Correlation of location of acute myocardial infarct after noncardiac vascular surgery with preoperative dobutamine echocardiographic findings.
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Adult↗
Biomedical subjects
I R Thomson
Publications and source records attributed to I R Thomson.
Predictors of cardiac events after major vascular surgery: Role of clinical characteristics, dobutamine echocardiography, and beta-blocker therapy.
CONTEXT: Patients who undergo major vascular surgery are at increased risk of perioperative cardiac complications. High-risk patients can be identified by clinical factors and noninvasive cardiac testing, such as dobutamine stress echocardiography (DSE); however, such noninvasive imaging techniques carry significant disadvantages. A recent study found that perioperative beta-blocker therapy reduces complication rates in high-risk individuals. OBJECTIVE: To examine the relationship of clinical characteristics, DSE results, beta-blocker therapy, and cardiac events in patients undergoing major vascular surgery. DESIGN AND SETTING: Cohort study conducted in 1996-1999 in the following 8 centers: Erasmus Medical Centre and Sint Clara Ziekenhuis, Rotterdam, Twee Steden Ziekenhuis, Tilburg, Academisch Ziekenhuis Utrecht, Utrecht, and Medisch Centrum Alkmaar, Alkmaar, the Netherlands; Ziekenhuis Middelheim, Antwerp, Belgium; and San Gerardo Hospital, Monza, Istituto di Ricovero e Cura a Carattere Scientifico, San Giovanni Rotondo, Italy. PATIENTS: A total of 1351 consecutive patients scheduled for major vascular surgery; DSE was performed in 1097 patients (81%), and 360 (27%) received beta-blocker therapy. MAIN OUTCOME MEASURE: Cardiac death or nonfatal myocardial infarction within 30 days after surgery, compared by clinical characteristics, DSE results, and beta-blocker use. RESULTS: Forty-five patients (3.3%) had perioperative cardiac death or nonfatal myocardial infarction. In multivariable analysis, important clinical determinants of adverse outcome were age 70 years or older; current or prior angina pectoris; and prior myocardial infarction, heart failure, or cerebrovascular accident. Eighty-three percent of patients had less than 3 clinical risk factors. Among this subgroup, patients receiving beta-blockers had a lower risk of cardiac complications (0.8% [2/263]) than those not receiving beta-blockers (2.3% [20/855]), and DSE had minimal additional prognostic value. In patients with 3 or more risk factors (17%), DSE provided additional prognostic information, for patients without stress-induced ischemia had much lower risk of events than those with stress-induced ischemia (among those receiving beta-blockers, 2.0% [1/50] vs 10.6% [5/47]). Moreover, patients with limited stress-induced ischemia (1-4 segments) experienced fewer cardiac events (2.8% [1/36]) than those with more extensive ischemia (>/=5 segments, 36% [4/11]). CONCLUSION: The additional predictive value of DSE is limited in clinically low-risk patients receiving beta-blockers. In clinical practice, DSE may be avoided in a large number of patients who can proceed safely for surgery without delay. In clinically intermediate- and high-risk patients receiving beta-blockers, DSE may help identify those in whom surgery can still be performed and those in whom cardiac revascularization should be considered.
Adrenergic beta-Antagonists↗
Bisoprolol reduces cardiac death and myocardial infarction in high-risk patients as long as 2 years after successful major vascular surgery.
AIM: To assess the long-term cardioprotective effect of bisoprolol in a randomized high-risk population after successful major vascular surgery. High-risk patients were defined by the presence of one or more cardiac risk factor(s) and a dobutamine echocardiography test positive for ischaemia. METHODS: 1351 patients were screened prior to surgery, 846 patients had one or more risk factor(s), and 173 of these patients also had ischaemia during dobutamine echocardiography. One hundred and twelve patients could be randomized for additional bisoprolol therapy or standard care. Eleven patients died in the peri-operative period (up to 1 month after surgery). Randomized patients continued bisoprolol or standard care after surgery. During follow-up of 101 survivors (median 22 months, range 11-30) cardiac death or myocardial infarction was noted. No patient was lost during follow-up. Results The incidence of cardiac events during follow-up in the bisoprolol group was 12% vs 32% in the standard care group (P=0.025). Cardiac death occurred in 15 patients, nine patients in the standard care and in six in the bisoprolol group; myocardial infarction occurred in six patients, five in the standard care and one in the bisoprolol group. The odds ratio for cardiac death or myocardial infarction after surgery in high-risk patients with additional bisoprolol therapy was 0.30 (0.11-0.83). CONCLUSIONS: Bisoprolol significantly reduced long-term cardiac death and myocardial infarction in high-risk patients after successful major cardiac vascular surgery.
