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Dai Z, Lin M, Li Y, Gao W, Wang P, Lin J, Wan Z, Jiang Y. Sevoflurane-Remifentanil Versus Propofol-Remifentanil Anesthesia During Noncardiac Surgery for Patients with Coronary Artery Disease - A Prospective Study Between 2016 and 2017 at a Single Center. Med Sci Monit 2021; 27:e929835. [PMID: 34417434 PMCID: PMC8386244 DOI: 10.12659/msm.929835] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Volatile anesthesia possesses cardioprotective properties, and it is widely used in patients undergoing coronary artery bypass surgery, but no randomized controlled trials (RCTs) are available on the use of sevoflurane-remifentanil versus propofol-remifentanil anesthesia for patients with coronary artery disease (CAD) during noncardiac surgery. This study was designed to compare the 2 different types of general anesthesia in patients with CAD undergoing noncardiac surgery at a single center. MATERIAL AND METHODS Patients with CAD undergoing noncardiac surgery were enrolled in an RCT conducted between March 2016 and December 2017. The participants were randomized to receive either sevoflurane-remifentanil or propofol-remifentanil anesthesia. The primary endpoint was occurrence of in-hospital cardiovascular events. The secondary endpoints included delirium, postoperative nausea and vomiting (PONV), Intensive Care Unit (ICU) length of stay (LOS), in-hospital morbidity and mortality, and hospital LOS. RESULTS A total of 164 participants completed the study (sevoflurane: 81; propofol: 83). The occurrence of in-hospital cardiovascular events did not differ between the 2 groups (42.6% vs 39.4%, P=0.86). The occurrence of delirium did not differ between the 2 groups after the operation. PONV had a higher frequency after sevoflurane anesthesia at 48 h compared with propofol. In-hospital morbidity and mortality, ICU LOS, and hospital LOS were similar between the 2 groups (all P>0.05). At 30 days after surgery, no between-group differences in cardiac morbidity and mortality were observed. CONCLUSIONS In this study, anesthesia using sevoflurane-remifentanil did not provide additional postoperative cardioprotection in comparison with propofol-remifentanil in patients with CAD undergoing noncardiac surgery.
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Affiliation(s)
- Zhongliang Dai
- Department of Anesthesiology, Shenzhen People's Hospital, The Second Clinical Medical College, Jinan University, The First Affiliated Hospital of Southern University of Science and Technology, Shenzhen, Guangdong, China (mainland)
| | - Miao Lin
- Department of Anesthesiology, Shenzhen People's Hospital, The Second Clinical Medical College, Jinan University, The First Affiliated Hospital of Southern University of Science and Technology, Shenzhen, Guangdong, China (mainland)
| | - Yali Li
- Department of Anesthesiology, Shenzhen People's Hospital, The Second Clinical Medical College, Jinan University, The First Affiliated Hospital of Southern University of Science and Technology, Shenzhen, Guangdong, China (mainland)
| | - Wenli Gao
- Department of Anesthesiology, Shenzhen People's Hospital, The Second Clinical Medical College, Jinan University, The First Affiliated Hospital of Southern University of Science and Technology, Shenzhen, Guangdong, China (mainland)
| | - Ping Wang
- Department of Anesthesiology, Shenzhen People's Hospital, The Second Clinical Medical College, Jinan University, The First Affiliated Hospital of Southern University of Science and Technology, Shenzhen, Guangdong, China (mainland)
| | - Juan Lin
- Department of Anesthesiology, Shenzhen People's Hospital, The Second Clinical Medical College, Jinan University, The First Affiliated Hospital of Southern University of Science and Technology, Shenzhen, Guangdong, China (mainland)
| | - Zhenzhen Wan
- Department of Anesthesiology, Maternal and Child Health Hospital of Hubei Province, Wuhan, Hubei, China (mainland)
| | - Yuanxu Jiang
- Department of Anesthesiology, Shenzhen People's Hospital, The Second Clinical Medical College, Jinan University, The First Affiliated Hospital of Southern University of Science and Technology, Shenzhen, Guangdong, China (mainland)
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Pagel PS. A Scientist-Skeptic-Agnostic’s View of the Church of Anesthetic Cardioprotection. J Cardiothorac Vasc Anesth 2015; 29:e77-8. [DOI: 10.1053/j.jvca.2015.07.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Indexed: 11/11/2022]
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Abstract
Sevoflurane has been available for clinical practice for about 20 years. Nowadays, its pharmacodynamic and pharmacokinetic properties together with its absence of major adverse side effects on the different organ systems have made this drug accepted worldwide as a safe and reliable anesthetic agent for clinical practice in various settings.
