A Recipe for Perioperative Cardioprotection: What Matters Most? The Ingredients or the Chef?

Medical College of Wisconsin, Milwaukee, WI.
Circulation (Impact Factor: 14.43). 11/2012; 126(23). DOI: 10.1161/CIRCULATIONAHA.112.147785
Source: PubMed


The question of what is the ideal anesthetic for patients with cardiovascular disease has been debated for nearly three decades, and similarly to the case for the use of perioperative beta blockers, the answer appears to be increasingly enigmatic. In the current issue of the Journal, Buse et al(1) report the results of a randomized clinical trial to evaluate the effects of the volatile anesthetic sevoflurane versus the intravenous anesthetic propofol on the incidence of myocardial ischemia in 385 patients with known coronary artery disease or with two or more risk factors for coronary artery disease undergoing non-cardiac surgery. Using continuous electrocardiography and troponin T plasma concentrations as the composite primary endpoint of the study, the incidence of myocardial ischemia was similar in both groups (sevoflurane: 40.8%; propofol: 40.3%); calling into question the current American College of Cardiology/American Heart Association guidelines recommending the use of volatile anesthetics for patients at cardiovascular risk who are undergoing non-cardiac surgery(2).

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    ABSTRACT: In 2007, the American Heart Association (AHA) recommended (class IIa, level of evidence B) in their guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery volatile anesthetics as first choice for general anesthesia in hemodynamically stable patients at risk for myocardial ischemia. This recommendation was based on results from patients undergoing coronary artery bypass grafting (CABG) surgery and thus subject to criticism. However, since a "good anesthetic" often resembles a piece of art in the complex perioperative environment, and is difficult to highly standardize, it seems unlikely that large-scale randomized control trials in noncardiac surgical patients will be performed in the near future to tackle this question. There is growing evidence that ether-derived volatile anesthetics and opioids provide cardioprotection in patients undergoing CABG surgery. Since 2011 the American College of Cardiology Foundation/AHA recommend a "volatile-based anesthesia" for these procedures (class IIa, level of evidence A). It is very likely that volatile anesthetics and opioids also protect hearts of noncardiac surgical patients. However, age, diabetes and myocardial remodeling diminish the cardioprotective benefits of anesthetics. In patients at risk for perioperative cardiovascular complications, it is essential to abandon the use of "anti-conditioning" drugs (sulfonylureas and COX-2 inhibitors) and probably glitazones. There is significant interference in cardioprotection between sevoflurane and propofol, which should not be used concomitantly during anesthesia if possible. Any type of ischemic "conditioning" appears to exhibit markedly reduced protection or completely loses protection in the presence of volatile anesthetics and/or opioids.
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    ABSTRACT: Background Early intravenous epinephrine administration may help to achieve return of spontaneous circulation in cardiac arrest (CA). However, venous access can be challenging in small children. This study investigates the effect of intravenous and intramuscular epinephrine in treatment of asphyxial CA.Methods Twenty-eight, 2–5-weeks-old, anesthetized piglets were asphyxiated by ventilation withdrawal. CA was untreated for 8 min, followed by 2 min of basic life support. Following this, epinephrine iv (10 μg·kg−1, group IV), epinephrine im (100 μg·kg−1, group IM), or normal saline (group NS) were administered. Further doses of epinephrine were given in group IV every 4 min, in group IM after 10 min if required. After twenty-two minutes of CA, iv epinephrine was given to all animals still in CA. Outcome measures were survival and epinephrine plasma concentrations.ResultsTen animals regained spontaneous circulation after 2 min of basic life support. Therefore, no drug treatment was administered (drop out). Resuscitation was effective in 2 pigs of group IM (n = 6), in 6 of group NS (n = 8) and in all of group IV (n = 4). Nonsurvivors had higher epinephrine (P < 0.01) and norepinephrine (P < 0.01) plasma concentrations prior to start of resuscitation. Median increase in epinephrine plasma concentration from T0 to T5 was 138, 134, and 29 nm in group IV, IM, and NS, respectively.Conclusions Intravenous and intramuscular administered epinephrine led to similar increase in plasma concentrations during resuscitation of asphyxial CA without hemodynamic or survival benefit. High endogenous epinephrine and norepinephrine plasma concentrations were negative predictors for survival.
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