery and extubation, and 10 ml/h during and up to 72 h after surgery of one of the following regimens: bupivacaine 0.125% solely, bupivacaine 0.125% with fentanyl 3 μg/ml or bupivacaine 0.125% with clonidine 0.6 μg/ml. Patients were block-randomized for one of the three treatments. Patient data, cortisol and glucose levels were compared. Multi-comparison ANOVA was used to compare the data, P < 0.05.

Immediate extubation after cardiac surgery as routine: Experience of more than 500 patients

METHODS: Five hundred and eight patients undergoing cardiac surgery with an ejection fraction of at least 25 % were included in this prospectiveaudit. Patients received one of the three regimens of analgesia: analgesia based A) on TEA B) on fentanyl during surgery and po. PCA-morphine or C) bilateral paravertebral blocks + fentanyl during surgery followed by PCA morphine. Anesthesia was induced using fentanyl 2-3 μg/kg, propofol 1-2 mg/kg, and maintained using sevoflurane titrated to a BIS of 40-50. All patient data were recorded; pain scores were compared between the analgesic groups using Kruskal Wallis test, P < 0.05.

Comparison of myocardiac protection of isoflurane versus sevoflurane in ultra fast track anesthesia in off-pump aorto-coronary bypass grafting (OPCAB)-a pilot study

INTRODUCTION: Volatile anesthetics provide protection against myocardial ischemia by pharmacologic preconditioning. So far, studies have focused on the effects and outcome of volatile anesthetics and not on comparing different agents. In this randomized, prospective study, we compare the cardioprotective propensities of sevoflurane versus isoflurane OPCAB with the hypothesis that sevoflurane offers superior myocardial protection.