Hemodynamic Responses to Two Different Anesthesia Regimens in Compromised Left Ventricular Function Patients Undergoing Coronary Artery Bypass Graft Surgery: Etomidate-Midazolam Versus Propofol-Ketamine

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Abstract

Background:

Various methods have been suggested to prevent hemodynamic instability caused by propofol and adverse effects caused by etomidate induction. The current study evaluated hemodynamic effects of propofol-ketamine mixture in comparison to etomidate-midazolam mixture during anesthesia induction.

Objectives:

The aim of this study was to evaluate the hemodynamic effects of etomidate-midazolam by comparing it with propofol-ketamine for the induction of anesthesia in patients with left ventricular dysfunction undergoing coronary artery bypass graft surgery.

Patients and Methods:

One-hundred patients aged between 40 and 65 with coronary artery disease and low ejection fraction scheduled for elective coronary artery bypass surgery participated in this study. The patients were randomly allotted to one of the two groups to receive either propofol-ketamine or etomidate-midazolam combination. Two groups were compared for pain on injection and myoclonus, Heart Rate (HR), Systolic Blood Pressure (SBP), Diastolic Blood Pressure (DBP), Mean Arterial Pressure (MAP), Cardiac Index (CI) and Systemic Vascular Resistance (SVR), before and one minute after induction of anesthesia, and one, three and five minutes after intubation.

Results:

Incidence of pain on injection (2 - 4%) and myoclonus (10%) was less in both groups. The hemodynamic response was similar in the two groups for all variables over the time interval, except for CI at one and three minutes after intubation (P = 0.024 and P = 0.048, respectively), and SVR in five minutes after intubation (P = 0.009), with differences being statistically significant.

Conclusions:

Both anesthetic regimens were acceptable for induction in patients with coronary artery disease and left ventricular dysfunction undergoing coronary artery bypass graft surgery.

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Most cited references 33

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Sympathetic responses to induction of anesthesia in humans with propofol or etomidate.

R Berens, M. Muzi, T Ebert … (1992)

Anesthetic induction with propofol commonly results in hypotension. This study explored potential mechanisms contributing to hypotension by recording cardiovascular responses including sympathetic neural activity from patients during induction of anesthesia with propofol (2.5 mg.kg-1 plus 200 micrograms.kg-1.min-1) or, for comparison, etomidate (0.3 mg.kg-1 plus 15 micrograms.kg-1.min-1). Twenty-five consenting, nonpremedicated, ASA physical status 1 and 2, surgical patients were evaluated. Measurements of R-R intervals (ECG), blood pressure (radial artery), forearm vascular resistance (plethysmography), and efferent muscle sympathetic nerve activity ([MSNA] microneurography: peroneal nerve) were obtained at rest and during induction of anesthesia. In addition, a sequential bolus of nitroprusside (100 micrograms) followed by phenylephrine (150 micrograms) was used to obtain data to quantitate the baroreflex regulation of cardiac function (R-R interval) and sympathetic outflow (MSNA) in the awake and anesthetized states. Etomidate induction preserved MSNA, forearm vascular resistance, and blood pressure, whereas propofol reduced MSNA by 76 +/- 5% (mean +/- SEM), leading to a reduction in forearm vascular resistance and a significant hypotension. Both cardiac and sympathetic baroslopes were maintained with etomidate but were significantly reduced with propofol, especially in response to hypotension. These findings suggest that propofol-induced hypotension is mediated by an inhibition of the sympathetic nervous system and impairment of baroreflex regulatory mechanisms. Etomidate, conversely, maintains hemodynamic stability through preservation of both sympathetic outflow and autonomic reflexes.

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Prevention of etomidate-induced myoclonus: Which is superior: Fentanyl, midazolam, or a combination? A Retrospective comparative study

Ilke Isitemiz, Sinan Uzman, Mehmet Toptas … (2014)

Background In this retrospective comparative study, we aimed to compare the effectiveness of fentanyl, midazolam, and a combination of fentanyl and midazolam to prevent etomidate-induced myoclonus. Material/Methods This study was performed based on anesthesia records. Depending on the drugs that would be given before the induction of anesthesia with etomidate, the patients were separated into 4 groups: no pretreatment (Group NP), fentanyl 1 μg·kg−1 (Group F), midazolam 0.03 mg·kg−1 (Group M), and midazolam 0.015 mg·kg−1 + fentanyl 0.5 μg·kg−1 (Group FM). Patients who received the same anesthetic procedure were selected: 2 minutes after intravenous injections of the pretreatment drugs, anesthesia is induced with 0.3 mg·kg−1 etomidate injected intravenously over a period of 20–30 seconds. Myoclonic movements are evaluated, which were observed and graded according to clinical severity during the 2 minutes after etomidate injection. The severity of pain due to etomidate injection, mean arterial pressure, heart rate, and adverse effects were also evaluated. Results Study results showed that myoclonus incidence was 85%, 40%, 70%, and 25% in Group NP, Group F, Group M, and Group FM, respectively, and were significantly lower in Group F and Group FM. Conclusions We conclude that pretreatment with fentanyl or combination of fentanyl and midazolam was effective in preventing etomidate-induced myoclonus.

