1
|
Effects of Pre-Cardiopulmonary Bypass Administration of Dexmedetomidine on Cardiac Injuries and the Inflammatory Response in Valve Replacement Surgery With a Sevoflurane Postconditioning Protocol: A Pilot Study. J Cardiovasc Pharmacol 2020; 74:91-97. [PMID: 31356535 PMCID: PMC6688713 DOI: 10.1097/fjc.0000000000000698] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Supplemental Digital Content is Available in the Text. Background: Preventing myocardial ischemia–reperfusion injury in on-pump cardiac surgeries remains an enormous challenge. Sevoflurane postconditioning has been effective at overcoming this challenge by modulating inflammatory mediators and ameliorating antioxidative stress. Dexmedetomidine (DEX) is a commonly used medication for cardiac patients with organ-protective properties that lead to positive outcomes. Whether DEX also has cardiac-protective properties and the associated mechanism in sevoflurane postconditioning–based valve replacement surgeries are unknown. Objective: This study was conducted to observe the effect of DEX administration before cardiopulmonary bypass (CPB) on myocardial injury, oxidative stress, and inflammatory response indicators in the peripheral blood. Methods: Twenty-eight eligible cardiac patients who underwent valve replacement surgery with standard sevoflurane postconditioning were included in the study. The patients were randomly divided into a DEX group and a non-DEX group according to whether DEX (0.5-µg/kg overload dose for 10 minutes and a 0.5-μg/kg/h maintenance dose) or saline was administered from induction to the beginning of CPB. The primary outcome was the cardiac troponin I concentration (cTnI) in the blood 24 hours after CPB. The levels of malondialdehyde (MDA), superoxide dismutase, tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6), and interleukin-8 (IL-8) were also measured. Results: The mean cTnI at 24 hours after CPB was clearly decreased in the DEX group compared with that in the non-DEX group (4.16 ± 1.58 vs. 6.90 ± 3.73, P < 0.05). TNF-α levels were lower in the DEX group after CPB (T1–T5), with a significant difference found at 1–6 hours after CPB (1 hour, 19.03 vs. 28.09; 6 hours, 20.74 vs. 30.94, P < 0.05). The IL-6 and IL-8 concentrations in the DEX group were dramatically increased at 6 hours after CPB (P < 0.05). The MDA content and superoxide dismutase activity were comparable between the 2 groups. A lower proportion of anemia cases were noted after CPB in the DEX group than in the non-DEX group (non-DEX, 10% vs. DEX, 5%, P < 0.05). Conclusions: In valve replacement surgery with sevoflurane postconditioning, pre-CPB administration of DEX can reduce the cTnI level at 24 hours after CPB and brings synergic benefits of the inflammatory response.
Collapse
|
2
|
Pagel PS, Crystal GJ. The Discovery of Myocardial Preconditioning Using Volatile Anesthetics: A History and Contemporary Clinical Perspective. J Cardiothorac Vasc Anesth 2018; 32:1112-1134. [DOI: 10.1053/j.jvca.2017.12.029] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Indexed: 12/24/2022]
|
3
|
Bignami E, Guarnieri M, Pieri M, De Simone F, Rodriguez A, Cassarà L, Lembo R, Landoni G, Zangrillo A. Volatile anaesthetics added to cardiopulmonary bypass are associated with reduced cardiac troponin. Perfusion 2017; 32:547-553. [DOI: 10.1177/0267659117701562] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Background: Every year, over 1 million cardiac surgical procedures are performed all over the world. Reducing myocardial necrosis could have strong implications in postoperative clinical outcomes. Volatile anaesthetics have cardiac protective properties in the perioperative period of cardiac surgery. However, little data exists on the administration of volatile agents during cardiopulmonary bypass. The aim of this study was to assess if volatile anaesthetics administration during cardiopulmonary bypass reduces cardiac troponin release after cardiac surgery. Materials and methods: We retrospectively analysed data from 942 patients who underwent cardiac surgery in a teaching hospital. The only difference between the groups was the management of anaesthesia during CPB. The volatile group received sevoflurane or desflurane while the control group received a combination of propofol infusion and fentanyl boluses. Patients who received volatile anaesthetics during cardiopulmonary bypass (n=314) were propensity-matched 1:2 with patients who did not receive volatile anaesthetics during CPB (n=628). Results: We found a reduction in peak postoperative troponin I, from 7.8 ng/ml (4.8-13.1) in the non-volatile group to 6.8 ng/ml (3.7-11.8) in the volatile group (p=0.013), with no differences in mortality [2 (0.6%) in the volatile group and 2 (0.3%) in the non-volatile group (p=0.6)]. Conclusions: Adding volatile anaesthetics during cardiopulmonary bypass was associated with reduced peak postoperative troponin levels. Larger studies are required to confirm our data and to assess the effect of volatile agents on survival.
