Wąsowicz Marcin, Jerath Angela, Luksun Warren, Sharma Vivek, Mitsakakis Nicholas, Meineri Massimilaino, Katznelson Rita, Yau Terrence, Rao Vivek, Beattie William Scott
Deaprtment of Anesthesia, Faculty of Medicine, University of Toronto; Department of Anesthesia and Pain Management, Toronto Genaral Hospital/University Health Network, Toronto, Ontario, Canada.
Anaesthesiol Intensive Ther. 2018;50(3):200-209. doi: 10.5603/AIT.a2018.0012. Epub 2018 Jun 18.
Clinical trials have shown conflicting results regarding the use of volatile anaesthesia before or after an ischaemic insult in cardiac surgical patients and its effect on myocardial injury. This may be attributable to the failure of continuing volatile agents into the early postoperative period. We hypothesised that combined volatilebased anaesthesia and postoperative sedation would decrease the extent of myocardial injury after coronary artery bypass grafting (CABG) when compared with an intravenous, propofol-based approach. This study aimed to assess the feasibility of the perioperative protocol and investigate whether volatile anaesthesia provides cardioprotection in patients undergoing CABG.
Randomized, controlled trial enrolling 157 patients with preserved left ventricular function scheduled for elective or urgent on-pump CABG. Patients received either volatile- or propofol-based anaesthesia and postoperative sedation. Volatile sedation in the ICU was provided with the use of the AnaConDa® device (Sedana Medical, Uppsala, Sweden). The primary outcome was myocardial injury measured by serial troponin measurement at the beginning of surgery, 2, 4 and 12-16 h after ICU admission. The secondary outcome was cardiac performance expressed as cardiac index (CI) and the need for inotropic and vasopressor drug support. The peak postoperative troponin level was defined as the highest level at any time in the first 16 h after surgery.
127 patients completed the study protocol, 60 patients in the volatile group and 67 patients in the propofol group. Troponin levels were similar between groups at all of the measured time points. There were no differences in cardiac index or vasoactive drug support except for the immediate post- cardiopulmonary bypass (CPB) period when patients in the volatile group had low systemic vascular resistance, high CI and required more vasopressors. There was no difference in postoperative kidney function, intensive care unit discharge or hospital discharge time.
The use of volatile-based anaesthesia and postoperative sedation did not confer any cardioprotection compared with propofol-based anaesthesia and sedation in patients who had good left ventricular function and were undergoing CABG.
关于心脏手术患者在缺血性损伤之前或之后使用挥发性麻醉及其对心肌损伤的影响，临床试验结果相互矛盾。这可能归因于术后早期未能持续使用挥发性药物。我们假设，与基于丙泊酚的静脉麻醉方法相比，联合使用基于挥发性药物的麻醉和术后镇静可减少冠状动脉旁路移植术（CABG）后心肌损伤的程度。本研究旨在评估围手术期方案的可行性，并调查挥发性麻醉是否为接受CABG的患者提供心脏保护。
一项随机对照试验，纳入157例左心室功能保留、计划进行择期或急诊体外循环CABG的患者。患者接受基于挥发性药物或丙泊酚的麻醉和术后镇静。在重症监护病房（ICU）使用AnaConDa®设备（瑞典乌普萨拉Sedana Medical公司）进行挥发性镇静。主要结局是在手术开始时、入住ICU后2、4和12 - 16小时通过连续测定肌钙蛋白来衡量心肌损伤。次要结局是用心脏指数（CI）表示的心脏功能以及对正性肌力药和血管升压药支持的需求。术后肌钙蛋白峰值水平定义为术后16小时内任何时间的最高水平。
127例患者完成了研究方案，挥发性药物组60例，丙泊酚组67例。在所有测量时间点，两组之间的肌钙蛋白水平相似。除了体外循环（CPB）后即刻，两组在心脏指数或血管活性药物支持方面没有差异，此时挥发性药物组患者的体循环血管阻力较低、CI较高且需要更多血管升压药。术后肾功能、ICU出院时间或住院出院时间没有差异。
对于左心室功能良好且接受CABG的患者，与基于丙泊酚的麻醉和镇静相比，使用基于挥发性药物的麻醉和术后镇静并未提供任何心脏保护。