Adrenergic beta-Antagonists↗
Pharmacokinetics of sufentanil in patients undergoing coronary artery bypass graft surgery.
OBJECTIVE: To determine the pharmacokinetics of sufentanil in patients undergoing coronary artery bypass graft surgery. DESIGN: Prospective, multigroup study. SETTING: University-affiliated hospital. PARTICIPANTS: Patients with good left ventricular function undergoing elective surgery (n = 103). INTERVENTIONS: Sufentanil was administered by target-controlled infusion, with target effect-site concentrations ranging from 0.4 to 4.5 ng/mL. Isoflurane was administered as required to maintain stable hemodynamics. Sufentanil pharmacokinetics were determined by population modeling. The potential effects of gender, weight, different premedications (lorazepam, morphine-scopolamine, or clonidine), and coinduction with propofol on sufentanil pharmacokinetics were explored. MEASUREMENTS AND MAIN RESULTS: The first model determined was a simple 3-compartment model, without any covariates, which had these parameters: V(1) = 5.7 L, V(2) = 18.1 L, V(3) = 225 L, Cl(1) = 0.69 L/min, Cl(2) = 3.1 L/min, and Cl(3) = 1.4 L/min. The overall predictive ability during the entire pre-cardiopulmonary bypass period of this model was excellent, with virtually no bias (median prediction error, -0.4%) and good precision (median absolute prediction error, 18.4%). More complex models with the various premedications used or coinduction with propofol as covariates did not improve the predictive accuracy or precision compared with the simple 3-compartment model. Similarly, including either gender or weight as a covariate did not improve predictive ability. CONCLUSION: The authors have determined a pharmacokinetic model for sufentanil that can be used to maintain desired target concentrations of sufentanil before cardiopulmonary bypass, with a high degree of accuracy and acceptable variability. Concomitantly administered medications (lorazepam, morphine-scopolamine, clonidine, or propofol) do not appear to have any clinically important effects on distribution-phase sufentanil pharmacokinetics.
Aged↗
Long-term prognostic value of dobutamine stress echocardiography in patients with atrial fibrillation.
STUDY OBJECTIVE: To assess the long-term prognostic value of dobutamine stress echocardiography (DSE) for cardiac events (cardiac death, myocardial infarction, and late revascularization) in patients with atrial fibrillation (AF). METHODS: Baseline ECGs were studied in patients undergoing DSE between 1989 and 1998. Sixty-nine patients had AF before DSE. Prognostic value of DSE in these patients was compared with a control group who had sinus rhythm (n = 1,664). The presence of stress-induced ischemia was noted for every patient. The mean follow-up period was 35 months (range, 6 to 84 months). Data are presented as hazards ratio (HR) with 95% confidence interval (CI). RESULTS: Heart rate at rest was higher in patients with AF (77 +/- 15 beats/min vs 73 +/- 14 beats/min; p = 0.04); however, double product at peak stress was not different between patients with AF and sinus rhythm (17,602 vs 17,169, respectively; p = 0.46). In patients with AF, target heart rate was achieved at a lower dobutamine dose (33 +/- 8 microg/kg/min vs 35 +/- 9 microg/kg/min; p = 0.01). Cardiac arrhythmias occurred more frequently (12% vs 5%; p = 0.001) in patients with AF during DSE. During a follow-up period of 7 years, cardiac death occurred in 5 patients, myocardial infarction in 2 patients, and late revascularization in 10 patients. Prognostic value of DSE for all late cardiac events was similar in patients with AF (HR, 3.0; 95% CI, 0.9 to 9.5) and sinus rhythm (HR, 3.4; 95% CI, 2.7 to 4.3; p = 0.85). CONCLUSION: The prognostic value of DSE for late cardiac events is maintained in patients with AF.
Aged↗
A comparison of fentanyl and sufentanil in patients undergoing coronary artery bypass graft surgery.