Collapse
Affiliation(s)
- Elena Bignami
- Anaesthesia and Intensive Care Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Marcello Guarnieri
- Anaesthesia and Intensive Care Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Marina Pieri
- Anaesthesia and Intensive Care Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesco De Simone
- Cardiothoracic Surgery Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alcira Rodriguez
- Cardiothoracic Surgery Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Luigi Cassarà
- Anaesthesia and Intensive Care Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Rosalba Lembo
- Anaesthesia and Intensive Care Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giovanni Landoni
- Anaesthesia and Intensive Care Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Alberto Zangrillo
- Anaesthesia and Intensive Care Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| |
Collapse
|
4
|
Ghaffari S, Pourafkari L, Manzouri S, Nader ND. Effect of remote ischemic postconditioning during thrombolysis in STEMI. Herz 2017; 43:161-168. [DOI: 10.1007/s00059-017-4550-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Revised: 01/08/2017] [Accepted: 02/02/2017] [Indexed: 01/08/2023]
|
5
|
Adding Emulsified Isoflurane to Cardioplegia Solution Produces Cardiac Protection in a Dog Cardiopulmonary Bypass Model. Sci Rep 2016; 6:23572. [PMID: 27121996 PMCID: PMC4848478 DOI: 10.1038/srep23572] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Accepted: 03/03/2016] [Indexed: 02/05/2023] Open
Abstract
This study investigated whether caridoplegia solution with Emulsified Isoflurane (EI) could improve cardiaoprotection in a dog CPB model of great similarity to clinical settings. Adult dogs were randomly assigned to receive one of the following cardioplegia solutions: St. Thomas with EI (group ST+EI), St. Thomas with 30% Intralipid (group ST+EL) and St. Thomas alone (group ST). The aorta was cross-clamped for two hours followed by reperfusion for another two hours, during which cardiac output was measured and dosages of positive inotropic agent to maintain normal hemodynamics were recorded. Serum level of cardiac troponin I (cTnI) and CK-MB were measured. Deletion of cardiac mitochondrial DNA was examined at the end of reperfusion. Compared with ST, ST+EI decreased the requirement of dopamine support while animals receiving ST+EI had a significantly larger cardiac output. ST+EI reduced post-CPB release of cTnI and CK-MB. Mitochondrial DNA loss was observed in only one of the tested animals from group ST+EI while it was seen in all the tested animals from group ST+EL and ST. Addition of emulsified isoflurane into cardioplegia solution protects against myocardial ischemia reperfusion injury. This protective effect might be mediated by preserving mitochondrial ultrastructure and DNA integrity.
