PRO-CONTRA DEBATE GENERAL ANAESTHESIA VS REGIONAL ANAESTHESIA IN

PATIENTS WITH CARDIAC PROBLEM IN NON CARDIAC SURGERY

Dr I Gusti Ngurah Artika SpAn KAKV

ABSTRACT

Administering anaesthesia to patients with preexisting cardiac disease is an interesting

challenge. IHD is number one cause of morbidity and mortality all over world. Among the
estimated 25 million patients in the United States who undergo each year, approximately 7
million are considered to be at high risk of IHD. These patients require identification of risk
factors, pre-operative evaluation & optimization, medical therapy, monitoring and the choice of
appropriate anaesthetic technique and drugs.1
Surgery and anesthesia cause significant stress on the cardiovascular system. The goals of
preoperative evaluation are to identify patients who would benefit from treatment of heart
disease prior to surgery, to provide assessment of cardiac risk prior to surgery, to determine the
level of perioperative vigilance requires and to initiate health maintenance.2
The impact of general versus regional anaesthesia on outcome in high-risk patients
undergoing non cardiac surgery has been tested in several large randomized controlled trials, all
of which failed to demonstrate a significant effect on perioperative mortality. Use of epidural
analgesia in the postoperative period was associated with reduced time to extubation and with
reduced pulmonary complications. In one study a post-hoc analysis of patients undergoing
abdominal aortic repair suggested a significantly lower incidence of death and major
complications in patients who had received epidural anesthesia. A meta-analysis of perioperative
outcomes after regional versus general anaesthesia concluded that perioperative deaths and major
complications were decreased in patients receiving regional anaesthesia.3
Recently published work suggests that appropriate analgesia may have an impact on
major perioperative complications. The preoperative institution of epidural analgesia was
associated with a reduced incidence of ischaemic episodes and of MI and death. 3 All anaesthetic
techniques must aim to keep myocardial oxygen supply greater than demand, and therefore avoid
ischaemia. The skill with which the anaesthetic is selected and delivered is more important than
the drugs used.4
Table 1. Cardiac and vascular outcomes in studies of regional vs general anesthesia in patients undergoing vascular surgery5

CHF (%) MI (%) Death (%) Vascular Graft

Occlusion (%)
Author n RA GA RA GA RA GA RA GA
Tuman et al 80 5 10 0 8 0 0 3 20
Baron et al 173 6 8 6 6 3 5 - -
Christoperson et al 100 - - 4 4 2 2 4 20
Bois et al 124 5 0 4 8 0 0 - -

References

1. Kaul TJ, Tayal G, Anaesthetic considerations in cardiac patients undergoing non cardiac
surgery, Indian Journal of Anaesthesia, 2007; 51 : 280-286
2. Bready LL, Dillman D, Noorily SH, Preoperative Cardiac Problems, Decision Making in
Anesthesiology, 4th edition, 2007; 43 : 120-123
3. Stevens RD, Strategies in the high-risk cardiac patient undergoing non-cardiac surgery,
Best Practice & Research Clinical Anaesthesiology, 2004 ; 18 : 549-563
4. Koh SH, Rogers J, Anaesthesia for patients with cardiac disease undergoing non-cardiac
surgery, Update in Anaesthesia, 2003: 11-17
5. Estafanous FG, Barash PG, Reves JG, The Cardiac Patient and anesthesia for noncardiac
surgery, Cardiac Anesthesia, 2nd edition, 2001 ; 6 : 911-929