Effects of anesthetic induction on myocardial function and metabolism: a comparison of fentanyl, sufentanil and alfentanil.

Anaesthetic induction may induce myocardial ischaemia. A prospective randomized trial was instituted to compare the effect on ventricular function and myocardial metabolism of induction with fentanyl (FEN) or its analogues sufentanil (SUF) or alfentanil (ALF) in 96 patients undergoing elective coronary artery bypass grafting (CABG). Haemodynamic, metabolic (coronary sinus oxygen and lactate extraction) and gated ventriculographic measurements were made awake pre-induction (PRE), after induction (IND) and after intubation (INT). Induction was performed with FEN 75 micrograms.kg-1, SUF 15 micrograms.kg-1 or ALF 125 micrograms.kg-1 and metocurine. Fentanyl induction was associated with the greatest stability of mean arterial pressure (MAP), cardiac performance, and systolic function without associated myocardial lactate production. SUF produced the greatest depression of systolic function (p less than 0.05) but without haemodynamic instability or myocardial lactate production in all but one patient. Induction with ALF produced the greatest reduction in MAP (p less than 0.05) associated with the greatest decrease in diastolic compliance (p less than 0.05) and 50 per cent incidence of myocardial lactate production (p less than 0.05) with no significant change in coronary blood flow or myocardial oxygen consumption.

Cardiac dysfunction during abdominal aortic operation: the limitations of pulmonary wedge pressures.

The mortality rate for elective abdominal aortic operations remains between 3% and 8% despite careful hemodynamic monitoring, and half of these deaths are cardiac in origin. An extensive evaluation of ventricular function was performed during abdominal aortic operation to detect subtle abnormalities in systolic or diastolic ventricular function that could precipitate progressive ischemic cardiac injury. Twenty-three patients undergoing elective abdominal aortic operations (14 patients with abdominal aortic aneurysm [AAA] and nine patients with aortoiliac occlusive disease [AIOD] ) had hemodynamic and nuclear ventriculographic measurements performed preoperatively, during aortic clamping, and immediately after aortic declamping. No differences were found in the hemodynamic response to operation between patients with AAA or AIOD. Volume loading was performed at each time period to assess ventricular function. Myocardial performance (the relation between cardiac index and end-diastolic volume index) and systolic function (the relation between systolic blood pressure and end-systolic volume index) were depressed during aortic clamping (p less than 0.05), suggesting decreased contractility, but returned to baseline values after declamping. Diastolic compliance (the relation between pulmonary capillary wedge pressure and end-diastolic volume index) decreased after declamping (p less than 0.05), suggesting early myocardial ischemia. The decrease in diastolic compliance rendered pulmonary capillary wedge pressure a poor index of left ventricular preload after declamping. Higher pressures were required to maintain adequate diastolic volumes. Despite careful hemodynamic monitoring, potentially ischemic ventricular dysfunction was found during abdominal aortic operation.