High thoracic epidural anaesthesia for cardiac surgery

Purpose of review Epidurals have been used for cardiac surgery for more than 20 years. The worldwide-published use is now large enough to determine that there is no additional risk for epidural use in cardiac versus noncardiac surgery. Recent findings Several large case series have been added to the literature without cases of spinal damage. The estimated risk of epidural haematoma is 1 :12 000 (95% confidence interval of 1 : 2100 to 1 : 68000), which is comparable to noncardiac surgery. The fear of an increased risk of epidural haematoma associated with cardiopulmonary bypass has not eventuated. Improved analgesia, reduced pulmonary complications and reduced atrial fibrillation in off-pump coronary surgery have been reported. There are some case series and numerous case reports of awake cardiac surgery performed under epidural anaesthesia. This review will focus on safety, benefits and the logistics of performing epidural anaesthesia for cardiac surgery. Summary Fear of an increased risk of epidural haematoma has largely prevented increased use of this technique for cardiac surgery. Clinicians can be reassured that the risk of epidural use in cardiac surgery is similar to that for noncardiac surgery, which provides a new platform for considering risk versus benefit in their practice.