Full text of DOI:10.1007/BF03017451

7
11
Cardiothoracic Anesthesia, Respiration and Airway
Intrathecal sufentanil-morphine shortens the dura-
tion of intubation and improves analgesia in fast-
track cardiac surgery
[L’administration intrathécale combinée de sufentanil-morphine réduit la durée de
l’intubation et améliore l’analgésie lors d’une intervention cardiaque “fast-track”]
Dominique A. Bettex MD,* Daniel Schmidlin MD,* Pierre-Guy Chassot MD,† Edith R. Schmid MD*
Purpose: To compare the effect of combined intrathecal morphine
and sufentanil with low-dose iv sufentanil during propofol anesthe-
sia for fast-track cardiac surgery.
Méthode : Vingt-quatre patients consécutifs ayant une fonction car-
diopulmonaire dans les limites de la normale ont été admis en vue
d’une intervention cardiaque programmée et ont été randomisés en
deux groupes distincts : l’un recevant une perfusion iv continue de 0,9
à 1,8 µg·kg ·min de sufentanil (13 patients) et l’autre une dose
unique intrathécale de 50 µg de sufentanil et 500 µg de morphine (11
patients). Nous avons étudié prospectivement l’analgésie périopéra-
toire, le délai d’extubation et la capacité inspiratoire maximale
postopératoire dans ces deux groupes de patients. Aux soins intensifs,
le personnel soignant médical et paramédical ignoraient la technique
analgésique utilisée.
Methods: Twenty-four consecutive patients with normal car-
diopulmonary function who were scheduled for elective cardiac
surgery were randomized to receive either a continuous iv infusion
–1
–1
–
1
–1
of sufentanil 0.9 to 1.8 µg·kg ·min (13 patients), or a single lum-
bar intrathecal dose of sufentanil 50 µg and morphine 500 µg (11
patients). We prospectively studied perioperative analgesia, time to
extubation and early postoperative maximal inspiratory capacity in
the two groups. In the intensive care unit, the medical and nursing
staff were blinded to the analgesic technique.
Résultats : L’administration intrathécale de sufentanil et de mor-
phine a permis une extubation plus rapide (104 ± 56,5 min vs 213
Results: Intrathecal sufentanil morphine allowed a shorter duration
of intubation (104 ± 56.5 min vs 213 ± 104 min; P = 0.01),
reduced the need for postoperative analgesia with nicomorphine
±
104 min ; P = 0,01), une réduction des besoins analgésiques en
nicomorphine (puissance équivalente à la morphine) (0,7 ± 0,4
mg·h–1 vs 1,2 ± 0,4 mg·h ; P = 0,008) et une amélioration de la
capacité inspiratoire maximale postopératoire (53,4 ± 16,1 vs 38,4
–1
–
1
–1
(
equipotent to morphine) (0.7 ± 0.4 mg·hr vs 1.2 ± 0.4 mg·hr ;
P = 0.008) and improved postoperative maximal inspiratory capac-
ity (53.4 ± 16.1 vs 38.4 ± 12.5% of the norm; P = 0.05).
±
12,5 % de la norme ; P = 0,05).
Conclusion : Chez les patients à bas risque opératoire programmés
pour des pontages aortocoronariens ou un remplacement valvulaire
simple, l’administration intrathécale de morphine et sufentanil en dose
unique satisfait les critères de chirurgie cardiaque “fast-track”.
Conclusion: In low-risk patients undergoing coronary artery
bypass graft or valve surgery, combined intrathecal sufentanil and
morphine with a target-controlled infusion of propofol satisfies the
goals of fast-track cardiac surgery.
AST-TRACK cardiac surgery entails early
postoperative extubation with intense con-
trol of pain and rapid transfer to the ward
But : Comparaison de l’effet de l’administration intrathécale com-
binée de morphine et de sufentanil avec l’administration iv de sufen-
tanil lors d’une anesthésie à base de propofol pour la chirurgie
cardiaque “fast-track”.
F
and is mostly applied to patients who have
well-preserved pulmonary and ventricular function.
