Spinal analgesia in cardiac surgery: a meta-analysis of randomized controlled trials.

OBJECTIVE Controversial results exist on the effects of spinal analgesia in cardiac surgery. The authors conducted a review of randomized studies to show whether there are any advantages in clinically relevant outcomes using spinal analgesia in patients undergoing cardiac surgery. DESIGN Meta-analysis. SETTING Multiple hospitals. PARTICIPANTS A total of 1,106 patients from 25 randomized trials. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULT PubMed, BioMedCentral, CENTRAL, EMBASE, Cochrane Central Register of Controlled Trials, and conference proceedings were searched (updated January 2009) for randomized trials that compared general anesthesia with an anesthetic plan including spinal analgesia in cardiac surgery. Four independent reviewers performed data extraction, with divergences resolved by consensus. A total of 1,106 patients from 25 randomized studies were included in the analysis. Overall analysis showed that there were no differences in terms of mortality (2/562 [0.4%] in the spinal group v 2/514 [0.4%] in the control arm [risk difference (RD) = 0.00 [-0.02, +0.02], p = 1.0), perioperative myocardial infarction (9/421 [2.1%] in the spinal group v 11/407 [2.7%] in the control arm [RD = 0.00, -(0.03, +0.02), p = 0.77), and the length of hospital stay (WMD = -0.28 days [-0.68, -0.13], p = 0.18, with 419 included patients). CONCLUSIONS This analysis indicated that spinal analgesia does not improve clinically relevant outcomes in patients undergoing cardiac surgery, discouraging further randomized controlled trials on this topic even if changes in techniques, devices, and drugs could modify the outlook of the comparison between spinal and standard anesthesia in this setting.

[1]  G. Biondi-Zoccai,et al.  Volatile anesthetics reduce mortality in cardiac surgery. , 2009, Journal of cardiothoracic and vascular anesthesia.

[2]  M. Tapia,et al.  Fast-track anesthesia with remifentanil and spinal analgesia for cardiac surgery: the effect on pain control and quality of recovery. , 2008, Journal of cardiothoracic and vascular anesthesia.

[3]  Elena Bignami,et al.  Desflurane and sevoflurane in cardiac surgery: a meta-analysis of randomized clinical trials. , 2007, Journal of cardiothoracic and vascular anesthesia.

[4]  R. Moore,et al.  DNA aneuploidy in early breast cancer. , 1995, British Journal of Cancer.

[5]  M. Lamy,et al.  The use of pre‐operative intrathecal morphine for analgesia following coronary artery bypass surgery , 2006, Anaesthesia.

[6]  A. Martínez-Escribano,et al.  [Postoperative analgesia in cardiac surgery: spinal versus intravenous morphine]. , 2006, Revista espanola de anestesiologia y reanimacion.

[7]  E. Romagnoli,et al.  Compliance with QUOROM and quality of reporting of overlapping meta-analyses on the role of acetylcysteine in the prevention of contrast associated nephropathy: case study , 2006, BMJ : British Medical Journal.

[8]  G. Turker,et al.  Combination of intrathecal morphine and remifentanil infusion for fast-track anesthesia in off-pump coronary artery bypass surgery. , 2005, Journal of cardiothoracic and vascular anesthesia.

[9]  H. Tymkew,et al.  Cardiothoracic Anesthesia, Respiration and Airway , 2005 .

[10]  M. Tapia,et al.  Fast-track coronary artery bypass grafting surgery under general anesthesia with remifentanil and spinal analgesia with morphine and clonidine. , 2005, Journal of cardiothoracic and vascular anesthesia.

[11]  F. Burzotta,et al.  A simple hint to improve Robinson and Dickersin's highly sensitive PubMed search strategy for controlled clinical trials. , 2004, International journal of epidemiology.

[12]  M. Kapoor,et al.  Epidural hematoma complicating high thoracic epidural catheter placement intended for cardiac surgery. , 2004, Journal of cardiothoracic and vascular anesthesia.

[13]  Christopher L. Wu,et al.  Effects of Perioperative Central Neuraxial Analgesia on Outcome after Coronary Artery Bypass Surgery: A Meta-analysis , 2004, Anesthesiology.

[14]  Y. Mehta,et al.  Spinal (subarachnoid) morphine for off-pump coronary artery bypass surgery. , 2004, The heart surgery forum.

