Regional Anesthetic Techniques

Although intrathecal and epidural anesthetic techniques have well-recognized desirable effects on the stress response, hemodynamics, coronary perfusion pressure, myocardial blood flow redistribution, and the potential for early extubation,^{[190] [191] [192]} their use in cardiac anesthesia is not widespread, in large part because of anticoagulation concerns and the potential for hematoma formation in the neuraxis. Moreover, these techniques need to be undertaken preoperatively. However, in one recently published excellent study, epidurals were administered on the day of surgery to patients receiving anticoagulants, and no clinical epidural hematomas were detected.^[193] As in noncardiac anesthesia, these techniques have their own specific side effects, such as hypotension and pruritus. In the optimal medicolegal and economic (allowing preoperative insertion) environments, neuraxial anesthesia could be a useful adjunct in certain patients undergoing cardiac surgery (e.g., those with compromised pulmonary function). Indeed, it is a relatively common practice in some environments. However, most practitioners in North America choose to not use these techniques in circumstances in which reasonable alternatives are available. One commentary^[194] on this topic suggests reserving this approach (specifically, epidurals) until the postoperative period and then using them only if conventional approaches fail (e.g., ventilator weaning in patients receiving systemic opioids) and when coagulation parameters are normal.