OBJECTIVE: To compare fentanyl and sufentanil, administered in equipotent concentrations by target-controlled infusion, as components of a balanced anesthetic in patients undergoing coronary artery bypass graft (CABG) surgery. DESIGN: A prospective, randomized, double-blind trial. SETTING: A university hospital. PARTICIPANTS: Twenty-one patients undergoing nonemergent, primary CABG surgery. INTERVENTIONS: Patients received fentanyl (group F, n = 10) or sufentanil (group S, n = 11) by target-controlled infusion throughout the pre-cardiopulmonary bypass (CPB) period. To ensure equipotency, the target effect-site concentrations employed (fentanyl, 8.1 ng/mL, and sufentanil, 0.68 ng/mL) were equal to the IC50 for electroencephalographic effect. Isoflurane was administered as needed to maintain pre-CPB hemodynamics near preoperative baseline values. MEASUREMENTS AND MAIN RESULTS: Hemodynamics and end-tidal isoflurane concentration were measured every 15 to 30 seconds. Serum opioid concentrations were measured 5 times between induction and CPB. Opioid cost was based on the number of ampules opened to provide the administered dose. The 2 groups were similar demographically. The pre-CPB serum opioid concentrations were constant and averaged fentanyl, 5.8 +/- 1.9 ng/mL, and sufentanil, 0.59 +/- 0.13 ng/mL. Pre-CPB hemodynamics were stable and similar in both groups. Pre-CPB end-tidal isoflurane requirements did not differ between groups and averaged 0.46 +/- 0.21% in group F and 0.56 +/- 0.24% in group S. The duration of post-operative endotracheal intubation was 9.1 +/- 5.0 hours in group F and 8.0 +/- 3.2 hours in group S (p = NS). The cost per patient of fentanyl (Canadian $6.12 +/- 1.04) was less than that of sufentanil (Canadian $17.47 +/- 4.65). CONCLUSIONS: When administered in a constant 10:1 concentration ratio, fentanyl and sufentanil do not differ in their ability to facilitate pre-CPB hemodynamic control. Although both opioids were relatively inexpensive, the acquisition cost of fentanyl was less than sufentanil. A recommendation regarding the opioid of choice for routine use in patients undergoing CABG surgery awaits more rigorous studies of recovery and cost after equipotent doses of fentanyl and sufentanil. When combined with isoflurane, effect-site opioid concentrations near the IC50 for electroencephalographic effect provide excellent pre-CPB hemodynamic control in patients undergoing CABG surgery.
Adjuvants, Anesthesia↗
Role of dobutamine stress echocardiography for preoperative cardiac risk assessment before major vascular surgery: a diagnostic tool comes of age.
BACKGROUND: Cardiac complications are a major cause for perioperative mortality and morbidity. Also, the presence and severity of underlying coronary artery disease (CAD) determine long-term prognosis after successful surgery. AIM: This overview evaluates the additional value of dobutamine stress echocardiography (DSE) to common clinical cardiac risk factors and other noninvasive cardiac imaging modalities for perioperative and late cardiac prognosis. RESULTS: DSE provides theattending physician with preoperative prognostic information for perioperative and long-term prognosis for cardiac events. It also enables the selection of high risk patients for evaluation of cardiac risk reduction therapies. CONCLUSIONS: DSE is a useful tool for preoperative cardiac risk evaluation in addition to common clinical cardiac risk factors.
Cardiotonic Agents↗
The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery. Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography Study Group.
BACKGROUND: Cardiovascular complications are the most important causes of perioperative morbidity and mortality among patients undergoing major vascular surgery. METHODS: We performed a randomized, multicenter trial to assess the effect of perioperative blockade of beta-adrenergic receptors on the incidence of death from cardiac causes and nonfatal myocardial infarction within 30 days after major vascular surgery in patients at high risk for these events. High-risk patients were identified by the presence of both clinical risk factors and positive results on dobutamine echocardiography. Eligible patients were randomly assigned to receive standard perioperative care or standard care plus perioperative beta-blockade with bisoprolol. RESULTS: A total of 1351 patients were screened, and 846 were found to have one or more cardiac risk factors. Of these 846 patients, 173 had positive results on dobutamine echocardiography. Fifty-nine patients were randomly assigned to receive bisoprolol, and 53 to receive standard care. Fifty-three patients were excluded from randomization because they were already taking a beta-blocker, and eight were excluded because they had extensive wall-motion abnormalities either at rest or during stress testing. Two patients in the bisoprolol group died of cardiac causes (3.4 percent), as compared with nine patients in the standard-care group (17 percent, P=0.02). Nonfatal myocardial infarction occurred in nine patients given standard care only (17 percent) and in none of those given standard care plus bisoprolol (P<0.001). Thus, the primary study end point of death from cardiac causes or nonfatal myocardial infarction occurred in 2 patients in the bisoprolol group (3.4 percent) and 18 patients in the standard-care group (34 percent, P<0.001). CONCLUSIONS: Bisoprolol reduces the perioperative incidence of death from cardiac causes and nonfatal myocardial infarction in high-risk patients who are undergoing major vascular surgery.
