EPIDURAL ANALGESIA AND INTRAVENOUS PATIENT-CONTROLLED ANALGESIA RESULT IN SIMILAR RATES OF POSTOPERATIVE MYOCARDIAL-ISCHEMIA AFTER AORTIC-SURGERY

To assess the role of postoperative analgesia on myocardial dial ische mia after aortic surgery, we compared intravenous patient-controlled a nalgesia (PCA) with thoracic epidural analgesia (TEA). One hundred twe nty-four patients were prospectively randomized to the PCA or TEA grou p. in the TEA group, a T6-7 or T7-8 epidural catheter was inserted bef ore the induction of general anesthesia. Within Ih of the end of surge ry, analgesia and 24-h two-channel Holter monitoring were begun. Myoca rdial ischemia was defined as ST segment depression greater than or eq ual to 1 mm, 0.06 s after the J point, and lasting for more than 1 min . In the PCA group, a bolus of morphine, 0.05 mg/kg, was given, follow ed by 0.02 mg/kg of morphine on demand every 10 min. Bupivacaine 0.125 % and fentanyl 10 mu g/mL was used in the TEA group. Analgesics were t itrated to maintain a visual analog scale score less than or equal to 3. The overall incidence of myocardial ischemia was 18.4%-18.2% for TE A and 18.6% for PCA (P = not significant). There were no differences b etween the groups in the total duration of ischemia per patient (22.2 +/- 119.8 min for TEA and 20.5 +/- 99 min for PCA) and the number of e pisodes per patient (0.69 +/- 2.1 for TEA and 1.2 +/- 4.9 for PCA). Tw enty-three patients had an adverse cardiac outcome, although there wer e no differences between the groups. The postoperative pain control wa s superior with TEA. In these patients undergoing elective aortic surg ery, the use of postoperative TEA did not result in a lower incidence of early myocardial ischemia compared with intravenous PCA with morphi ne, despite better analgesia with TEA. Implications: Postoperative myo cardial ischemia is associated with adverse cardiac outcome. Using Hol ter monitoring after aortic surgery, this study shows that the use of thoracic epidural analgesia with bupivacaine and fentanyl did not resu lt in a lower incidence of myocardial ischemia compared with intraveno us patient-controlled analgesia with morphine.