Original Article
Turk J Anaesth Reanim 2014; 42: 308-12
DOI: 10.5152/TJAR.2014.37232
Comparison of the Haemodynamic Effects of Three Different Methods at the Induction of Anaesthesia Mehmet Levent Uygur1, Ayşın Ersoy2, Aysel Altan3, Zekeriya Ervatan2, Sedat Kamalı4 Clinic of Anaesthesiology and Reanimation, Gaziantep Şehit Kemal State Hospital, Gaziantep, Turkey Clinic of Anaesthesiology and Reanimation, Okmeydanı Training and Research Hospital, İstanbul, Turkey 3 Department of Anaesthesiology and Reanimation, Kafkas University Faculty of Medicine, Kars, Turkey 4 Clinic of General Surgery, Okmeydanı Training and Research Hospital, İstanbul, Turkey 1
Abstract
2
Objective: Haemodynamic variations are inevitable during induction of anaesthetic drugs. The present study investigates the haemodynamic variations of three different drugs (thiopental, propofol, and etomidate) used for induction of general anaesthesia together with fentanyl. Methods: In a randomized, double-blind study, 45 patients were assigned to one of three groups (n=15 each). Fentanyl 1 μg kg-1 was injected over 60 sec followed by propofol 2 mg kg-1 (Group P), thiopentone 6 mg kg-1 (Group T), or etomidate 0.3 mg kg-1 (Group E). Noninvasive measurements of systolic arterial pressure (SAP), diastolic arterial pressure (DAP), mean arterial pressure (MAP), and heart rate (HR) was performed on admittance, immediately before the induction of anaesthesia, and 1, 3, and 5 min thereafter. Cardiac output (CO) values were recorded before induction, immediately after the injection of the drug, and at 1 min after the intubation. Results: In all groups, during the study period, SAP, DAP, MAP, and CO values decreased with respect to time before induction. Following the administration of the induction dose of propofol (Group P), a significantly greater decrease of systolic and diastolic blood pressure was observed with etomidate (Group E) or thiopentone (Group T). Decrease in CO was also more marked with propofol (Group P) than with etomidate (Group E) or thiopentone (Group T). Conclusion: It’s concluded that, in this study, the combination of fentanyl- etomidate is safer than both the groups of fentanyl-propofol and fentanyl-thiopental in terms of providing haemodynamic stability. Key Words: Propofol, thiopental, etomidate, induction, haemodynamic changes
Introduction
S
tress response resulting from intubation, extubation and surgical stimulus can lead to some haemodynamic changes. Cardiovascular depression emerging during the induction of anaesthesia and the stress response caused by endotracheal intubation are important, especially for patients who are under cardiac risk. This haemodynamic response affects myocardial perfusion in a negative way by increasing myocardial oxygen consumption and cardiac workload, and it can lead to ischaemia (1). Stimulation of laryngeal and tracheal tissues during intubation causes catecholamine discharge, with an increase in sympathetico-adrenergic activity and also an increase in systemic arterial pressure and heart rate (2, 3). These increases begin with the laryngoscope, reach to the maximum level within 1-2 minutes and decrease to the values before the laryngoscope (4-6). Extrasystoles and ventricular premature beats can also be seen in this period (7, 8). Use of general anaesthetic agents with intravenous induction can often cause hypotension. Many mechanisms have been described on this issue, but the most important of these are the suppressive effects of these agents on myocardial contractility, sympathetic activity, baroreflex activity and central nervous system activity (9-12). This study aims to compare the stress response-induced haemodynamic effects of etomidate, propofol and thiopental by measuring cardiac output and arterial tension values in the anaesthetic induction of patients under cardiac risk who undergo elective surgery.
