Eur J Anaesthesiol 2014; 31:597–605
ORIGINAL ARTICLE
Effect of increasing age on the haemodynamic response to thoracic epidural anaesthesia An observational study Jeroen Wink, Bernadette Th. Veering, Leon P.H.J. Aarts and Patrick F. Wouters BACKGROUND Sympathetic blockade with thoracic epidural anaesthesia (TEA) results in circulatory changes and may directly alter cardiac function. Ageing is associated with an impairment of autonomic nervous system control and a deterioration of myocardial diastolic performance. OBJECTIVES We postulated that haemodynamic changes induced by TEA could vary with age. DESIGN An observational study. SETTINGS Tertiary, university hospital. PATIENTS Thirty-five patients scheduled for pulmonary surgery and TEA stratified into three age groups: 18 to 45 years; 46 to 65 years; and at least 66 years. INTERVENTIONS Cardiac performance was evaluated in awake patients using transthoracic echocardiography (TTE) at baseline and 45 min after institution of TEA. Intravenous volume loading was used to preserve preload. MAIN OUTCOME MEASURES Tissue Doppler imaging (TDI) and other derived indices from TTE were used to quantify biventricular systolic and diastolic function. RESULTS Baseline systolic and diastolic left ventricular function and right ventricular diastolic function decreased
with age. After TEA, mean arterial pressure (MAP) decreased (91.2 vs. 79.2 mmHg; P < 0.001) and cardiac index increased (2.7 vs. 3.0 l min1 m-2; P ¼ 0.005), although heart rate and Doppler-derived indices of left ventricular contractility remained unchanged. Right ventricular ejection indices increased and TDI-derived measures of diastolic performance increased for the left ventricle (LV) as well as the right ventricle (RV). With the exception of Tricuspid Annular Plane Systolic Excursion (TAPSE), which increased with increasing age (R ¼ 0.53; P ¼ 0.003), TEA effects on biventricular function were not influenced by age. CONCLUSION When preload is preserved with volume loading, TEA predominantly causes systemic vasodilatation and increases global haemodynamic performance. Indices of left ventricular systolic function do not change, whereas left ventricular and right ventricular diastolic function appears to improve. The effects of TEA on right ventricular systolic function are inconclusive. Although increasing age causes a consistent decline of baseline diastolic function, the cardiovascular response to TEA is not impaired in the elderly. TRIAL REGISTRY NUMBER EudraCT 2009-010594-20. Published online 4 September 2014
Introduction Thoracic epidural anaesthesia (TEA) combined with general anaesthesia is considered by many to be the gold standard for anaesthesia in pulmonary surgery. The cardiac sympathetic outflow emerges from the spinal cord at C5 to T5 levels, with the main supply to the ventricles from T1 to T4.1 TEA results in blockade of these nerves and changes in heart rate (HR), left and right
ventricular function and myocardial oxygen demand may occur. TEA may be cardioprotective,2 has been successfully used in humans to treat refractory angina3 and may increase the diameter of stenotic epicardial coronary arteries in patients with coronary artery disease.4 However, TEA decreases arterial and venous vessel tone influencing preload and afterload of the heart and may directly affect myocardial performance.5
From the Department of Anaesthesiology, Leiden University Medical Centre, Leiden, the Netherlands (JW, BTV, PHJA), and Department of Anaesthesia, University Hospitals Ghent, Ghent, Belgium (PFW) Correspondence to Jeroen Wink, Department of Anaesthesiology, Leiden University Medical Center, P.O. Box 9600, 2300 RC Leiden, the Netherlands Tel: +31 71 5262301; fax: +31 71 5266230; e-mail: [email protected] 0265-0215 ß 2014 Copyright European Society of Anaesthesiology
DOI:10.1097/EJA.0000000000000125
Copyright © European Society of Anaesthesiology. Unauthorized reproduction of this article is prohibited.