From the Divisions of Cardiovascular Anesthesia, University Hospital of Zürich,* Zürich; and the University Hospital of Lausanne,†
Lausanne, Switzerland.
Address correspondence to: Dr. Dominique A. Bettex, Division of Cardiovascular Anesthesia, USZ - Rämistrasse 100, CH – 8091
Zürich, Switzerland. Phone: +41 1 255 59 33; Fax: +41 255 45 61; E-mail: dominique.bettex@ifa.usz.ch
Accepted for publication February 26, 2002.
Revision accepted May 29, 2002.
CAN J ANESTH 2002 / 49: 7 / pp 711–717

712
CANADIAN JOURNAL OF ANESTHESIA
Among the reported advantages are fewer respiratory
complications, improved cardiac function and patient
comfort, reduced intensive care unit (ICU) require-
ments and shorter ICU and hospital duration of
stay.1 The use of volatile anesthetics or iv propofol in
combination with low-dose or short-acting opioids
sis; patients who required a reoperation, an emergency
procedure or a combined operation (CABG and valve
surgery, double valve replacement); patients with
severe hemodynamic, pulmonary, metabolic or renal
(dialysis) impairment; patients with neurologic or ver-
tebral pathology; and patients receiving preoperative
iv or subcutaneous heparin, coumadin derivatives,
aspirin less than seven days before operation, or nons-
teroidal anti-inflammatory drugs less than three days
before operation. By previous agreement with the sur-
geons, the surgery would be delayed 24 hr if a bloody
tap occurred. Bloody tap was defined as arterial blood
(blood-gas analysis) suctioned or running freely
through the spinal needle.
–2
(
fentanyl, alfentanil, remifentanil)3–4 results in early
extubation but requires supplemental analgesia in the
early postoperative period with frequent patient dis-
comfort or respiratory depression. The use of periop-
erative epidural anesthesia and analgesia allows intense
postoperative analgesia, stress-response attenuation
and thoracic cardiac sympathectomy with possible
5
reduction of the risk of myocardial ischemia.
However, this technique can be associated with unde-
sirable drug effects and increases the risk of epidural
hematoma formation.
Anesthesia protocol
Preoperative medications, except angiotensin-convert-
ing enzyme inhibitors, diuretics and digoxin, were
continued until the morning of surgery. One to two
hours before induction of anesthesia, all patients
received either oral flunitrazepam (1–2 mg) or mida-
zolam (7.5–15 mg). Prior to arrival in the operating
room, every patient was randomized using a classical
table of random numbers (Geigy Scientific Tables) to
receive either IT sufentanil and morphine (IT group)
or iv sufentanil (iv group).
Routine monitoring was instituted initially with 5-
lead electrocardiography (ECG), pulse oximetry (SpO2)
and radial artery pressure. Patients in the IT group were
then turned on their sides, and after standard sterile
preparation, a lumbar puncture at the L3–L4 or L2–L3
level was performed, with the use of a 25-gauge
Quincke-tipped spinal needle (Sprotte Standard
Needle, Pajunk, Germany). Every lumbar puncture was
done by the same anesthesiologist, and no more than
three attempts were allowed. Once clear cerebrospinal
fluid was obtained, preservative-free sufentanil 50 µg
and morphine 500 µg diluted in 6 mL of sodium chlo-
ride were injected into the IT space and the needle
removed. The patients were brought into the dorsal
decubitus position and anesthesia induced with a target-
controlled infusion of propofol (TCI-propofol; begin-
Intrathecal (IT) analgesia entails a lower risk of
6
hematoma formation than epidural access. IT mor-
phine allows intense postoperative analgesia but does
not cover the operative period and may cause pro-
7
longed ventilatory depression. IT sufentanil provides
8
intense and fast-onset analgesia and, along with IT
morphine, appears to be a suitable choice for fast-track
cardiac surgery.9
The aim of this prospective randomized study was
to assess the effect of intraoperative combined IT
sufentanil and morphine in comparison to low-dose iv
sufentanil in low-risk patients undergoing elective car-
diac surgery. Both anesthetic techniques were com-
bined with a target-controlled infusion of propofol.
