Epidural infusion of bupivacaine and fentanyl reduces perioperative myocardial ischaemia in elderly patients with hip fracture - a randomized controlled trial

Background: Perioperative myocardial ischaemia is an important risk factor for cardiac morbidity and mortality after noncardiac surgery. The impact of analgesic management on the incidence and severity of cardiac ischemia was studied in 77 elderly patients undergoing surgical treatment of traumatic hip fracture. Methods: After hospital admission and written consent, patients were random ised to conventional analgesic regimen (intramuscular oxycodone, OPI group) or continuous epidural infusion of bupivacaine/fentanyl (EPI group). The a nalgesic regimens were started preoperatively. patients were operated under spinal anaesthesia and the treatments were continued three days postoperat ively. ECG was continuously recorded. ST segment depression of greater than or equal to 0.1 mV or elevation of greater than or equal to 0.2 mV lasting greater than or equal to 1 min were considered as ischaemic episodes. Noct urnal arterial oxygen saturation (SaO2) was recorded perioperatively, and s ubjective pain was assessed Every morning using a visual analogue scale (VA S). Results: Fifty-nine (OPI 30, EPI 29) patients were evaluable for efficacy. Thirteen patients (43%) in the OPI and 12 patients (41%) in the EPT group h ad ischaemic episodes (NS). However, significantly more patients in the OPI group had ischaemic episodes during the surgery (8 vs. 0 in the EPI group, P=0.005). The median (quartal deviation) total ischaemic burden (i.e. inte gral of ST-change vs. time) in patients with ischaemic episodes was ten tim es larger in the OPI group (340 [342] mm.min) compared with the EPI group ( 30 [36] mm.min) (P=0.002). There were no significant differences between th e groups in average heart rates or in heart rates at the start of ischaemic episodes or in maximal heart rates during the attacks. Average nocturnal S aO2 was similar in the two groups and there were no differences in the numb er of hypoxaemic (SaO2<90%) episodes. Preoperatively there were no differen ces in subjective pain, but postoperative and average perioperative VAS sco res for pain were almost 40% lower in the EPI group (P=0.006). Perioperativ e myocardial infarctions were not detected. Conclusions: Continuous epidural bupivacaine/fentanyl analgesic regimen, st arted preoperatively, reduces the amount of myocardial ischaemia in elderly patients with hip fracture.