Epidural analgesia for adults undergoing cardiac surgery with or without cardiopulmonary bypass

Objectives

Epidural analgesia versus systemic analgesia

Trials show there may be no difference in mortality at 0 to 30 days (risk difference (RD) 0.00, 95% confidence interval (CI) −0.01 to 0.01; 38 trials with 3418 participants; low‐quality evidence), and there may be a reduction in myocardial infarction at 0 to 30 days (RD −0.01, 95% CI −0.02 to 0.00; 26 trials with 2713 participants; low‐quality evidence). Epidural analgesia may reduce the risk of 0 to 30 days respiratory depression (RD −0.03, 95% CI −0.05 to −0.01; 21 trials with 1736 participants; low‐quality evidence). There is probably little or no difference in risk of pneumonia at 0 to 30 days (RD −0.03, 95% CI −0.07 to 0.01; 10 trials with 1107 participants; moderate‐quality evidence), and epidural analgesia probably reduces the risk of atrial fibrillation or atrial flutter at 0 to 2 weeks (RD −0.06, 95% CI −0.10 to −0.01; 18 trials with 2431 participants; moderate‐quality evidence). There may be no difference in cerebrovascular accidents at 0 to 30 days (RD −0.00, 95% CI −0.01 to 0.01; 18 trials with 2232 participants; very low‐quality evidence), and none of the included trials reported any epidural haematoma events at 0 to 30 days (53 trials with 3982 participants; low‐quality evidence). Epidural analgesia probably reduces the duration of tracheal intubation by the equivalent of 2.4 hours (standardized mean difference (SMD) −0.78, 95% CI −1.01 to −0.55; 40 trials with 3353 participants; moderate‐quality evidence). Epidural analgesia reduces pain at rest and on movement up to 72 hours after surgery. At six to eight hours, researchers noted a reduction in pain, equivalent to a reduction of 1 point on a 0 to 10 pain scale (SMD −1.35, 95% CI −1.98 to −0.72; 10 trials with 502 participants; moderate‐quality evidence). Epidural analgesia may increase risk of hypotension (RD 0.21, 95% CI 0.09 to 0.33; 17 trials with 870 participants; low‐quality evidence) but may make little or no difference in the need for infusion of inotropics or vasopressors (RD 0.00, 95% CI −0.06 to 0.07; 23 trials with 1821 participants; low‐quality evidence).

Epidural analgesia versus other comparators

Fewer studies compared epidural analgesia versus peripheral nerve blocks (four studies), intrapleural analgesia (one study), and wound infiltration (one study). Investigators provided no data for pulmonary complications, atrial fibrillation or flutter, or for any of the comparisons. When reported, other outcomes for these comparisons (mortality, myocardial infarction, neurological complications, duration of tracheal intubation, pain, and haemodynamic support) were uncertain due to the small numbers of trials and participants.

Authors’ conclusions

Compared with systemic analgesia, epidural analgesia may reduce the risk of myocardial infarction, respiratory depression, and atrial fibrillation/atrial flutter, as well as the duration of tracheal intubation and pain, in adults undergoing cardiac surgery. There may be little or no difference in mortality, pneumonia, and epidural haematoma, and effects on cerebrovascular accident are uncertain. Evidence is insufficient to show the effects of epidural analgesia compared with peripheral nerve blocks, intrapleural analgesia, or wound infiltration.