Methods
Patient population and exclusion criteria
After approval of the Ethics Committee and written
informed consent, patients with well-preserved ven-
tricular function (ejection fraction 40%) and pul-
monary function [forced expiratory volume in one
second (FEV ) and ratio of FEV and forced vital
1
1
capacity (Tiffenau ratio) > 80% of predictive values]
who were scheduled for elective coronary artery
bypass graft (CABG) surgery or valve surgery under
cardiopulmonary bypass (CPB) participated in the
study. Surgery was scheduled in the early morning
because of the risk of delayed extubation with late
admission into the ICU.10 Normal coagulation tests
–1
ning with a target dose of 1.5 µg·mL and gradually
increasing, according to patient hemodynamic
response, to a maximal target dose of 3 µg·mL ), pan-
–1
–1
curonium 0.1 mg·kg and a bolus dose of iv sufentanil
–1
(
prothrombin time, partial thromboplastin time,
0.5 µg·kg . The time between lumbar puncture and
anesthesia induction was kept as short as possible, to
avoid patient discomfort through the early appearance
of pruritus, thoracic rigidity or respiratory depression
secondary to IT sufentanil. Maintenance of anesthesia
was ensured with TCI-propofol; no further iv opioids
were given. Anesthesia in patients in the iv group was
thrombin time, fibrinogen, platelet count > 100,000
–1
mL ) and no history of abnormal bleeding or known
coagulation disorders were required. The following
patients were excluded: patients with mainstem coro-
nary artery stenosis, left ventricular ejection fraction <
40%, unstable angina or severe aortic or mitral steno-

Bettex et al.: COMBINED INTRATHECAL OPIOIDS IN CARDIAC SURGERY
713
–
1
induced with TCI-propofol (target dose, 1.5–3
imum of 30 min with a vital capacity > 12 mL·kg , res-
–1
–1
-1
µg··mL ), pancuronium 0.1 mg·kg and a bolus dose
piratory rate between 10 and 20 min , PaCO < 50
2
–1
of iv sufentanil 1 µg·kg . Continuous infusion of sufen-
mmHg, pH > 7.30 and PaO > 75 mmHg on a FIO <
2
2
–1
–1
–1
tanil was then begun: 1.8 µg·kg ·hr until CPB, fol-
40%) and minimal chest tube drainage (< 100 mL·hr ).
After extubation, the patients used a patient-controlled
analgesia device with nicomorphine (iv bolus of 2 mg
every eight minutes, maximum).
–1
–1
lowed by 0.9 µg·kg ·hr until closure of the chest. The
use of vasoactive substances as well as the occurrence of
ECG changes, arrhythmia or hemodynamic variations
of more than 20% of the awake values were observed by
an independent anesthesiologist and recorded.
11
A two-hour sedation score using the Ramsay scale
and a four-hour analgesic score [visual analogue scale
(VAS), 1–10] was recorded by the nurses in the ICU.
Patients were questioned regarding the occurrence of
pruritus, nausea and vomiting as well as intraoperative
awareness. The times between ICU admission and
extubation and between cessation of propofol infusion
and extubation were recorded as well as the maximal
inspiratory capacity on the first postoperative day
(Coach 2 breathing exerciser, DHD Healthcare, New
York, NY, USA). The latter value was normalized to
the expected value considering the size and age of the
After endotracheal intubation and initiation of
mechanical ventilation (Servo C, Siemens-Elema AB,
Sweden), a three-lumen central venous catheter
(
Arrow-Howes 7F, Arrow International; Erding,
Germany), a percutaneous sheath introducer set (8.5F,
Arrow International) and a continuous cardiac output
pulmonary catheter (Swan-Ganz CCO/VIP 7.5F,
Baxter; Unterschleissheim, Germany) were inserted in
the right internal jugular vein in both groups. Before
–1
aortic cannulation, bovine heparin 300 IU·kg was
administered intravenously and the CPB was started
when a minimal activated clotting time (ACT) of 300
sec was reached (Medtronic Hemotec, Inc. Parker, CO,
USA). During CPB, an ACT 500 sec was maintained.