598 Wink et al.
Ageing is accompanied by a greater sensitivity to volumetric status of the cardiovascular system6 due to impaired autonomic nervous system control and diastolic function.7 These factors suggest that elderly patients may be particularly vulnerable to the haemodynamic effects of TEA. There is, however, a paucity of data on the relationship between age and the haemodynamic response to TEA. In a previous study, we did not find that age affected the total amount of spinal segments blocked after TEA with a fixed dose of ropivacaine at the T3-T4 interspace.8 In the present study, we tested the hypothesis that TEA results in more profound cardiovascular effects in the elderly than in younger patients. Using contemporary echocardiographic techniques to assess diastolic and systolic function, we quantified the effects of TEA on biventricular function of patients across a wide age range presenting for pulmonary surgery.
Materials and methods The protocol of this study was reviewed and approved by the Committee on Medical Ethics of the Leiden University Medical Centre (reg. no: P09060), Leiden, The Netherlands (Chairperson Prof. Dr A.J. Rabelink) on 6 July 2009 and approved by the Centrale Commissie Mensgebonden Onderzoek (CCMO) as Competent Authority for the review of clinical trials in the Netherlands, NL27041.058.09. The individuals reported in this study have been previously reported in an article presenting data on the effects of age on the segmental spread of local anaesthetics.8 Patients scheduled for pulmonary surgery (full thoracotomies and video-assisted thoracoscopic surgical procedures) under TEA and general anaesthesia were included in this open, observational, single-centre study. All study measurements were done in nonanaesthetised patients. After written informed consent, patients were stratified in one of three age groups (Group 1: 18 to 45 years; Group 2: 46 to 65 years; and Group 3: 66 years and older) to ensure an even age distribution. Patients with a contraindication to epidural anaesthesia and pregnant women were excluded from the study. The groups were not matched with regard to antihypertensive or antiarrhythmic medication in order to have a population sample that resembles clinical reality, which encompasses the natural confounders of age and use of medication. For the same reason, we did not exclude patients with hypertension or diabetes. None of the patients included in this study had a history or signs of ischaemic heart disease. Patients were fasted from midnight on the day of surgery. Antihypertensive medication was continued on the day of surgery. Patients were premedicated with oral midazolam 7.5 mg (if
ORIGINAL ARTICLE
Effect of increasing age on the haemodynamic response to thoracic epidural anaesthesia An observational study Jeroen Wink, Bernadette Th. Veering, Leon P.H.J. Aarts and Patrick F. Wouters BACKGROUND Sympathetic blockade with thoracic epidural anaesthesia (TEA) results in circulatory changes and may directly alter cardiac function. Ageing is associated with an impairment of autonomic nervous system control and a deterioration of myocardial diastolic performance. OBJECTIVES We postulated that haemodynamic changes induced by TEA could vary with age. DESIGN An observational study. SETTINGS Tertiary, university hospital. PATIENTS Thirty-five patients scheduled for pulmonary surgery and TEA stratified into three age groups: 18 to 45 years; 46 to 65 years; and at least 66 years. INTERVENTIONS Cardiac performance was evaluated in awake patients using transthoracic echocardiography (TTE) at baseline and 45 min after institution of TEA. Intravenous volume loading was used to preserve preload. MAIN OUTCOME MEASURES Tissue Doppler imaging (TDI) and other derived indices from TTE were used to quantify biventricular systolic and diastolic function. RESULTS Baseline systolic and diastolic left ventricular function and right ventricular diastolic function decreased
with age. After TEA, mean arterial pressure (MAP) decreased (91.2 vs. 79.2 mmHg; P < 0.001) and cardiac index increased (2.7 vs. 3.0 l min1 m-2; P ¼ 0.005), although heart rate and Doppler-derived indices of left ventricular contractility remained unchanged. Right ventricular ejection indices increased and TDI-derived measures of diastolic performance increased for the left ventricle (LV) as well as the right ventricle (RV). With the exception of Tricuspid Annular Plane Systolic Excursion (TAPSE), which increased with increasing age (R ¼ 0.53; P ¼ 0.003), TEA effects on biventricular function were not influenced by age. CONCLUSION When preload is preserved with volume loading, TEA predominantly causes systemic vasodilatation and increases global haemodynamic performance. Indices of left ventricular systolic function do not change, whereas left ventricular and right ventricular diastolic function appears to improve. The effects of TEA on right ventricular systolic function are inconclusive. Although increasing age causes a consistent decline of baseline diastolic function, the cardiovascular response to TEA is not impaired in the elderly. TRIAL REGISTRY NUMBER EudraCT 2009-010594-20. Published online 4 September 2014