Adrenergic beta-Antagonists↗
Long-term prognostic value of dobutamine-atropine stress echocardiography in 1737 patients with known or suspected coronary artery disease: A single-center experience.
BACKGROUND: The purpose of this study was to assess the long-term value of dobutamine-atropine stress echocardiography (DSE) for prediction of late cardiac events in patients with proven or suspected coronary artery disease. METHODS AND RESULTS: Clinical data and DSE results were analyzed in 1734 consecutive patients undergoing DSE between 1989 and 1997. Seventy-four patients who underwent revascularization within 3 months of DSE and 1 patient lost to follow-up were excluded; the remaining 1659 (median age, 62 years; range, 14 to 99 years) were followed up for 36 months (range, 6 to 96 months). Wall motion abnormalities at rest and the presence and extent of stress-induced wall motion abnormalities (ischemia) were scored for each patient. Cardiac events were related to clinical and ECG data and DSE results. Four hundred twenty-eight cardiac events occurred in 366, documented cardiac death in 108 (total death, 247), nonfatal infarction in 128, and late revascularization in 192 patients. In a multivariable Cox proportional-hazards model, the ratio of documented cardiac death or (re)infarction was increased in the presence of stress-induced ischemia (hazard ratio, 3.3; 95% CI, 2.4 to 4.4) and extensive rest wall motion abnormalities (hazard ratio, 1.9; 95% CI, 1.3 to 2.6). The number of ischemic segments was predictive for late cardiac events. A normal DSE carried a relatively good prognosis, with an annual event rate of cardiac death or infarction of 1.3% over a 5-year period. CONCLUSIONS: In a large group of patients, DSE has an added value for predicting late cardiac events during long-term follow-up, improving the separation between high- risk and very-low-risk patients.
Adolescent↗
Does sufentanil concentration influence isoflurane requirements during coronary artery bypass grafting?
OBJECTIVE: To search for concentration-related suppression of hemodynamic responsiveness by sufentanil. DESIGN: Prospective, randomized, double-blind study. SETTING: University hospital. PARTICIPANTS: Patients undergoing elective coronary artery bypass grafting (CABG). INTERVENTION: Patients were assigned to target effect-site sufentanil concentrations of 1.5 ng/mL (group L; n = 14), 3.0 ng/mL (group M; n = 13), or 4.5 ng/mL (group H; n = 12). Sufentanil was administered by computer-assisted continuous infusion. Isoflurane was used to maintain intraoperative hemodynamics near preoperative values. MEASUREMENTS AND MAIN RESULTS: Hemodynamics, the electroencephalographic spectral edge (SE95), and end-tidal isoflurane concentration (ET-ISO) were measured every 10 to 30 seconds during the prebypass period. Serum sufentanil concentration was measured at intervals. Prebypass serum sufentanil concentrations were stable, averaging 3.0 +/- 0.7, 5.1 +/- 1.1, and 7.1 +/- 1.3 ng/mL in groups L, M, and H, respectively. The groups did not differ with respect to the speed of induction, intraoperative hemodynamics, incidence of isoflurane use, or isoflurane concentrations required. ET-ISO and serum sufentanil levels were not correlated. Among seven group L patients who did not require isoflurane, the average prebypass serum sufentanil concentration ranged from 1.7 to 3.3 ng/mL. CONCLUSION: Sufentanil does not induce concentration-related suppression of hemodynamic responsiveness over the range studied. A stable serum sufentanil concentration of 3.0 +/- 0.7 ng/mL induces the maximal opioid effect and need not be exceeded in patients undergoing CABG. A sufentanil concentration of 1.7 ng/mL provides clinically adequate anesthesia without supplementation in some premedicated patients undergoing CABG.