Collapse
|
6
|
Xenon triggers pro-inflammatory effects and suppresses the anti-inflammatory response compared to sevoflurane in patients undergoing cardiac surgery. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:365. [PMID: 26467531 PMCID: PMC4607103 DOI: 10.1186/s13054-015-1082-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Accepted: 09/27/2015] [Indexed: 12/02/2022]
Abstract
Introduction Cardiac surgery encompasses various stimuli that trigger pro-inflammatory mediators, reactive oxygen species and mobilization of leucocytes. The aim of this study was to evaluate the effect of xenon on the inflammatory response during cardiac surgery. Methods This randomized trial enrolled 30 patients who underwent elective on-pump coronary-artery bypass grafting in balanced anaesthesia of either xenon or sevoflurane. For this secondary analysis, blood samples were drawn prior to the operation, intra-operatively and on the first post-operative day to measure the pro- and anti-inflammatory cytokines interleukin-6 (IL-6), interleukin-8/C-X-C motif ligand 8 (IL-8/CXCL8), and interleukin-10 (IL-10). Chemokines such as C-X-C motif ligand 12/ stromal cell-derived factor-1α (CXCL12/SDF-1α) and macrophage migration inhibitory factor (MIF) were measured to characterize xenon’s perioperative inflammatory profile and its impact on migration of peripheral blood mononuclear cells (PBMC). Results Xenon enhanced the postoperative increase of IL-6 compared to sevoflurane (Xenon: 90.7 versus sevoflurane: 33.7 pg/ml; p = 0.035) and attenuated the increase of IL-10 (Xenon: 127.9 versus sevoflurane: 548.3 pg/ml; p = 0.028). Both groups demonstrated a comparable intraoperative increase of oxidative stress (intra-OP: p = 0.29; post-OP: p = 0.65). While both groups showed an intraoperative increase of the cardioprotective mediators MIF and CXCL12/SDF-1α, only MIF levels decreased in the xenon group on the first postoperative day (50.0 ng/ml compared to 23.3 ng/ml; p = 0.012), whereas it remained elevated after sevoflurane anaesthesia (58.3 ng/ml to 53.6 ng/ml). Effects of patients’ serum on chemotactic migration of peripheral mononuclear blood cells taken from healthy volunteers indicated a tendency towards enhanced migration after sevoflurane anaesthesia (p = 0.07). Conclusions Compared to sevoflurane, balanced xenon anaesthesia triggers pro-inflammatory effects and suppresses the anti-inflammatory response in cardiac surgery patients even though the clinical significance remains unknown. Trial registration This clinical trial was approved by the European Medicines Agency (EudraCT-number: 2010-023942-63) and at ClinicalTrials.gov (NCT01285271; first received: January 24, 2011). Electronic supplementary material The online version of this article (doi:10.1186/s13054-015-1082-7) contains supplementary material, which is available to authorized users.
Collapse
|
7
|
De Hert S, Moerman A. Myocardial injury and protection related to cardiopulmonary bypass. Best Pract Res Clin Anaesthesiol 2015; 29:137-49. [DOI: 10.1016/j.bpa.2015.03.002] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2015] [Revised: 02/13/2015] [Accepted: 03/19/2015] [Indexed: 02/06/2023]
|
8
|
van der Baan A, Kortekaas KA, van Es E, Meier S, Klautz RJM, Engbers FHM. Sevoflurane-enriched blood cardioplegia: the intramyocardial delivery of a volatile anesthetic. Perfusion 2014; 30:295-301. [DOI: 10.1177/0267659114545666] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Myocardial ischemia/reperfusion injury is a major problem in cardiac surgery, characterized by an enhanced inflammatory response postoperatively. Sevoflurane has anti-inflammatory effects and may attenuate this injury. This study describes a novel approach to using sevoflurane as a local anti-inflammatory drug and not as an anesthetic. Therefore, a pediatric oxygenator with a sevoflurane vaporizer was integrated into the blood cardioplegia system of an adult bypass system. In addition, a gas blender was implemented to regulate pO2 and pCO2 concentrations in the cardioplegia. This proof-of-principle study was tested in vivo and shows that it is feasible to deliver sevoflurane locally while regulating O2 and CO2 concentrations. Moreover, this set-up enables one to use only the specific cardioprotective features of sevoflurane. Inflammatory responses were attenuated, both locally (i.e. the heart) as well as systemically through intramyocardial delivery of sevoflurane.