Following initiation of CPB, patients were cooled to a
minimum rectal temperature of 32°C and were later
rewarmed to 36°C before being taken off bypass. The
use of vasoactive drugs was left to the discretion of the
attending anesthesiologist. Heparinization was reversed
with an initial 1:100 protamine iv dose (1 mg for 100
IU of heparin administered). An additional dose of 0.5
12
patient and compared with the preoperative value of
FEV and of Tiffenau ratio, both also normalized to
1
the expected value.
ICU discharge criteria included patient orientation,
hemodynamic stability without the use of iv vasoactive
substances, SpO > 90% with nasal O at less than 4
L·min and urine output > 0.5 mL·kg ·hr . Chest
tubes, pulmonary catheter and arterial lines were
removed before transfer to the ward.
2
2
–1
–1
–1
Statistics
–1
to 1 mg·kg of protamine was given when the ACT
remained above 140 sec.
The primary outcome measurements were duration of
intubation, postoperative analgesia requirements and
postoperative spirometry. Results are expressed as the
mean ± SD (range), unless otherwise indicated.
Operative and postoperative variables were compared
by means of the Mann-Whitney U test for continuous
variables and Fischer’s exact test for nominal variables.
P < 0.05 was considered significant.
Postoperative management
After surgery, patients were transferred to the ICU. The
medical and nursing staff of the ICU were blinded to
the anesthetic technique. A continuous infusion of
–1
–1
propofol (0.5 to 1 mg·kg ·hr ) was maintained until
normothermia, hemodynamic stability and minimal
–1
chest tube drainage (< 100 mL·hr ) were attained. For
acute pain control prior to extubation, the nursing staff
administered an iv bolus of nicomorphine (increments
of 2 mg) as required. Nicomorphine is known to be
equipotent to morphine but should induce less adverse
effects such as respiratory depression, pruritus, nausea
and vomiting. Ibuprofen 400 mg was given rectally or
orally three times a day. Forced air warming was used to
maintain core temperature above 36°C and shivering
was treated with iv meperidine (12.5–25 mg). The cri-
teria for extubation included normal neurologic status,
stable hemodynamics under minimal inotropic support
Results
Eleven patients were randomized to the IT group and
13 patients were randomized to the iv group. The
groups were similar in patient characteristics, preoper-
ative risk scores (EuroSCORE ; Table I) and preop-
erative medications. Surgical data including type of
procedure, duration of CPB and aortic cross-clamp-
ing, were also similar between groups (Table II).
13
Anesthesia, intraoperative analgesia and surgery
All lumbar punctures were performed without com-
plication. The mean ± SD time from lumbar puncture
to systemic heparinization in the IT group was 101 ±
27 min (range, 64–137 min). The mean ± SD time
–1
–1
(
< 5 µg·kg ·min dopamine or dobutamine), adequate
pulmonary function (spontaneous ventilation for a min-

714
CANADIAN JOURNAL OF ANESTHESIA
between lumbar puncture and intubation was 12 ± 2.6
min (range, 8–17 min). Patients in the IT group
received significantly more propofol (Table II). The
use of vasoactive substances and the occurrence of ST
segment changes, hypotension or arrhythmia during
induction (Table II), were not significantly different
between the two groups. The occurrence of hyperten-
sion during induction, defined as more than 20% aug-
mentation of mean basal arterial pressure, was signifi-
cantly more frequent in the IT group. The occurrence
of hypotension during induction, defined as more
than 20% reduction of mean basal arterial pressure was
similar in both groups. The CPB and post-CPB peri-
ods were uneventful for all patients and intraoperative
surgical complications did not occur. Two patients
(one in each group) received dopamine (1–2.5
–
1
–1
µg·kg ·min ), and one patient in the iv group
–1
–1
received dobutamine (5 µg·kg ·min ) to facilitate
separation from bypass (Table II).
