Volatile Agents for Cardiac Protection in Noncardiac Surgery: A Randomized Controlled Study
Volatile anesthetics reduce the risk of myocardial infarction and mortality in coronary artery surgery. Recently, the American College of Cardiology/American Heart Association Guidelines suggested the use of volatile anesthetic agents for the maintenance of general anesthesia during noncardiac surgery in patients at risk for perioperative myocardial ischemia, but no randomized experience to document the cardioprotective effects of these agents exists in this setting. Therefore, the authors performed a prospective, randomized, controlled trial to compare the effects of sevoflurane versus total intravenous anesthesia, in terms of postoperative cardiac troponin I release in patients undergoing noncardiac surgery.
A randomized, controlled trial.
A teaching hospital.
Eighty-eight consecutive patients undergoing noncardiac surgery.
Patients were allocated randomly to receive either volatile anesthetic (44 patients) as the main anesthetic agent or total intravenous anesthesia (TIVA) (44 patients).
Postoperative cardiac troponin I release was measured as a marker of myocardial necrosis. Patients with detectable postoperative troponin I in the sevoflurane group (12/44, 27.3%) were similar to those in the propofol group (9/44, 20.5%; p = 0.6). There was no significant reduction of postoperative median peak cTnI release (0.16 ± 0.71 ng/mL in the sevoflurane group compared with the TIVA group, 0.03 ± 0.08 ng/mL; p = 0.4). Three patients died at the 1-year follow-up for noncardiac causes (2 in the TIVA group).
In the authors' experience, patients undergoing noncardiac surgery did not benefit from anesthesia based on halogenated anesthetics. Further studies are necessary to evaluate the cardioprotective effects of volatile agents in noncardiac surgery.
Available from: Erol Cavus
- "Preconditioning by sevoflurane is a pharmacological alternative to IPC. Patients who received sevoflurane for anesthesia during cardiac surgery had decreased postoperative mortality, less myocardial infarction and shorter length of hospital stay [6,7]. "
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ABSTRACT: Background: Ischemic or volatile anesthetic preconditioning is defined as tissue protection from impending ischemic cell damage by repetitive short periods of tissue exposure to ischemia or volatile anesthetics. Objective of this study was to elucidate, if ischemic preconditioning and pharmacological preconditioning with sevoflurane have effects on muscle tissue oxygen saturation in patients undergoing surgical revascularization of the lower limb. Methods: In this prospective randomized pilot study ischemic and pharmacological (sevoflurane) preconditioning was performed in 40 patients with lower limb arterial occlusive disease undergoing surgical revascularization. Sevoflurane preconditioning was performed in one group (N = 20) by repetitive application of sevoflurane for six minutes interspersed by six minutes of washout. Thereafter, ischemic preconditioning was performed in all patients (N = 40) by repetitive clamping of the femoral artery for six minutes interspersed by six minutes of reperfusion. The effect of both procedures on leg muscle tissue oxygen saturation (rSO(2)) was measured by near-infrared spectroscopy during both procedures and during surgery and reperfusion (INVOS (R) 5100C Oxymeter with Small Adult SomaSensor (R) SAFB-SM, Somanetics, Troy, Michigan, USA). Results: Repetitive clamping and reperfusion of the femoral artery resulted in significant cyclic decrease and increase of muscle rSO(2) (p < 0.0001). Pharmacological preconditioning with sevoflurane resulted in a faster and higher increase of rSO(2) during postoperative reperfusion (Maximal 111% baseline +/- 20 versus 103% baseline +/- 14, p = 0.008) consistent with an additional effect of pharmacological preconditioning on leg perfusion. Conclusions: Ischemic preconditioning of lower limb muscle tissue and pharmacological preconditioning with sevoflurane have an effect on tissue oxygenation in patients with lower limb occlusive arterial disease.