Collapse
Affiliation(s)
- A van der Baan
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - K A Kortekaas
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - E van Es
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - S Meier
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
| | - R J M Klautz
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - F H M Engbers
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
| |
Collapse
|
9
|
Kortekaas K, van der Baan A, Aarts L, Palmen M, Cobbaert C, Verhagen J, Engbers F, Klautz R, Lindeman J. Cardiospecific sevoflurane treatment quenches inflammation but does not attenuate myocardial cell damage markers: a proof-of-concept study in patients undergoing mitral valve repair. Br J Anaesth 2014; 112:1005-14. [DOI: 10.1093/bja/aet588] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
|
10
|
Pagel PS. Myocardial Protection by Volatile Anesthetics in Patients Undergoing Cardiac Surgery: A Critical Review of the Laboratory and Clinical Evidence. J Cardiothorac Vasc Anesth 2013; 27:972-82. [DOI: 10.1053/j.jvca.2012.10.011] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2012] [Indexed: 11/11/2022]
|
11
|
Bignami E, Landoni G, Biondi-Zoccai G, Greco T, Zangrillo A. Clinically Relevant Outcomes and Long-term Follow-up in Cardiac Anesthesia. J Cardiothorac Vasc Anesth 2011. [DOI: 10.1053/j.jvca.2011.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
|
12
|
Abstract
The occurrence of myocardial ischaemia will result in either reversible or irreversible myocardial dysfunction. Even when revascularization is successful, some reperfusion injury may occur that transiently impairs myocardial function. Therefore, treatment should not only be directed towards prompt restoration of myocardial blood flow but measures should also be taken to prevent or alleviate the consequences of myocardial reperfusion injury. Over the years, various strategies have been developed. The present contribution reviews a number of these strategies focusing on pharmacological treatments that have been developed to address myocardial reperfusion injury.
Collapse
|
13
|
Huang H, Zhang W, Liu S, Yanfang C, Li T, Liu J. Cardioprotection Afforded by St Thomas Solution Is Enhanced by Emulsified Isoflurane in an Isolated Heart Ischemia Reperfusion Injury Model in Rats. J Cardiothorac Vasc Anesth 2010; 24:99-103. [DOI: 10.1053/j.jvca.2009.10.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2009] [Indexed: 11/11/2022]
|
14
|
De Hert S, Vlasselaers D, Barbé R, Ory JP, Dekegel D, Donnadonni R, Demeere JL, Mulier J, Wouters P. A comparison of volatile and non volatile agents for cardioprotection during on-pump coronary surgery. Anaesthesia 2009; 64:953-60. [DOI: 10.1111/j.1365-2044.2009.06008.x] [Citation(s) in RCA: 122] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
15
|
Frässdorf J, De Hert S, Schlack W. Anaesthesia and myocardial ischaemia/reperfusion injury. Br J Anaesth 2009; 103:89-98. [PMID: 19502287 DOI: 10.1093/bja/aep141] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Anaesthetists are confronted on a daily basis with patients with coronary artery disease, myocardial ischaemia, or both during the perioperative period. Therefore, prevention and ultimately adequate therapy of perioperative myocardial ischaemia and its consequences are the major challenges in current anaesthetic practice. This review will focus on the translation of the laboratory evidence of anaesthetic-induced cardioprotection into daily clinical practice.
Collapse
Affiliation(s)
- J Frässdorf
- Departement of Anesthesiology, AMC-University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands.
