Technical aspects of high thoracic epidural analgesia in cardiac surgery

This review focuses on technical aspects of high thoracic epidural analgesia (TEA) when used in conjunction with general anesthesia for patients undergoing cardiac surgery. Several issues are discussed: the type of surgery, the importance of anticoagulation, and the timing of the TEA insertion. In addition, practical concerns, such as the type and dose of local anesthetics and possible adjuncts, the duration of TEA treatment, the interaction between TEA and postoperative anticoagulation, or the consequence of inadvertent bloody tap, are presented. This author proposes the insertion of the thoracic epidural catheter at least 1 hour before heparinization, in the high thoracic region via median approach. Correct positioning of the catheter, which should be fixed with a secure dressing device, can be achieved via the injection of 2 mL lidocaine 1% with epinephrine 1:200,000. Should a bloody tap occur, a distinction between venous and arterial origin should be made and surgery postponed for at least 24 hours, only in the case of arterial tap. Trouble-shooting for commonly encountered problems with TEA in cardiac surgery is outlined as well as management of suspected epidural hematoma.