[15]  D. Rosen,et al.  An epidural hematoma in an adolescent patient after cardiac surgery. , 2004, Anesthesia and analgesia.

[16]  G. Biondi-Zoccai,et al.  Parallel hierarchy of scientific studies in cardiovascular medicine. , 2003, Italian heart journal : official journal of the Italian Federation of Cardiology.

[17]  F. Bonnet,et al.  Intrathecal morphine and clonidine for coronary artery bypass grafting. , 2003, British journal of anaesthesia.

[18]  H. Grocott,et al.  High Spinal Anesthesia for Cardiac Surgery: Effects on &bgr;-Adrenergic Receptor Function, Stress Response, and Hemodynamics , 2003, Anesthesiology.

[19]  R. Rosenquist,et al.  Regional Anesthesia in the Anticoagulated Patient: Defining the Risks (The Second ASRA Consensus Conference on Neuraxial Anesthesia and Anticoagulation) , 2003, Regional Anesthesia & Pain Medicine.

[20]  Judith E. Hall,et al.  A combination of intrathecal morphine and remifentanil anesthesia for fast-track cardiac anesthesia and surgery. , 2002, Journal of cardiothoracic and vascular anesthesia.

[21]  M. Choinière,et al.  Intrathecal Morphine after Cardiac Surgery , 2002, The Annals of pharmacotherapy.

[22]  E. Schmid,et al.  Intrathecal sufentanil-morphine shortens the duration of intubation and improves analgesia in fasttrack cardiac surgery , 2002, Canadian journal of anaesthesia = Journal canadien d'anesthesie.

[23]  Anthony Rodgers,et al.  Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials , 2000, BMJ : British Medical Journal.

[24]  P. White,et al.  Fast-track cardiac anesthesia: a comparison of remifentanil plus intrathecal morphine with sufentanil in a desflurane-based anesthetic. , 2000, Journal of cardiothoracic and vascular anesthesia.

[25]  M. Sharpe,et al.  Effect of subarachnoid morphine administration on extubation time after coronary artery bypass graft surgery. , 2000, Journal of cardiothoracic and vascular anesthesia.

[26]  P. White,et al.  Fast-Track Cardiac Anesthesia: Use of Remifentanil Combined with Intrathecal Morphine as an Alternative to Sufentanil During Desflurane Anesthesia , 2000, Anesthesia and analgesia.

[27]  R. Hall,et al.  Does intrathecal morphine alter the stress response following coronary artery bypass grafting surgery? , 2000, Canadian journal of anaesthesia = Journal canadien d'anesthesie.

[28]  A. Ho,et al.  Neuraxial blockade and hematoma in cardiac surgery: estimating the risk of a rare adverse event that has not (yet) occurred. , 2000, Chest.

[29]  I. Olkin,et al.  Improving the quality of reports of meta-analyses of randomised controlled trials: the QUOROM statement , 1999, The Lancet.

[30]  M. Chaney,et al.  Intrathecal morphine for coronary artery bypass graft procedure and early extubation revisited. , 1999, Journal of cardiothoracic and vascular anesthesia.

[31]  G. A. Rooke,et al.  Effects of intrathecal opioid on extubation time, analgesia, and intensive care unit stay following coronary artery bypass grafting. , 1997, Journal of clinical anesthesia.

[32]  M. Chaney,et al.  Intrathecal Morphine for Coronary Artery Bypass Grafting and Early Extubation , 1997, Anesthesia and analgesia.

[33]  M. Chaney,et al.  Large-Dose Intrathecal Morphine for Coronary Artery Bypass Grafting , 1996, Anesthesia and analgesia.

[34]  D. Moriarty,et al.  Intrathecal morphine in the management of pain following cardiac surgery. A comparison with morphine i.v. , 1988, British journal of anaesthesia.

[35]  G. Vanstrum,et al.  Postoperative Effects of Intrathecal Morphine in Coronary Artery Bypass Surgery , 1988, Anesthesia and analgesia.

[36]  J. Ramsay,et al.  The role of intrathecal morphine in the anesthetic management of patients undergoing coronary artery bypass surgery. , 1987, Journal of cardiothoracic anesthesia.

[37]  T. M. Savege,et al.  Intrathecal morphine in cardiac surgery. , 1985, European journal of anaesthesiology.

[38]  P. Sebel,et al.  Endocrinological effects of intrathecal morphine. , 1985, European journal of anaesthesiology.