Aged↗
Safety and utility of atropine addition during dobutamine stress echocardiography for the assessment of viable myocardium in patients with severe left ventricular dysfunction.
OBJECTIVE: To assess the feasibility safety and side effects of the addition of atropine to dobutamine stress echocardiography for the detection of viable myocardium in patients with left ventricular dysfunction (ejection fraction < or = 35%) prior to coronary revascularization. BACKGROUND: The assessment of viable and/or ischaemic myocardium has high prognostic value as regards improvement of function and survival after coronary revascularization. The addition of atropine to dobutamine during echocardiographic testing for the presence of viable myocardium is not common practice. Consequently, no data exist on the safety and additional diagnostic value of this practice. METHODS: Two hundred patients with left ventricular ejection fraction < or = 35% were studied. RESULTS: Test end-points were: target heart rate in 164 (82%) of the patients, severe angina in 18 (9%), maximum dobutamine-atropine dose in six (3%), severe ST segment changes in five (2%), cardiac arrhythmias in four (2%), and hypotension in three (1%). Viability could be assessed echocardiogaphically in 105/200 (53%) from a biphasic response (improvement of wall motion with low dose dobutamine and worsening with high dose), in 93 from ischaemia and in 12 from sustained or late improvements. In 36/105 (34%) patients, ischaemic myocardium could only be assessed after the addition of atropine. Cardiac arrhythmias occurred in 11/200 (6%) and hypotension (decrease of systolic blood pressure >30 mmHg) in 21/200 (11%). Neither the use of atropine nor the induction of ischaemia were associated with an increased incidence of cardiac arrhythmias or hypotension. CONCLUSIONS: In a large group of patients with severe left ventricular dysfunction, dobutamine stress echocardiography is feasible and safe in 186/200 (93%); the addition of atropine was necessary in 34% to assess myocardial viability. Hypotension and cardiac arrhythmias were the most frequent side effects, but were not related to the induction of ischaemia or addition of atropine.
Adult↗
A comparison of clonidine with conventional preanesthetic medication in patients undergoing coronary artery bypass grafting.
UNLABELLED: In this controlled study, we compared clonidine with conventional premedication in 35 patients undergoing coronary artery bypass grafting (CABG). After premedication with clonidine 5 microg/kg p.o. (Group C, n = 11), lorazepam 60 microg/kg p.o. (Group L, n = 13), or morphine 0.1 mg/kg plus scopolamine 6 microg/kg i.m. (Group M, n = 11), sedation, anxiety, and quality of premedication were graded. After the administration of sufentanil 2.0 microg/kg over 12.5 min, a computer-assisted infusion device targeted a sufentanil effect-site concentration of 0.75 ng/mL. Hemodynamic variables, end-tidal isoflurane concentration (ET-ISO), the electroencephalographic spectral edge, and the serum sufentanil concentration (SUF) were measured. There were no intergroup differences in anxiety, sedation, quality of premedication, the dose of sufentanil causing unconsciousness, or the electroencephalographic (EEG) response to induction. Intraoperative SUF was stable, with no intergroup difference. The average prebypass ET-ISO was lower in Group C than in Group M. The ET-ISO and peak ET-ISO after intense surgical stimulation were lower in Group C versus Groups L and M. Mean arterial blood pressure was lower in Group C versus Groups L and M. There were no intergroup differences in pharmacologic intervention, time to extubation, or intensive care unit stay. Clonidine produces sedation, anxiolysis, and quality of premedication comparable to conventional premedication. Compared with other drugs, clonidine does not alter the dose of sufentanil inducing unconsciousness or EEG slowing, but it uniquely reduces isoflurane requirements. IMPLICATIONS: In patients undergoing coronary artery bypass grafting, clonidine produces sedation and relieves anxiety as effectively as conventional premedication. Clonidine does not uniquely alter the dose of sufentanil inducing unconsciousness or electroencephalographic slowing, but it significantly reduces isoflurane requirements.
Adrenergic alpha-Agonists↗
Concentration-response relationships for fentanyl and sufentanil in patients undergoing coronary artery bypass grafting.