TABLE I Patient characteristics and preoperative risk score (Euro
Score)
IT group (n = 11)
iv group (n = 13)
P value
Extubation, postoperative analgesia and complications
14
Postoperative risk scores (APACHE II; Table III)
and use of vasoactive drugs were similar in both
groups. The trachea could not be extubated in seven
patients (three in the IT group and four in the iv
group) within the first six hours after operation: three
because of hemodynamic instability or postoperative
ST segment changes (one patient in the IT group fol-
Age
53.5 ± 11.4 (32–66) 57.2 ± 9.4 (37–71)
9/2
76 ± 12 (53–97)
173 ± 9.5 (152–182) 176 ± 8 (166–192)
62 ± 11 (40–79)
1.5 ± 1.5 (0–4)
NS
NS
Sex (M/F)
Weight (kg)
Height (cm)
EF (%)
13/0
81.5 ± 13.5 (61–104) NS
NS
NS
NS
62 ± 9 (49–81)
1.8 ± 1.6 (0–6)
13
EuroSCORE
Values are expressed as number of patients or mean ± SD (range).
IT = intrathecal; EF = ejection fraction; NS = not significant.
TABLE II Surgical procedures and patient outcome
IT group (n = 11)
iv group (n = 13)
P value
Coronary artery bypass graft
Aortic valve replacement
7
3
11
1
NS
NS
Mitral valve repair
1
1
NS
Aortic cross-clamp time (min)
Cardiopulmonary bypass time (min)
63 ± 17 (35–79)
111.5 ± 23 (69–143)
20.1 ± 5.7 (11.3–28.4)
0.5 ± 0.2 (0.25–0.9)
5
1
0
1
0
65.5 ± 21 (39–114)
98.5 ± 29 (56–165)
14.3 ± 7.5 (6.8–31.9)
7.6 ± 1.8 (4.2–9.9)
0
4
0
1
1
NS
NS
0.045
0.0001
0.03
NS
NS
NS
NS
–1
Total iv propofol (mg·kg )
–1
Total iv sufentanil (µg·kg )
Hypertension during induction*
Hypotension during induction†
Segment changes during induction
Off-bypass use of dopamine
Off-bypass use of dobutamine
Values are expressed as number of patients or mean ± SD (range). IT = intrathecal; NS = not significant.*Hypertension during induction
of anesthesia was defined as more than 20% augmentation of mean basal arterial pressure. †Hypotension during induction of anesthesia
was defined as more than 20% reduction of mean basal arterial pressure.
TABLE III Patient outcome in ICU
IT group (n = 11)
iv group (n = 13)
P value
APACHE II14
11.7 ± 3.3 (6–17)
101 ± 121.5 (0–375)
12 ± 3 (6–16)
142.5 ± 65 (35–210)
NS
NS
Time between ICU admission
and time of adequate answer
to simple command (min)
Time between ICU admission and
extubation (min)
Time between cessation of propofol
and extubation (min)
Sedation score, two hours
Sedation score, four hours
Extubation time > six hours
231 ± 149.5 (80–540)
104 ± 56.5 (10–180)
332 ± 115 (130–555)
213 ± 104 (65–400)
0.05
0.01
11
3.2 ± 1.2
3.7 ± 0.9
4
2.1 ± 1
3.3 ± 0.8
3
0.02
NS
NS
Values are expressed as number of patients or mean ± SD (range). IT = intrathecal; ICU = intensive care unit.

Bettex et al.: COMBINED INTRATHECAL OPIOIDS IN CARDIAC SURGERY
715
FIGURE 2 Postoperative maximal inspiratory capacity (spirome-
try), preoperative Tiffenau and FEV1 in percent of the predictive
value in the iv group (open boxes) and the intrathecal (IT) group
(hatched boxes). Significantly different between groups. *P = 0.05.
FIGURE 1 Postoperative visual analogue scale scores (A) and
nicomorphine use (B) in the iv group (open boxes) and the
intrathecal (IT) group (hatched boxes). Significantly different
between groups. *P = 0.008.