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Ability of a meta-analysis to prevent redundant research: systematic review of studies on pain from propofol injection

Céline Habre, Martin Tramèr, Daniel Pöpping … (2014)

Objective To examine whether, according to the conclusions of a 2000 systematic review with meta-analysis on interventions to prevent pain from propofol injection that provided a research agenda to guide further research on the topic, subsequently published trials were more often optimally blinded, reported on children, and used the most efficacious intervention as comparator; and to check whether the number of new trials published each year had decreased and whether the designs of trials that cited the review differed from those that did not. Study design Systematic review comparing old trials (published before, and included in, the review) with new trials (published afterwards). Data sources Medline, Cochrane, Embase, and bibliographies to January 2013. Eligibility criteria for study selection Randomised studies testing any intervention to prevent pain from propofol injection in humans. Results 136 new trials (19 778 patients) were retrieved. Compared with the 56 old trials (6264 patients), the proportion of optimally blinded trials had increased from 10.7% to 38.2% (difference 27.5%, 95% confidence interval 16.0% to 39.0%, P<0.001), and the proportion of trials that used the most efficacious intervention as comparator had increased from 12.5% to 27.9% (difference 15.4%, 4.0% to 26.9%, P=0.022). The proportion of paediatric trials had increased from 5.4% to 12.5%, although this was not significant (difference 7.1%, −1.0% to 15.2%, P=0.141). The number of new trials published each year was significantly higher (median number/year 12 (range 7-20) v 2.5 (0-9), P<0.001) with no obvious decreasing trend. 72.8% (n=99) of the new trials cited the review, with their designs similar to trials not citing the review. Only 36.0% (n=49) of the new trials were considered clinically relevant since they used the most efficacious intervention as comparator or included a paediatric population. Conclusions The impact of the systematic review on the design of subsequent research was low. There was an improvement in the reporting of optimal blinding procedures and a tendency towards an increase in the proportion of paediatric trials. The most efficacious intervention was more often chosen as comparator but remained marginally used, and the number of trials published per year had not decreased. The use of systematic reviews should be encouraged to inform rational, and thus ethical, trial design and improve the relevance of new research.

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Author and article information

Journal

Journal ID (nlm-ta): Anesth Pain Med

Journal ID (iso-abbrev): Anesth Pain Med

Journal ID (doi): 10.5812/aapm

Journal ID (publisher-id): Kowsar

Title: Anesthesiology and Pain Medicine

Publisher: Kowsar

ISSN (Print): 2228-7523

ISSN (Electronic): 2228-7531

Publication date (Electronic): 22 June 2015

Publication date Collection: June 2015

Volume: 5

Issue: 3

Electronic Location Identifier: e27966

Affiliations

[1 ]Rajaie Cardiovascular Medical Research Center, Iran University of Medical Sciences, Tehran, Iran

Author notes

[* ]Corresponding author: Mohsen Ziyaeifard, Rajaie Cardiovascular Medical Research Center, Iran University of Medical Sciences, Tehran, Iran. Tel: +98-2123922152, Fax: +98-2122663293, E-mail: Mziyaeifard@ 123456yahoo.com

Article

DOI: 10.5812/aapm.27966v2

PMC ID: 4493732

SO-VID: 66e222cb-bbf2-4564-b68a-cc5df3c4307d

License:

This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License ( http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited.

History

Date received : 14 February 2015

Date revision received : 01 March 2015

Date accepted : 08 March 2015

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Hemodynamic Responses to Two Different Anesthesia Regimens in Compromised Left Ventricular Function Patients Undergoing Coronary Artery Bypass Graft Surgery: Etomidate-Midazolam Versus Propofol-Ketamine

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Abstract

Background:

Objectives:

Patients and Methods:

Results:

Conclusions:

Related collections

Probing cerebral hemodynamics with BOLD fMRI

Most cited references 33

Sympathetic responses to induction of anesthesia in humans with propofol or etomidate.

Prevention of etomidate-induced myoclonus: Which is superior: Fentanyl, midazolam, or a combination? A Retrospective comparative study

Ability of a meta-analysis to prevent redundant research: systematic review of studies on pain from propofol injection

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Cited by 8