Available from: Prakash A Patel
- "Although a meta-analysis  has suggested that volatile anesthetics are cardioprotective, a string of recent randomized trials has failed to demonstrate any reduction of perioperative myocardial risk both in cardiac and non-cardiac surgery [57,58,59,60]. These trials have all been single-center investigations and thus may have failed to detect an outcome effect from exposure to volatile anesthesia due to inadequate power. "
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ABSTRACT: The past year has witnessed major advances in of cardiovascular anesthesia and intensive care. Perioperative interventions such as anesthetic design, inotrope choice, glycemic therapy, blood management, and noninvasive ventilation have significant potential to enhance perioperative outcomes even further.
The major theme for 2011 is the international consensus conference that focused on ancillary interventions likely to reduce mortality in cardiac anesthesia and intensive care. This landmark conference prioritized volatile anesthetics, levosimendan, and insulin therapy for their promising life-saving perioperative potential. Although extensive evidence has demonstrated the cardioprotective effects of volatile anesthetics, levosimendan as well as glucose, insulin and potassium therapy, the clinical relevance of these beneficial effects remains to be fully elucidated. Furthermore, controversy still persists about how tight perioperative glucose control should be in adult cardiac surgery because of the risk of hypoglycemia.
A second major theme in 2011 has been perioperative hemostasis with the release of multispecialty guidelines. Furthermore, hemostatic agents such as recombinant factor VIIa and tranexamic acid have been studied intensively, even in the setting of major non-cardiac surgery. This review then highlights the remaining two major themes for 2011, namely the expanding role of noninvasive ventilation in our specialty and the formation of the Roland Hetzer International Cardiothoracic and Vascular Surgery Society.
In conclusion, it is time for large adequately powered multicenter trials to test whether prioritized perioperative interventions truly reduce mortality and morbidity in cardiac surgical patients. This essential paradigm shift represents a major clinical opportunity for the global cardiovascular anesthesia and critical care community.
Available from: Tobias Piegeler
- "Volatile anesthetics might induce a protective signaling in the myocardial cells in defined windows only. Such considerations would also explain the results of the randomized controlled study performed by Zangrillo et al. , in which conditioning with volatile anesthetics in patients undergoing noncardiac surgery was not superior to an anesthesia regimen with propofol. Therefore evidence of the guidelines from the American College of Cardiology/American Heart Association  recommending volatile anesthetics for maintenance of general anesthesia in patients at risk for myocardial events is questionable . "
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ABSTRACT: INTRODUCTION: The aim of this randomized controlled trial was to investigate whether volatile anesthetics used for postoperative sedation have any beneficial effects on myocardial injury in cardiac surgery patients after on-pump valve replacement. METHODS: Anesthesia was performed with propofol. After arrival in the intensive care unit (ICU), 117 patients were randomized to be sedated for at least 4 hours with either propofol or sevoflurane. Sevoflurane was administered by using the anesthetic-conserving device. Troponin T, creatine kinase, creatine kinase from heart muscle tissue, myoglobin, and oxygenation index were determined on arrival at the ICU, 4 hours after sedation, and in the morning of the first postoperative day (POD1). Primary end points were cardiac injury markers on POD1. As secondary end points oxygenation, postoperative pulmonary complications, and ICU and hospital stay were documented. RESULTS: Fifty-six patients were analyzed in the propofol arm, and 46 patients in the sevoflurane arm. Treatment groups were comparable with regard to patient demographics and intraoperative characteristics. Concentration of troponin T as the most sensitive marker for myocardial injury at POD1 was significantly lower in the sevoflurane group compared with the propofol group (unadjusted difference, -0.4; 95% CI, -0.7 to -0.1; P < 0.01; adjusted difference, -0.2; 95% CI, -0.4 to -0.02; P = 0.03, respectively). CONCLUSIONS: The data presented in this investigation indicate that late postconditioning with the volatile anesthetic sevoflurane might mediate cardiac protection, even with a late, brief, and low-dose application.
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