| | | | | |
Collapse
|
16
|
Cho EJ, Yoon JH, Hong SJ, Lee SH, Sim SB. The effects of sevoflurane on systemic and pulmonary inflammatory responses after cardiopulmonary bypass. J Cardiothorac Vasc Anesth 2009; 23:639-45. [PMID: 19362013 DOI: 10.1053/j.jvca.2009.01.025] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2008] [Indexed: 12/13/2022]
Abstract
OBJECTIVE During reperfusion after cardiopulmonary bypass, leukocytes are retained in the lungs. The purpose of this study was to examine the effect of sevoflurane on the inflammatory responses of the lungs after cardiopulmonary bypass. DESIGN A prospective, randomized clinical investigation. SETTING A university hospital. PARTICIPANTS Thirty patients undergoing valve replacement surgery using cardiopulmonary bypass. INTERVENTIONS Fifteen patients in whom anesthesia was maintained with sevoflurane and the priming solution was saturated with sevoflurane were randomly assigned to the sevoflurane group. Similarly, 15 patients in whom anesthesia was maintained with sufentanil and the priming solution was mixed with sufentanil were randomly assigned to the sufentanil group MEASUREMENTS AND MAIN RESULTS After induction, an arterial blood sample was obtained for the baseline leukocyte count. Blood was collected from the pulmonary artery (PA) and vein (PV) before cardiopulmonary bypass and 10 minutes after the restoration of heart beats. The leukocyte count, levels of interleukin-6, interleukin-8, interleukin-10, and tumor necrosis factor-alpha were measured. The PV/PA ratio of each parameter was determined for the assessment of inflammatory response of the lung. The leukocyte counts and plasma levels of cytokines increased more in the sufentanil group than the sevoflurane group. The PV/PA ratio of neutrophils decreased after the restoration of heart beats in the sufentanil group but was unchanged in the sevoflurane group. The PV/PA ratio of IL-6 was higher in the sufentanil group. The PV/PA ratio of interleukin-8 and interleukin-10 increased after the restoration of the pulmonary circulation in the sufentanil group but decreased in the sevoflurane group. The PV/PA ratio of tumor necrosis factor alpha increased in the sufentanil group but remained unchanged in the sevoflurane group. CONCLUSIONS Sevoflurane attenuates the pulmonary sequestration of neutrophil and leukocytes and also preserves the pulmonary consumption of cytokines at the time of early pulmonary reperfusion. Sevoflurane attenuates the systemic inflammatory response induced by cardiopulmonary bypass.
Collapse
Affiliation(s)
- Eun Jung Cho
- Department of Anesthesiology and Pain Medicine, Incheon St Mary's Hospital, Catholic University of Korea, Medical College, Incheon, Korea
| | | | | | | | | |
Collapse
|
17
|
Suleiman MS, Zacharowski K, Angelini GD. Inflammatory response and cardioprotection during open-heart surgery: the importance of anaesthetics. Br J Pharmacol 2007; 153:21-33. [PMID: 17952108 DOI: 10.1038/sj.bjp.0707526] [Citation(s) in RCA: 105] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Open-heart surgery triggers an inflammatory response that is largely the result of surgical trauma, cardiopulmonary bypass, and organ reperfusion injury (e.g. heart). The heart sustains injury triggered by ischaemia and reperfusion and also as a result of the effects of systemic inflammatory mediators. In addition, the heart itself is a source of inflammatory mediators and reactive oxygen species that are likely to contribute to the impairment of cardiac pump function. Formulating strategies to protect the heart during open heart surgery by attenuating reperfusion injury and systemic inflammatory response is essential to reduce morbidity. Although many anaesthetic drugs have cardioprotective actions, the diversity of the proposed mechanisms for protection (e.g. attenuating Ca(2+) overload, anti-inflammatory and antioxidant effects, pre- and post-conditioning-like protection) may have contributed to the slow adoption of anaesthetics as cardioprotective agents during open heart surgery. Clinical trials have suggested at least some cardioprotective effects of volatile anaesthetics. Whether these benefits are relevant in terms of morbidity and mortality is unclear and needs further investigation. This review describes the main mediators of myocardial injury during open heart surgery, explores available evidence of anaesthetics induced cardioprotection and addresses the efforts made to translate bench work into clinical practice.
Collapse
Affiliation(s)
- M-S Suleiman
- Bristol Heart Institute and Department of Anaesthesia, Faculty of Medicine and Dentistry, Bristol Royal Infirmary, University of Bristol, Bristol, UK.