Introduction Thoracic epidural anaesthesia (TEA) combined with general anaesthesia is considered by many to be the gold standard for anaesthesia in pulmonary surgery. The cardiac sympathetic outflow emerges from the spinal cord at C5 to T5 levels, with the main supply to the ventricles from T1 to T4.1 TEA results in blockade of these nerves and changes in heart rate (HR), left and right
ventricular function and myocardial oxygen demand may occur. TEA may be cardioprotective,2 has been successfully used in humans to treat refractory angina3 and may increase the diameter of stenotic epicardial coronary arteries in patients with coronary artery disease.4 However, TEA decreases arterial and venous vessel tone influencing preload and afterload of the heart and may directly affect myocardial performance.5
From the Department of Anaesthesiology, Leiden University Medical Centre, Leiden, the Netherlands (JW, BTV, PHJA), and Department of Anaesthesia, University Hospitals Ghent, Ghent, Belgium (PFW) Correspondence to Jeroen Wink, Department of Anaesthesiology, Leiden University Medical Center, P.O. Box 9600, 2300 RC Leiden, the Netherlands Tel: +31 71 5262301; fax: +31 71 5266230; e-mail: [email protected] 0265-0215 ß 2014 Copyright European Society of Anaesthesiology
DOI:10.1097/EJA.0000000000000125
Copyright © European Society of Anaesthesiology. Unauthorized reproduction of this article is prohibited.
598 Wink et al.
Ageing is accompanied by a greater sensitivity to volumetric status of the cardiovascular system6 due to impaired autonomic nervous system control and diastolic function.7 These factors suggest that elderly patients may be particularly vulnerable to the haemodynamic effects of TEA. There is, however, a paucity of data on the relationship between age and the haemodynamic response to TEA. In a previous study, we did not find that age affected the total amount of spinal segments blocked after TEA with a fixed dose of ropivacaine at the T3-T4 interspace.8 In the present study, we tested the hypothesis that TEA results in more profound cardiovascular effects in the elderly than in younger patients. Using contemporary echocardiographic techniques to assess diastolic and systolic function, we quantified the effects of TEA on biventricular function of patients across a wide age range presenting for pulmonary surgery.
Materials and methods The protocol of this study was reviewed and approved by the Committee on Medical Ethics of the Leiden University Medical Centre (reg. no: P09060), Leiden, The Netherlands (Chairperson Prof. Dr A.J. Rabelink) on 6 July 2009 and approved by the Centrale Commissie Mensgebonden Onderzoek (CCMO) as Competent Authority for the review of clinical trials in the Netherlands, NL27041.058.09. The individuals reported in this study have been previously reported in an article presenting data on the effects of age on the segmental spread of local anaesthetics.8 Patients scheduled for pulmonary surgery (full thoracotomies and video-assisted thoracoscopic surgical procedures) under TEA and general anaesthesia were included in this open, observational, single-centre study. All study measurements were done in nonanaesthetised patients. After written informed consent, patients were stratified in one of three age groups (Group 1: 18 to 45 years; Group 2: 46 to 65 years; and Group 3: 66 years and older) to ensure an even age distribution. Patients with a contraindication to epidural anaesthesia and pregnant women were excluded from the study. The groups were not matched with regard to antihypertensive or antiarrhythmic medication in order to have a population sample that resembles clinical reality, which encompasses the natural confounders of age and use of medication. For the same reason, we did not exclude patients with hypertension or diabetes. None of the patients included in this study had a history or signs of ischaemic heart disease. Patients were fasted from midnight on the day of surgery. Antihypertensive medication was continued on the day of surgery. Patients were premedicated with oral midazolam 7.5 mg (if