BACKGROUND: Concentration-response relationships for sufentanil and fentanyl are undefined in patients undergoing coronary artery bypass grafting. METHODS: Separate studies of sufentanil and fentanyl were performed in lorazepam-premedicated patients undergoing coronary artery bypass grafting. Patients were assigned randomly to groups with different prebypass effect-site opioid concentrations targeted by computer-assisted infusion. The target sufentanil concentrations were 0.4 ng/ml (group LS, n = 11), 0.8 ng/ml (group MS, n = 10), and 1.2 ng/ml (group HS, n = 11); the target fentanyl concentrations were 5 ng/ml (group LF, n = 7), 10 ng/ml (group MF, n = 7), and 15 ng/ml (group HF, n = 6). Propofol at a dose of 1 mg/kg was administered at induction of anesthesia and isoflurane was used for hemodynamic control Hemodynamics, end-tidal isoflurane concentration, and opioid concentration in arterial blood were measured at specific intervals. RESULTS: Intraoperative opioid concentrations were constant, averaging 0.71 +/- 0.13, 1.25 +/- 0.21, and 2.03 +/- 0.46 ng/ml for groups LS, MS, and HS, respectively, and 7.3 +/- 1.1, 13.2 +/- 2.2, and 24.4 +/- 5.8 ng/ml for groups LF, MF, and HF, respectively (all mean +/- SD). Isoflurane requirements were significantly greater in group LS than in groups MS and HS and greater in group LF than in groups MF and HF. The serum opioid and end-tidal isoflurane concentrations were correlated significantly. There were no intergroup differences in hemodynamics. CONCLUSIONS: Serum sufentanil and fentanyl concentrations of 0.71 +/- 0.13 ng/ml and 7.3 +/- 1.3 ng/ml, respectively, are on the steep parts of the concentration-response relationships and facilitate prebypass hemodynamic control in patients undergoing coronary artery bypass grafting with opioid-isoflurane anesthesia. Concentrations of sufentanil > or = 1.25 +/- 0.21 ng/ml and of fentanyl > or = 13.3 +/- 2.2 ng/ml minimize isoflurane requirements but do not improve hemodynamic control.
Aged↗
Sustained prognostic value of dobutamine stress echocardiography for late cardiac events after major noncardiac vascular surgery.
BACKGROUND: Late cardiac events after major noncardiac vascular surgery are an important cause of morbidity and mortality. We studied the prognostic value of preoperative dobutamine stress echocardiography, relative to clinical risk assessment, in predicting late cardiac events. METHODS AND RESULTS: Three hundred sixteen patients undergoing major vascular surgery were studied. All patients underwent clinical evaluation for the presence of cardiac risk factors (smoking, hypertension, angina, diabetes, history of heart failure, previous infarction, and age > 70 years) and dobutamine stress echocardiography. Left ventricular wall motion was evaluated at rest, and the extent and severity of stress-induced new wall motion abnormalities were quantified. The heart rate threshold at which new wall motion abnormalities occurred was noted. Patients were followed perioperatively and for 19 +/- 11 months postoperatively, and the occurrence of cardiac events was noted. Univariate and multivariate Cox proportional hazards regression models were used to identify predictors of late cardiac events. Thirty-two cardiac events occurred (11 cardiac deaths, 11 nonfatal myocardial infarctions, and 10 incidents of unstable angina). By multivariate regression analysis, the occurrence of extensive (three or more segments) or limited (one or two segments) stress-induced new wall motion abnormalities and previous infarction independently predicted late cardiac events, elevating the risk by 6.5-, 2.9-, and 3.8-fold, respectively. The severity of ischemia during stress and the heart rate threshold for ischemia were not independently predictive. CONCLUSIONS: Patients with a history of myocardial infarction or stress-induced ischemia have a high risk of fatal and nonfatal cardiac events after vascular surgery. Patients with both a history of infarction and extensive stress-induced ischemia are at especially high risk and deserve intensive management.
Adult↗
Dose-response to anaesthetic induction with sufentanil: haemodynamic and electroencephalographic effects.