308
Address for Correspondence: Dr. Ayşın Ersoy, Clinic of Anaesthesiology and Reanimation, Okmeydanı Training and Research Hospital, İstanbul, Turkey Phone: +90 212 221 77 77 E-mail: [email protected] ©Copyright 2014 by Turkish Anaesthesiology and Intensive Care Society - Available online at www.jtaics.org
Received: 07.04.2013 Accepted: 21.12.2013 Available Online Date: 11.07.2014
Uygur et al. Three Different Methods in the Anaesthesia Induction
Methods After getting approval from the ethics committee of Okmeydanı Training and Research Hospital (dated May 07, 2009, numbered 250), the study involved 45 patients aged between 18-65 years who were undergoing elective surgery and who were classified in group II-III according to the risk classification of American Society of Anesthesiology (ASA) and in Class II-III according to the functional classification of New York Heart Association (NYHA) (Table 1). Written informed consent was obtained from the patients during their preoperative examinations, and they were informed about the method. Patients who had hepatic and renal failure, who were allergic to the medications and who might have difficulty in intubation were excluded from the study. All patients who were operated were monitored using a Datex Ohmeda S/5 Anaesthesia Monitor (AKG, pulse oximeter and non-invasive blood pressure). Vascular access was established on the hands of the patients with a 20 G branule, and 0.9% NaCl infusion was initiated at a rate of 10 mL hour-1. The patients were randomly divided into three groups: the propofol group who recevied 2 mg kg-1 propofol (Pofol® i.v. ampoule, Sandoz) (Group P, n=15), the etomidate group who recevied 0.3 mg kg-1 etomidate (Hypnomidate® i.v. ampoule, Johnson & Johnson) (Group E, n=15) and the thiopental group who recevied 5 mg kg-1 (Pental® sodium vial, İbrahim Etem İlaç) (Group T, n=15). All three groups were exposed to 1 µg kg-1 fentanyl (Fentanyl Citrate® ampoule, Abbott) with an induction agent. While tracheal intubation was performed with 0.15 mg kg-1 cisatracurium (Nimbex® ampoule, Glaxo Smith Kline), 50%-50% oxygen and nitrous oxide and 0.81.2 MAC sevoflurane were used for maintenance. Cardiac output (CO) of the patients was measured through impedance cardiograph method (Bo Med Medical Manufacturing Irvine CA) before induction (basal value, T0), before intubation (T1) and in the 1st minute after intubation (T2). Moreover, heart rate (HR) and systolic (SAP), diastolic (DAP) and mean arterial pressure (MAP) were recorded before induction (basal value, T0), before intubation (T1) and in the 1st (T2), 3rd (T3), and 5th (T4) minutes after intubation (T2). Statistical analysis Statistic Package for Social Sciences for Windows 15.0 (SPSS, Chicago, IL, USA) was used for the statistical analysis. In addition to descriptive statistics, such as mean and standard deviation, Kruskal-Wallis test was employed for comparing multiple groups, Bonferroni-corrected Mann-Whitney U test was used as a post hoc test and chi-square test was used for comparing qualitative data. The results were evaluated with 95% confidence interval and a significance value of p
Turk J Anaesth Reanim 2014; 42: 308-12
DOI: 10.5152/TJAR.2014.37232
Comparison of the Haemodynamic Effects of Three Different Methods at the Induction of Anaesthesia Mehmet Levent Uygur1, Ayşın Ersoy2, Aysel Altan3, Zekeriya Ervatan2, Sedat Kamalı4 Clinic of Anaesthesiology and Reanimation, Gaziantep Şehit Kemal State Hospital, Gaziantep, Turkey Clinic of Anaesthesiology and Reanimation, Okmeydanı Training and Research Hospital, İstanbul, Turkey 3 Department of Anaesthesiology and Reanimation, Kafkas University Faculty of Medicine, Kars, Turkey 4 Clinic of General Surgery, Okmeydanı Training and Research Hospital, İstanbul, Turkey 1
Abstract
2
Objective: Haemodynamic variations are inevitable during induction of anaesthetic drugs. The present study investigates the haemodynamic variations of three different drugs (thiopental, propofol, and etomidate) used for induction of general anaesthesia together with fentanyl. Methods: In a randomized, double-blind study, 45 patients were assigned to one of three groups (n=15 each). Fentanyl 1 μg kg-1 was injected over 60 sec followed by propofol 2 mg kg-1 (Group P), thiopentone 6 mg kg-1 (Group T), or etomidate 0.3 mg kg-1 (Group E). Noninvasive measurements of systolic arterial pressure (SAP), diastolic arterial pressure (DAP), mean arterial pressure (MAP), and heart rate (HR) was performed on admittance, immediately before the induction of anaesthesia, and 1, 3, and 5 min thereafter. Cardiac output (CO) values were recorded before induction, immediately after the injection of the drug, and at 1 min after the intubation. Results: In all groups, during the study period, SAP, DAP, MAP, and CO values decreased with respect to time before induction. Following the administration of the induction dose of propofol (Group P), a significantly greater decrease of systolic and diastolic blood pressure was observed with etomidate (Group E) or thiopentone (Group T). Decrease in CO was also more marked with propofol (Group P) than with etomidate (Group E) or thiopentone (Group T). Conclusion: It’s concluded that, in this study, the combination of fentanyl- etomidate is safer than both the groups of fentanyl-propofol and fentanyl-thiopental in terms of providing haemodynamic stability. Key Words: Propofol, thiopental, etomidate, induction, haemodynamic changes