Discussion
Our data suggest that in low-risk patients undergoing
CABG or valve surgery without contraindication to
locoregional anesthesia, combined IT sufentanil and
morphine with TCI-propofol allows a shorter postop-
erative duration of intubation, adequate analgesia and
better maximal inspiratory capacity as compared with
lowing aortic valve replacement and one in each group
following CABG surgery), one in the iv group
because of hypothermia at ICU admission (34.4°C),
one in the IT group because of mediastinal bleeding
requiring rethoracotomy and two in the iv group
because of delayed awakening and/or respiratory
depression. The maximal duration of intubation was
nine hours and 15 min. The sedation score was signif-
icantly lower in the iv group after two hours but was
comparable between groups after four hours (Table
III). The time from ICU admission to extubation and
the time between cessation of sedation and extubation
were significantly higher in the iv group (Table III).
No patient required reintubation. The need for iv
nicomorphine was significantly higher in the iv group
even though the two groups’ VAS scores were not sig-
nificantly different (Figure 1). Five patients suffered
from nausea or vomiting (three in the IT group and
two in the iv group), and one patient complained of
pruritus (IT group).
3
a standard iv anesthetic technique.
Choice and advantages of the method used
Recent evidence suggests that fast-track cardiac
surgery is not only safe but may improve patient out-
come by decreasing the incidence of postoperative car-
diopulmonary morbidity and may lower the cost of
1–3,9
cardiac surgery.
The optimal anesthetic technique
to reach this goal remains debatable. TCI-propofol
offers stable hemodynamics with minimal negative
inotropism and a rapid and controlled recovery; it is
15
widely used for noncardiac as well as cardiac surgery.
Because of its previously demonstrated advantages for
3
fast-track cardiac surgery, we chose TCI- propofol for
induction and maintenance of anesthesia.
Previous studies have shown that although IT mor-
phine prior to cardiac surgery provides profound post-
Despite comparable results in preoperative pul-
monary function tests, patients in the IT group had a
better maximal inspiratory capacity after operation
16,17
operative analgesia
it does not offer sufficient
intraoperative analgesia because of its delayed peak of
action. Concerns have been raised regarding the
potential for ventilatory depression and delayed extu-
bation when IT morphine is used as part of a fast-
tracking program, especially with the concomitant use
(
Figure 2). There was no perioperative myocardial
infarction (defined as troponine, creatine kinase or
creatine kinase-MB elevation or new Q-wave on the
ECG). According to the routine in our institution,
every patient stayed overnight in the ICU for moni-
toring purposes; ICU duration of stay was the same in
both groups.
8,18,19
of iv analgesics and sedatives.
IT sufentanil is
known to provide an intense and fast-onset analge-
8,9
sia. We postulated that the combination of IT mor-

716
CANADIAN JOURNAL OF ANESTHESIA
phine and sufentanil could avoid deleterious effects
and increase patient comfort because of their different
peaks of activity.8
have indicated the development of subarachnoid or
7,19,24
epidural hematoma.
However, usual precautions
,16,17
24
should be followed to decrease this risk. Our exclu-
sion criteria with respect to this potential complication
were particularly strict, and we were ready, in agree-
ment with the surgeons, to delay surgery in case of a
bloody tap (which did not occur). The minimal delay
between lumbar puncture and heparinization was 64
min, which is close to the 70 min previously reported
In our study, the combination of IT morphine and
sufentanil provided effective intraoperative analgesia.
The trend toward hypertension during induction in
the spinal group did not result in increased require-
ments for vasoactive substances because of its non-sus-
tained nature. There was no need for iv opioids except
shortly before intubation when IT sufentanil is not
7
by Chaney et al. This delay might have clinical rele-
9
active. The IT group required significantly more iv
vance upon intradural hematoma formation but this
remains unclear. We observed no clinical evidence of
central neuraxial hematoma in any patient enrolled in
our study, but our series is obviously too small to infer
the safety of this method.
propofol, however, probably because they received
20
less iv sufentanil, which has its own sedative effect.