PURPOSE: To determine the effect of a five-fold variation in sufentanil dose on the haemodynamic and electroencephalo graphic (EEG) response to anaesthetic induction and tracheal intubation. METHODS: Thirty-four patients undergoing elective coronary artery bypass grafting (CABG) participated in this randomized double-blind study. Patients in Group L (n = 17) received 3 micrograms.kg-1 sufentanil and those in Group H (n = 17) 15 micrograms.kg-1. Premedication was 60 micrograms.kg-1 lorazepam po. Anaesthesia and neuromuscular blockade were induced by infusing sufentanil and 0.15 mg.kg-1 vecuronium i.v. over five minutes. Haemodynamic data and the electroencephalographic (EEG) spectral edge were acquired by computer and compared at Control, Induction and Intubation. RESULTS: Sufentanil dose did not affect the haemodynamic or EEG response at end-induction. No bradyarrhythmias occurred, and the incidence of hypotension was 12% in both groups. However, during induction apparent electromyographic artifacts and a transiently greater increase in heart rate were observed in Group H. The serum sufentanil concentration at Induction was 6.1 +/- 1.8 ng.ml-1 in Group L and 25.4 +/- 8.8 ng.ml-1 in Group H, and did not correlate with haemodynamic changes. No patient recalled any intraoperative event. CONCLUSION: Increasing sufentanil dose from 3 to 15 micrograms-1 does not influence the ultimate haemodynamic response to induction. Combined with lorazepam premedication, 3 micrograms-1 sufentanil produces near-maximal haemodynamic and EEG effects and is adequate for induction and tracheal intubation of patients undergoing CABG. Sufentanil 15 micrograms.kg-1 is no more efficacious, and causes transient cardiovascular stimulation.
Aged↗
Prognostic value of dobutamine-atropine stress echocardiography for peri-operative and late cardiac events in patients scheduled for vascular surgery.
Cardiac events in the peri-operative phase and late after non-cardiac vascular surgery are a major cause of morbidity and mortality. Numerous tests and diagnostic strategies--usually consisting of a combination of analysis of clinical risk factors and additional non-exercise dependent stress testing, such as thallium scintigraphy, or stress echocardiography--have been developed to preoperatively identify patients with increased risk. The tests ideally should identify three subpopulations in a group with a high prevalence of coronary artery disease; (1) low-risk patients who can be referred for surgery without extra cardiac intervention. (2) patients whose peri-operative cardiac risk outweighs the potential benefits of vascular surgery, (3) patients whose risk may be reduced by peri-operative therapeutic interventions. This review will discuss the prognostic value of dobutamine stress echocardiography for risk stratification in patients scheduled for non-cardiac vascular surgery and discuss guidelines for future management.
Atropine↗
High-dose thiopentone for open-chamber cardiac surgery: a retrospective review.
PURPOSE: High-dose thiopentone has been reported to reduce the incidence of neurological dysfunction after open-chamber cardiac surgery. However, this technique delays tracheal extubation and increases requirements for inotropic support after cardiopulmonary bypass. As a quality assurance measure to determine the safety of high-dose thiopentone, we reviewed the records of all patients undergoing elective, open-chamber surgery at our institution between 1st March, 1987 and 31st Dec, 1989. METHODS: The charts of 236 patients were reviewed retrospectively, and 227 met our inclusion criteria. The perioperative characteristics of patients anaesthetized with thiopentone (Group T, n = 80) were compared with those of patients anaesthetized with opioids (Group O, n = 147). RESULTS: Anaesthetic technique was chosen by the attending anaesthetist. in Group T (n = 80) thiopentone 38.1 +/- 11.8 mg.kg-1 was infused to produce electroencephalographic burst-suppression during bypass. Moderate hypothermia and arterial line filtration were used during bypass. The groups did not differ with respect to demographics, type of surgery, or conduct of bypass. There were no strokes in Group T and 4 in Group O (P = NS). The time to extubation was prolonged in Group T compared with Group O (39 +/- 51 vs 27 +/- 24 h, P = 0.014), as was the duration of stay in intensive care (66 +/- 56 vs 51 +/- 29 h, P = 0.010). Thiopentone did not increase the need for inotropic or mechanical support after bypass. In-hospital mortality was lower in Group T than in Group O (1.2% vs 9.5%, P = 0.034). CONCLUSION: High-dose thiopentone delays extubation after open-chamber procedures. However, the technique appears safe, and further prospective investigation is justifiable.
Anesthesia, Intravenous↗
New volatile anaesthetics in cardiovascular anaesthesia: one step forward, two steps back?
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Anesthetics, Inhalation↗