| | | | | |
Collapse
|
18
|
Ndoko SK, Tual L, Ait Mamar B, Sauvat S, Jabre P, Zakhouri M, Rosanval O, Abdi M, Kirsch M, Pouzet B, Loisance D, Dhonneur G. Isoflurane, 0.5 Minimum Alveolar Concentration Administered Through the Precardiopulmonary Bypass Period, Reduces Postoperative Dobutamine Requirements of Cardiac Surgery Patients: A Randomized Study. J Cardiothorac Vasc Anesth 2007; 21:683-9. [PMID: 17905274 DOI: 10.1053/j.jvca.2006.12.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2006] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Cardioprotective properties have been shown with halogenated volatile agents. It was hypothesized that low-dose isoflurane administered before aortic cross-clamping may reduce the amount of dobutamine required to improve impaired postoperative cardiac function after various types of cardiac surgery. DESIGN A prospective, randomized trial. SETTING An anesthesia and intensive care unit, university hospital. PARTICIPANTS Two hundred eighty cardiac surgery patients. INTERVENTIONS All patients allocated to either isoflurane treatment (T) or no treatment (control group [C]) received total intravenous anesthesia. In the treatment group, isoflurane was administered at a 0.5 minimum alveolar concentration (MAC) from tracheal intubation to initiation of cardiopulmonary bypass (CPB). During weaning from CPB, dobutamine was introduced by using a hemodynamically driven decision tree. MEASUREMENTS AND MAIN RESULTS The number of patients receiving dobutamine was comparable (66 v 78, p = 0.07, in T and C groups, respectively). The total amount of postoperative dobutamine indexed to patient weight, considered as the primary endpoint, was reduced in the isoflurane-treated group (4.2 +/- 8 v 7.2 +/- 15, p < 0.02, in T and C, respectively). Isoflurane was identified as an independent variable significantly (odds ratio [confidence interval]) influencing the total amount of postoperative dobutamine (0.53 [0.31-0.92], p < 0.02). Postoperative troponin I release at 20 hours was not affected by isoflurane treatment. CONCLUSIONS This study revealed that exposure to 0.5 MAC isoflurane before CPB reduced the total amount of dobutamine required to normalize postoperative cardiac dysfunction in various types of cardiac surgical patients.
Collapse
Affiliation(s)
- Serge K Ndoko
- Department of Anesthesiology and Surgical Intensive Care, Paris XII, University Hospital Henri Mondor, Créteil, France.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
19
|
Landoni G, Biondi-Zoccai GGL, Zangrillo A, Bignami E, D'Avolio S, Marchetti C, Calabrò MG, Fochi O, Guarracino F, Tritapepe L, De Hert S, Torri G. Desflurane and Sevoflurane in Cardiac Surgery: A Meta-Analysis of Randomized Clinical Trials. J Cardiothorac Vasc Anesth 2007; 21:502-11. [PMID: 17678775 DOI: 10.1053/j.jvca.2007.02.013] [Citation(s) in RCA: 207] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2006] [Indexed: 02/08/2023]
Abstract
OBJECTIVES The authors performed a meta-analysis to investigate whether the cardioprotective effects of volatile anesthetics translate into decreased morbidity and mortality in patients undergoing cardiac surgery. BACKGROUND It is commonly believed that the choice of the primary anesthetic agent does not result in different outcomes after cardiac surgery. Recent evidence, however, has indicated that volatile anesthetics improve postischemic recovery at a cellular level, in isolated hearts, in animals, and in humans. METHODS Four investigators independently searched BioMedCentral and PubMed. Inclusion criteria were random allocation to treatment and comparison of a total intravenous anesthesia regimen versus an anesthesia plan including desflurane or sevoflurane performed on cardiosurgical patients. Exclusion criteria were duplicate publications, nonhuman experimental studies, and no outcome data. The endpoints were the rate of perioperative myocardial infarction and hospital mortality. RESULTS The search yielded 22 studies, involving 1,922 patients. Volatile anesthetics were associated with significant reductions of myocardial infarctions (24/979 [2.4%] in the volatile anesthetics group v 45/874 [5.1%] in the control arm, odds ratio [OR] = 0.51 [0.32-0.84], p for effect = 0.008, and p for heterogeneity = 0.77) and mortality (4/977 [0.4%] v 14/872 [1.6%], OR = 0.31 [0.12-0.80], p for effect = 0.02, and p for heterogeneity = 0.88). CONCLUSIONS Desflurane and sevoflurane have cardioprotective effects that result in decreased morbidity and mortality. The present data show for the first time that the choice of an anesthetic regimen based on administration of halogenated anesthetics is associated with a better outcome after cardiac surgery.
Collapse
Affiliation(s)
- Giovanni Landoni
- Department of Cardiothoracic Anesthesia and Intensive Care, Università Vita-Salute San Raffaele, Milano, Milan, Italy.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|