Epidural anesthesia with fentanyl resulted in fewer postoperative arterial thrombotic complications (5 events) compared to general anesthesia with morphine (17 events).
RCT (n=95)
Does epidural anesthesia with epidural fentanyl reduce postoperative arterial thrombosis and improve fibrinolysis compared to general anesthesia with intravenous morphine in patients undergoing elective lower extremity vascular reconstruction?
Epidural anesthesia combined with epidural fentanyl prevents postoperative inhibition of fibrinolysis and may decrease the risk of arterial thrombotic complications compared to general anesthesia in patients undergoing lower extremity revascularization.
BACKGROUND: The purpose of this clinical trial was to compare the effects of different anesthetic and analgesic regimens on hemostatic function and postoperative arterial thrombotic complications. METHODS: Ninety-five patients scheduled for elective lower extremity vascular reconstruction were randomized to receive either epidural anesthesia followed by epidural fentanyl (RA) or general anesthesia followed by intravenous morphine (GA). Intraoperative and postoperative care were controlled by protocol using predetermined limits for heart rate, blood pressure, and other monitoring criteria. Data collection included serial physical examinations, electrocardiograms, and cardiac isoenzymes to detect arterial thrombosis (defined as unstable angina, myocardial infarction, or vascular graft occlusion requiring reoperation). Fibrinogen, plasminogen activator inhibitor-1 (PAI-1), and D-dimer levels were measured preoperatively and at 24 and 72 h postoperatively. RESULTS: Preoperative fibrinogen levels were similar in both groups, remained unchanged after 24 h, and increased equally (45%) in the first 72 h postoperatively. PAI-1 levels in the GA group increased from 13.6 +/- 2.1 activity units (AU)/ml to 20.2 +/- 2.6 AU/ml at 24 h and returned to baseline at 72 h. In contrast, PAI-1 levels in the RA group remained unchanged over time. Twenty-two of 95 patients (23%) had postoperative arterial thrombosis, 17 of whom had received GA and 5 of whom, RA. Preoperative PAI-1 levels were higher in patients who developed postoperative arterial thrombosis (20.5 +/- 3.6 AU/ml vs. 11.2 +/- 1.4 AU/ml). Multiple logistic regression analysis indicated that GA and preoperative PAI-1 levels were predictive of postoperative arterial thrombotic complications. CONCLUSIONS: Impaired fibrinolysis may be related causally to postoperative arterial thrombosis. Because RA combined with epidural fentanyl analgesia appears to prevent postoperative inhibition of fibrinolysis, this form of perioperative management may decrease the risk of arterial thrombotic complications in patients undergoing lower extremity revascularization.
Rosenfeld et al. (Wed,) conducted a rct in Elective lower extremity vascular reconstruction (n=95). Epidural anesthesia followed by epidural fentanyl (RA) vs. General anesthesia followed by intravenous morphine (GA) was evaluated on Postoperative arterial thrombosis (unstable angina, myocardial infarction, or vascular graft occlusion requiring reoperation). Epidural anesthesia with fentanyl resulted in fewer postoperative arterial thrombotic complications (5 events) compared to general anesthesia with morphine (17 events).