Introduction
S
tress response resulting from intubation, extubation and surgical stimulus can lead to some haemodynamic changes. Cardiovascular depression emerging during the induction of anaesthesia and the stress response caused by endotracheal intubation are important, especially for patients who are under cardiac risk. This haemodynamic response affects myocardial perfusion in a negative way by increasing myocardial oxygen consumption and cardiac workload, and it can lead to ischaemia (1). Stimulation of laryngeal and tracheal tissues during intubation causes catecholamine discharge, with an increase in sympathetico-adrenergic activity and also an increase in systemic arterial pressure and heart rate (2, 3). These increases begin with the laryngoscope, reach to the maximum level within 1-2 minutes and decrease to the values before the laryngoscope (4-6). Extrasystoles and ventricular premature beats can also be seen in this period (7, 8). Use of general anaesthetic agents with intravenous induction can often cause hypotension. Many mechanisms have been described on this issue, but the most important of these are the suppressive effects of these agents on myocardial contractility, sympathetic activity, baroreflex activity and central nervous system activity (9-12). This study aims to compare the stress response-induced haemodynamic effects of etomidate, propofol and thiopental by measuring cardiac output and arterial tension values in the anaesthetic induction of patients under cardiac risk who undergo elective surgery.
308
Address for Correspondence: Dr. Ayşın Ersoy, Clinic of Anaesthesiology and Reanimation, Okmeydanı Training and Research Hospital, İstanbul, Turkey Phone: +90 212 221 77 77 E-mail: [email protected] ©Copyright 2014 by Turkish Anaesthesiology and Intensive Care Society - Available online at www.jtaics.org
Received: 07.04.2013 Accepted: 21.12.2013 Available Online Date: 11.07.2014
Uygur et al. Three Different Methods in the Anaesthesia Induction
Methods After getting approval from the ethics committee of Okmeydanı Training and Research Hospital (dated May 07, 2009, numbered 250), the study involved 45 patients aged between 18-65 years who were undergoing elective surgery and who were classified in group II-III according to the risk classification of American Society of Anesthesiology (ASA) and in Class II-III according to the functional classification of New York Heart Association (NYHA) (Table 1). Written informed consent was obtained from the patients during their preoperative examinations, and they were informed about the method. Patients who had hepatic and renal failure, who were allergic to the medications and who might have difficulty in intubation were excluded from the study. All patients who were operated were monitored using a Datex Ohmeda S/5 Anaesthesia Monitor (AKG, pulse oximeter and non-invasive blood pressure). Vascular access was established on the hands of the patients with a 20 G branule, and 0.9% NaCl infusion was initiated at a rate of 10 mL hour-1. The patients were randomly divided into three groups: the propofol group who recevied 2 mg kg-1 propofol (Pofol® i.v. ampoule, Sandoz) (Group P, n=15), the etomidate group who recevied 0.3 mg kg-1 etomidate (Hypnomidate® i.v. ampoule, Johnson & Johnson) (Group E, n=15) and the thiopental group who recevied 5 mg kg-1 (Pental® sodium vial, İbrahim Etem İlaç) (Group T, n=15). All three groups were exposed to 1 µg kg-1 fentanyl (Fentanyl Citrate® ampoule, Abbott) with an induction agent. While tracheal intubation was performed with 0.15 mg kg-1 cisatracurium (Nimbex® ampoule, Glaxo Smith Kline), 50%-50% oxygen and nitrous oxide and 0.81.2 MAC sevoflurane were used for maintenance. Cardiac output (CO) of the patients was measured through impedance cardiograph method (Bo Med Medical Manufacturing Irvine CA) before induction (basal value, T0), before intubation (T1) and in the 1st minute after intubation (T2). Moreover, heart rate (HR) and systolic (SAP), diastolic (DAP) and mean arterial pressure (MAP) were recorded before induction (basal value, T0), before intubation (T1) and in the 1st (T2), 3rd (T3), and 5th (T4) minutes after intubation (T2). Statistical analysis Statistic Package for Social Sciences for Windows 15.0 (SPSS, Chicago, IL, USA) was used for the statistical analysis. In addition to descriptive statistics, such as mean and standard deviation, Kruskal-Wallis test was employed for comparing multiple groups, Bonferroni-corrected Mann-Whitney U test was used as a post hoc test and chi-square test was used for comparing qualitative data. The results were evaluated with 95% confidence interval and a significance value of p
