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Volatile Anesthetics
Giovanni Landoni, MD
Head of Research
Dept. of Anaesthesiology & Intensive Care
Vita-Salute University of Milan, Italy
Introduction
1
mitral surgery. Most authors administered volatile anesthetics
throughout all the procedures while six authors administered the
volatile anesthetics for a short time (5 to 30 minutes) and only
before or during the expected cardiac damage.
2
Figure 1
3
Figure 2
4
<0.00001, I2=93.7% with 1,593 included patients), and time
on mechanical ventilation (WMD=-0.49 hours [-0.97; -0.02], p
for effect =0.04, p for heterogeneity 0.03, I2=44.1% with 1,846
included patients). Finally, only two studies reported one-year,
follow-up data concerning major cardiac events (defined as
cardiac death, nonfatal MI, unstable angina, intercurrent coronary
angioplasty, coronary artery bypass grafting, arrhythmias requiring
hospitalization and new episodes of congestive heart failure): 4/48
[8.3%] in the volatile anesthetics group vs. 11/45 [24.4%] in
the control arm, OR=0.23 [0.06-0.88], p for effect=0.03, p for
heterogeneity=0.47, I2=0%.
5
Clinical Evidence in
Non-Cardiac Surgery
6
Mechanism of Action
7
Anesthetic preconditioning appears to be based on a dose-
dependent signal: the degree of protection is related to the
concentration of drug administered and to the duration of
the administration itself. Furthermore, it is not dependent on
ischaemic preconditioning and does not require
pre-emptive ischaemia.
8
demonstrate that translocation of PKC d and e isoforms — one
of the mechanisms implicated as a pivotal step in anesthetic
preconditioning — occurred in the human myocardium in
response to sevoflurane. Reduction in postoperative dismissal
of cardiac damage markers has been confirmed by many
subsequent studies. 9–12
9
the choice of morphine instead of fentanyl may allow an APC protocol to
yield a better cardiac function following CABG14. These data support the
idea that the cardioprotective effects of anesthetic agents depend upon an
interaction of factors such as the administration protocols, the choice of a
specific agent, the concomitant use of other drugs, and the variables used
to assess myocardial function15.
10
Conclusions
11
References
12
11. De Hert SG, Van der Linden PJ, Cromheecke S, Meeus R, Nelis A, Van Reeth V, et al.
Cardioprotective properties of sevoflurane in patients undergoing coronary surgery with
cardiopulmonary bypass are related to the modalities of its administration. Anesthesiology
2004;101(2):299-310.
12. De Hert SG, ten Broecke PW, Mertens E, Van Sommeren EW, De Blier IG, Stockman BA,
et al. Sevoflurane but not propofol preserves myocardial function in coronary surgery patients.
Anesthesiology 2002;97(1):42-9.
13. Tuman KJ, McCarthy RJ, Spiess BD, DaValle M, Dabir R, Ivankovich AD. Does choice
of anesthetic agent significantly affect outcome after coronary artery surgery? Anesthesiology
1989;70(2):189-98.
14. Murphy GS, Szokol JW, Marymont JH, Avram MJ, Vender JS. Opioids and
cardioprotection: the impact of morphine and fentanyl on recovery of ventricular function after
cardiopulmonary bypass. J Cardiothorac Vasc Anesth 2006;20(4):493-502.
15. De Hert SG. Anesthetic preconditioning: how important is it in today's cardiac anesthesia? J
Cardiothorac Vasc Anesth 2006;20(4):473-6.
16. Landoni G, Calabrò MG, Marchetti C, Bignami E, Scandroglio AM, Dedola E, et al.
Pharmacological preconditioning in patients undergoing mitral surgery with or without
concomitant ischaemic disease. J Cardiothorac Vasc Anesth 2007, In press.
13
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