The time to extubation was significantly shorter in the
IT group despite a similar time between ICU admis-
sion and time of adequate answer to simple command.
We attribute this to the larger amount of iv sufentanil
and nicomorphine required in the iv group. None of
the patients who remained intubated for more than six
hours had respiratory problems related to IT opioids.
Actually, only two of the seven patients with slightly
prolonged intubation times required a longer intuba-
tion because of delayed awakening or respiratory
depression; they both belonged to the iv group. The
five other patients suffered from hemodynamic insta-
bility or bleeding complications, which were not like-
ly related to anesthetic technique.
Study limitations
Limitations include a predominantly male population,
a small sample size, and a nonuniform type of surgery.
Female sex may impart additional operative risk in
25
CABG surgery and was an adverse risk factor for
early extubation univariately in one study and multi-
26,27
variately in another.
Although sex-related differ-
ences in pain perception as well as response to pain
28
have been described, we are not aware of a sex-
linked difference in the effect of spinal analgesia. The
difficulty recruiting patients was predictable because
patients taking aspirin were excluded. A recently
adopted policy in our institution is to continue aspirin
until the day of surgery, so this change forced us to
stop the study. The type of cardiac surgery, with the
exception of minimally invasive procedures, does not
appear to have a significant influence on intubation
time, suggesting that patients undergoing valve repair
or replacement are not at increased risk for delayed
Postoperative comfort
IT morphine and sufentanil provided effective postop-
erative analgesia, as indicated by a significant decrease in
the need for postoperative iv nicomorphine in the IT
group for comparable VAS analgesia scores. The well-
known side effects of IT opioids, besides ventilatory
depression, are pruritus, nausea, vomiting and urinary
retention. None of the patients experienced severe pru-
ritus; the incidence of nausea and vomiting was similar
in both groups, and no patient experienced urinary
retention after removal of the urinary catheter or venti-
latory depression after tracheal extubation. We used iv
propofol for ICU sedation as it is known to facilitate the
process of weaning patients from mechanical ventilation
10
extubation.
The optimal dose of IT sufentanil and morphine
has not been determined and should remain the sub-
ject of future studies. The beneficial effects on imme-
diate postoperative ventilatory function documented
in our study should be investigated in patients with
poor preoperative ventilatory function before the use
of IT sufentanil and morphine for fast-track cardiac
surgery in this type of patient can be recommended.
21
after cardiac surgery when compared with midazolam.
The low incidence of postoperative opioid-related nau-
sea and vomiting could be attributed to the antiemetic
effect of propofol.22
Conclusion
In patients with well-preserved ventricular and respi-
ratory function scheduled for fast-track cardiac
surgery, the use of combined IT morphine and sufen-
tanil provides superior postoperative analgesia and
maximal inspiratory capacity when compared with iv
sufentanil during TCI-propofol anesthesia.
Risk of IT analgesia
Although extremely rare, subarachnoid and epidural
hematomas have occurred in patients when a diagnos-
tic or therapeutic lumbar puncture was followed by
systemic heparinization.23 None of the previous
reports of the use of IT morphine for cardiac surgery

Bettex et al.: COMBINED INTRATHECAL OPIOIDS IN CARDIAC SURGERY
717
Acknowledgement
tem for cardiac operative risk evaluation
We are indebted to Burkhardt Seifert, MD, for his
outstanding contributions.
(EuroSCORE). Eur J Cardiothorac Surg 1999; 16:
9–13.
4 Knaus WA, Draper EA, Wagner DP, Zimmerman JE.
APACHE II: a severity of disease classification system.
Crit Care Med 1985; 13: 818–29.
15 Chaudhri S, White M, Kenny GNC. Induction of anaes-
thesia with propofol using a target-controlled infusion
system. Anaesthesia 1992; 47: 551–3.
16 Chaney MA, Smith KR, Barclay JC, Slogoff S. Large-
dose intrathecal morphine for coronary artery bypass
grafting. Anesth Analg 1996; 83: 215–22.
1
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