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Affiliation(s)
- Stefan De Hert
- Department of Anesthesiology, Ghent University Hospital, De Pintelaan 185, Ghent, B-9000, Belgium
| | - Anneliese Moerman
- Department of Anesthesiology, Ghent University Hospital, De Pintelaan 185, Ghent, B-9000, Belgium
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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]
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Kunst G, Klein AA. Peri-operative anaesthetic myocardial preconditioning and protection - cellular mechanisms and clinical relevance in cardiac anaesthesia. Anaesthesia 2015; 70:467-82. [PMID: 25764404 PMCID: PMC4402000 DOI: 10.1111/anae.12975] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/05/2014] [Indexed: 12/11/2022]
Abstract
Preconditioning has been shown to reduce myocardial damage caused by ischaemia–reperfusion injury peri-operatively. Volatile anaesthetic agents have the potential to provide myocardial protection by anaesthetic preconditioning and, in addition, they also mediate renal and cerebral protection. A number of proof-of-concept trials have confirmed that the experimental evidence can be translated into clinical practice with regard to postoperative markers of myocardial injury; however, this effect has not been ubiquitous. The clinical trials published to date have also been too small to investigate clinical outcome and mortality. Data from recent meta-analyses in cardiac anaesthesia are also not conclusive regarding intra-operative volatile anaesthesia. These inconclusive clinical results have led to great variability currently in the type of anaesthetic agent used during cardiac surgery. This review summarises experimentally proposed mechanisms of anaesthetic preconditioning, and assesses randomised controlled clinical trials in cardiac anaesthesia that have been aimed at translating experimental results into the clinical setting.
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Affiliation(s)
- G Kunst
- Department of Anaesthetics, King's College Hospital NHS Foundation Trust, London, UK
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Sivaraman V, Pickard JMJ, Hausenloy DJ. Remote ischaemic conditioning: cardiac protection from afar. Anaesthesia 2015; 70:732-48. [PMID: 25961420 PMCID: PMC4737100 DOI: 10.1111/anae.12973] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/05/2014] [Indexed: 12/17/2022]
Abstract
For patients with ischaemic heart disease, remote ischaemic conditioning may offer an innovative, non‐invasive and virtually cost‐free therapy for protecting the myocardium against the detrimental effects of acute ischaemia‐reperfusion injury, preserving cardiac function and improving clinical outcomes. The intriguing phenomenon of remote ischaemic conditioning was first discovered over 20 years ago, when it was shown that the heart could be rendered resistant to acute ischaemia‐reperfusion injury by applying one or more cycles of brief ischaemia and reperfusion to an organ or tissue away from the heart – initially termed ‘cardioprotection at a distance’. Subsequent pre‐clinical and then clinical studies made the important discovery that remote ischaemic conditioning could be elicited non‐invasively, by inducing brief ischaemia and reperfusion to the upper or lower limb using a cuff. The actual mechanism underlying remote ischaemic conditioning cardioprotection remains unclear, although a neuro‐hormonal pathway has been implicated. Since its initial discovery in 1993, the first proof‐of‐concept clinical studies of remote ischaemic conditioning followed in 2006, and now multicentre clinical outcome studies are underway. In this review article, we explore the potential mechanisms underlying this academic curiosity, and assess the success of its application in the clinical setting.
