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      Induction of anesthesia in coronary artery bypass graft surgery: the hemodynamic and analgesic effects of ketamine

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          Abstract

          OBJECTIVE

          The aim of this prospective, randomized study was to evaluate the hemodynamic and analgesic effects of ketamine by comparing it with propofol starting at the induction of anesthesia until the end of sternotomy in patients undergoing coronary artery bypass grafting surgery.

          INTRODUCTION

          Anesthetic induction and maintenance may induce myocardial ischemia in patients with coronary artery disease. A primary goal in the anesthesia of patients undergoing coronary artery bypass grafting surgery is both the attenuation of sympathetic responses to noxious stimuli and the prevention of hypotension.

          METHODS

          Thirty patients undergoing coronary artery bypass grafting surgery were randomized to receive either ketamine 2 mg.kg −1 (Group K) or propofol 0.5 mg.kg −1 (Group P) during induction of anesthesia. Patients also received standardized doses of midazolam, fentanyl, and rocuronium in the induction sequence. The duration of anesthesia from induction to skin incision and sternotomy, as well as the supplemental doses of fentanyl and sevoflurane, were recorded. Heart rate, mean arterial pressure, central venous pressure, pulmonary arterial pressure, pulmonary capillary wedge pressure, cardiac index, systemic and pulmonary vascular resistance indices, stroke work index, and left and right ventricular stroke work indices were obtained before induction of anesthesia; one minute after induction; one, three, five, and ten minutes after intubation; one minute after skin incision; and at one minute after sternotomy.

          RESULTS

          There were significant changes in the measured and calculated hemodynamic variables when compared to their values before induction. One minute after induction, mean arterial pressure and the systemic vascular resistance index decreased significantly in group P (p<0.01).

          CONCLUSION

          There were no differences between groups in the consumption of sevoflurane or in the use of additional fentanyl. The combination of ketamine, midazolam, and fentanyl for the induction of anesthesia provided better hemodynamic stability during induction and until the end of sternotomy in patients undergoing coronary artery bypass grafting surgery.

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          Ketamine: an update on the first twenty-five years of clinical experience.

          G Silvay, D Reich (1989)
          In nearly 25 years of clinical experience, the benefits and limitations of ketamine analgesia and anaesthesia have generally been well-defined. The extensive review of White et al. and the cardiovascular review of Reves et al. are broad in their scope and have advanced the understanding of dissociative anaesthesia. Nevertheless, recent research continues to illuminate different aspects of ketamine pharmacology, and suggests new clinical uses for this drug. The identification of the N-methylaspartate receptor gives further support to the concept that ketamine's analgesic and anaesthetic effects are mediated by separate mechanisms. The stereospecific binding of (+)ketamine to opiate receptors in vitro, more rapid emergence from anaesthesia, and the lower incidence of emergence sequelae, make (+)ketamine a promising drug for future research. Clinical applications of ketamine that have emerged recently, and are likely to increase in the future, are the use of oral, rectal, and intranasal preparations for the purposes of analgesia, sedation, and anaesthetic induction. Ketamine is now considered a reasonable option for anaesthetic induction in the hypotensive preterm neonate. The initial experience with epidural and intrathecal ketamine administration has not been very promising but the data are only preliminary in this area. The use of ketamine in military and catastrophic settings is likely to become more common. The clinical availability of midazolam will complement ketamine anaesthesia in several ways. This rapidly metabolized benzodiazepine reduces ketamine's cardiovascular stimulation and emergence phenomena, and does not have active metabolites. It is dispensed in an aqueous medium, which is usually non-irritating on intravenous injection, unlike diazepam. The combination of ketamine and midazolam is expected to achieve high patient acceptance, which never occurred with ketamine as a sole agent. Finally, it is necessary to point out the potential for abuse of ketamine. While ketamine is not a controlled substance (in the United States), the prudent physician should take appropriate precautions against the unauthorized use of this drug.
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            The cardiovascular effects of ketamine used for induction of anaesthesia in patients with valvular heart disease.

            P Skovsted, M Sørensen, J Korshin … (1979)
            The effects of induction of anaesthesia by ketamine 2 mg.kg-1 were studied in six patients with valvular heart disease before tracheal intubation and operation. Cardiac index was unaffected because a mean decrease in stroke index was compensated for a mean increase in heart rate. A significant increase was found in mean arterial pressure, pulmonary arterial mean pressure, pulmonary capillary wedge pressure and central venous pressure. Systemic vascular resistance increased, but not significantly, whereas pulmonary vascular resistance increased significantly by more than 150 per cent. Right ventricular minute work index increased in all patients, and the increase was as much as 400 per cent. Left ventricular minute work index increased in four of the six patients, but the magnitude of the increase was not so marked. It is therefore concluded that ketamine causes pronounced pulmonary vasoconstriction and an undesirable strain on the myocardium. Such effects could prove deleterious in patients with limited functional reserve of the right ventricle.
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              Effect of bispectral index monitoring on sevoflurane consumption.

              U Büyükkoçak, A Apan, H Basar … (2003)
              The bispectral index, a parameter derived from the electroencephalograph, has been shown to correlate with the loss of consciousness and sedation. This study was designed to assess the effects of bispectral index monitoring on sevoflurane and its recovery profiles. Sixty ASA I and II patients undergoing open abdominal surgery were randomized into two groups: one monitored using the bispectral index (Group BIS) and the other without its use (controls). After a standardized induction, anaesthesia was maintained with sevoflurane in both groups. In Group BIS, sevoflurane was titrated to maintain the bispectral index in the range 40-60. In the control group, the administered sevoflurane concentration was adjusted according to the signs of anaesthesia. The end-tidal sevoflurane concentration, bispectral index and routine haemodynamic variables were noted every 5 min during surgery. The consumption of sevoflurane was computed. At the conclusion of surgery operations, the time to 'open eyes on verbal command', 'motor response to verbal command' and Aldrete's score were recorded by a blinded anaesthesiologist. The difference in the consumption of sevoflurane was not significant between the groups. Bispectral index monitoring was associated with a reduction of 4.73% in sevoflurane usage and 2.19 mL h(-1) was saved. Bispectral index monitoring during anaesthesia provides only a small advantage related to the need to monitor the depth of anaesthesia.
              Article 0 comments Cited 7 times – based on 0 reviews     Review now
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                Author and article information

                Journal
                Journal ID (nlm-ta): Clinics (Sao Paulo)
                Title: Clinics
                Publisher: Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo
                ISSN (Print): 1807-5932
                ISSN (Electronic): 1980-5322
                Publication date (Print): February 2010
                Volume: 65
                Issue: 2
                Pages: 133-138
                Affiliations
                Uludag University School of Medicine, Department of Anesthesiology and Reanimation - Bursa, Turkey, Email: basagan@ 123456uludag.edu.tr , Tel.: 90 224 442 80 39
                Article
                Publisher ID: cln_65p133
                DOI: 10.1590/S1807-59322010000200003
                PMC ID: 2827698
                PubMed ID: 20186295
                SO-VID: e5fce9b1-d9cb-40a0-b120-b1ecee3bdbc5
                Copyright © Copyright © 2010 Hospital das Clínicas da FMUSP
                History
                Date received : 26 October 2009
                Date accepted : 3 November 2009
                Categories
                Subject: Clinical Sciences

                ScienceOpen disciplines: Medicine
                Keywords: propofol,fentanyl,coronary artery bypass grafting,midazolam,ketamine
                Data availability:
                ScienceOpen disciplines: Medicine
                Keywords: propofol, fentanyl, coronary artery bypass grafting, midazolam, ketamine

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