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Affiliation(s)
- V Sivaraman
- The Hatter Cardiovascular Institute, University College London, London, UK
| | - J M J Pickard
- The Hatter Cardiovascular Institute, University College London, London, UK
| | - D J Hausenloy
- The Hatter Cardiovascular Institute, University College London, London, UK
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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
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Esteve N, Valdivia J, Ferrer A, Mora C, Ribera H, Garrido P. [Do anesthetic techniques influence postoperative outcomes? Part I]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2013; 60:37-46. [PMID: 23116699 DOI: 10.1016/j.redar.2012.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/13/2011] [Accepted: 09/04/2012] [Indexed: 06/01/2023]
Abstract
The influence of anesthetic technique on postoperative outcomes has opened a wide field of research in recent years. High-risk patients undergoing non-cardiac surgery are those who have higher incidence of postoperative complications and mortality. A proper definition of this group of patients should focus maximal efforts and resources to improve the results. In view of the significant reduction in postoperative mortality and morbidity in last 20 years, perioperative research should take into account new indicators to investigate the role of anesthetic techniques on postoperative outcomes. Studies focused on the evaluation of intermediate outcomes would probably discriminate better effectiveness differences between anesthetic techniques. We review some of the major controversies arising in the literature about the impact of anesthetic techniques on postoperative outcomes. We have grouped the impact of these techniques into 9 major investigation areas: mortality, cardiovascular complications, respiratory complications, postoperative cognitive dysfunction, chronic postoperative pain, cancer recurrence, postoperative nausea/vomiting, surgical outcomes and resources utilization. In this first part of the review, we discuss the basis on postoperative outcomes research, mortality, cardiovascular and respiratory complications.
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Affiliation(s)
- N Esteve
- Hospital Universitario Son Espases, Palma de Mallorca, Islas Baleares, España.
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Lurati Buse GAL, Schumacher P, Seeberger E, Studer W, Schuman RM, Fassl J, Kasper J, Filipovic M, Bolliger D, Seeberger MD. Randomized comparison of sevoflurane versus propofol to reduce perioperative myocardial ischemia in patients undergoing noncardiac surgery. Circulation 2012; 126:2696-704. [PMID: 23136158 DOI: 10.1161/circulationaha.112.126144] [Citation(s) in RCA: 88] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Volatile anesthetics provide myocardial preconditioning in coronary surgery patients. We hypothesized that sevoflurane compared with propofol reduces the incidence of myocardial ischemia in patients undergoing major noncardiac surgery. METHODS AND RESULTS We enrolled 385 patients at cardiovascular risk in 3 centers. Patients were randomized to maintenance of anesthesia with sevoflurane or propofol. We recorded continuous ECG for 48 hours perioperatively, measured troponin T and N-terminal prohormone of brain natriuretic peptide (NT-proBNP) on postoperative days 1 and 2, and evaluated postoperative delirium by the Confusion Assessment Method. At 6 and 12 months, we contacted patients by telephone to assess major adverse cardiac events. The primary end point was a composite of myocardial ischemia detected by continuous ECG and/or troponin elevation. Additional end points were postoperative NT-proBNP concentrations, major adverse cardiac events, and delirium. Patients and outcome assessors were blinded. We tested dichotomous end points by χ(2) test and NT-proBNP by Mann-Whitney test on an intention-to-treat basis. Myocardial ischemia occurred in 75 patients (40.8%) in the sevoflurane and 81 (40.3%) in the propofol group (relative risk, 1.01; 95% confidence interval, 0.78-1.30). NT-proBNP release did not differ across allocation on postoperative day 1 or 2. Within 12 months, 14 patients (7.6%) suffered a major adverse cardiac event after sevoflurane and 17 (8.5%) after propofol (relative risk, 0.90; 95% confidence interval, 0.44-1.83). The incidence of delirium did not differ (11.4% versus 14.4%; P=0.379). CONCLUSIONS Compared with propofol, sevoflurane did not reduce the incidence of myocardial ischemia in high-risk patients undergoing major noncardiac surgery. The sevoflurane and propofol groups did not differ in postoperative NT-proBNP release, major adverse cardiac events at 1 year, or delirium.
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Affiliation(s)
- Giovanna A L Lurati Buse
- Department of Anesthesia and Intensive Care Medicine, University Hospital Basel, Spitalstrasse 21, CH-4031 Basel, Switzerland.
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