Effect of Volatile Anesthetics on Myocardial Infarction After Coronary Artery Surgery: A Post Hoc Analysis of a Randomized Trial.

OBJECTIVE: To investigate the effect of volatile anesthetics on the rates of postoperative myocardial infarction (MI) and cardiac death after coronary artery bypass graft (CABG). DESIGN: A post hoc analysis of a randomized trial. SETTING: Cardiac surgical operating rooms. PARTICIPANTS: Patients undergoing elective, isolated CABG. INTERVENTIONS: Patients were randomized to receive a volatile anesthetic (desflurane, isoflurane, or sevoflurane) or total intravenous anesthesia (TIVA). The primary outcome was hemodynamically relevant MI (MI requiring high-dose inotropic support or prolonged intensive care unit stay) occurring within 48 hours from surgery. The secondary outcome was 1-year death due to cardiac causes. MEASUREMENTS AND MAIN RESULTS: A total of 5,400 patients were enrolled between April 2014 and September 2017 (2,709 patients randomized to the volatile anesthetics group and 2,691 to TIVA). The mean age was 62 ± 8.4 years, and the median baseline ejection fraction was 57% (50-67), without differences between the 2 groups. Patients in the volatile group had a lower incidence of MI with hemodynamic complications both in the per-protocol (14 of 2,530 [0.6%] v 27 of 2,501 [1.1%] in the TIVA group; p = 0.038) and as-treated analyses (16 of 2,708 [0.6%] v 29 of 2,617 [1.1%] in the TIVA group; p = 0.039), but not in the intention-to-treat analysis (17 of 2,663 [0.6%] v 28 of 2,667 [1.0%] in the TIVA group; p = 0.10). Overall, deaths due to cardiac causes were lower in the volatile group (23 of 2,685 [0.9%] v 40 of 2,668 [1.5%] than in the TIVA group; p = 0.03). CONCLUSIONS: An anesthetic regimen, including volatile agents, may be associated with a lower rate of postoperative MI with hemodynamic complication in patients undergoing CABG. Furthermore, it may reduce long-term cardiac mortality.

Effect of volatile anesthetics on myocardial infarction after coronary artery surgery: a post hoc analysis of a randomized trial

OBJECTIVE: To investigate the effect of volatile anesthetics on the rates of postoperative myocardial infarction (MI) and cardiac death after coronary artery bypass graft (CABG). DESIGN: A post hoc analysis of a randomized trial. SETTING: Cardiac surgical operating rooms. PARTICIPANTS: Patients undergoing elective, isolated CABG. INTERVENTIONS: Patients were randomized to receive a volatile anesthetic (desflurane, isoflurane, or sevoflurane) or total intravenous anesthesia (TIVA). The primary outcome was hemodynamically relevant MI (MI requiring high-dose inotropic support or prolonged intensive care unit stay) occurring within 48 hours from surgery. The secondary outcome was 1-year death due to cardiac causes. Measurements and main Results: A total of 5,400 patients were enrolled between April 2014 and September 2017 (2,709 patients randomized to the volatile anesthetics group and 2,691 to TIVA). The mean age was 62 ± 8.4 years, and the median baseline ejection fraction was 57% (50-67), without differences between the 2 groups. Patients in the volatile group had a lower incidence of MI with hemodynamic complications both in the per-protocol (14 of 2,530 [0.6%] v 27 of 2,501 [1.1%] in the TIVA group; p = 0.038) and as-treated analyses (16 of 2,708 [0.6%] v 29 of 2,617 [1.1%] in the TIVA group; p = 0.039), but not in the intention-to-treat analysis (17 of 2,663 [0.6%] v 28 of 2,667 [1.0%] in the TIVA group; p = 0.10). Overall, deaths due to cardiac causes were lower in the volatile group (23 of 2,685 [0.9%] v 40 of 2,668 [1.5%] than in the TIVA group; p = 0.03). CONCLUSIONS: An anesthetic regimen, including volatile agents, may be associated with a lower rate of postoperative MI with hemodynamic complication in patients undergoing CABG. Furthermore, it may reduce long-term cardiac mortality.

Development of a prototype anti-pollution filter for volatile anesthetics

Introduction: The use of volatile agents during cardiopulmonary bypass allows a "single drug anesthesia" and is associated with reduced peak postoperative troponin levels. Connecting the exhaust systems to the oxygenator's gas outlet port is mandatory and allows to prevent operating room (but not atmospheric) pollution by volatile agents. The aim of this study was to create a prototype filter for volatile agents and to test its adsorption efficacy during an ex-vivo simulated conventional cardiopulmonary bypass test. Methods: We carried out bench tests to conceive a prototype filter that could prevent room and environment pollution without damaging membrane oxygenators. We performed the tests at the Engineering Center for Circulatory Assistance Laboratory, Dante Pazzanese Institute of Cardiology, São Paulo, Brazil. Bench tests included simulation of integral adsorption tests, filter dimensions and design, flow versus pressure curve, sizing, and tightness. Results: Calgon AT 410 was the best kind of activated charcoal granules for adsorption of sevoflurane, isoflurane, and desflurane. Filter dimension tests showed that a chamber of 30-cm width over 10-cm diameter filled with 200g of the Calgon AT410 granules was the minimum required to fully adsorb sevoflurane for 90min. Adsorption tests showed that the prototype filter fully adsorbed isoflurane in 100±2.3min, sevoflurane in 95±3.4min, and desflurane in 95±4.3min. Conclusion: The new version of our prototype filter adsorbed most of the volatile anesthetics agents during an ex-vivo simulated conventional cardiopulmonary bypass test.

[New oropharyngeal double lumen cannula for sedation for transesophageal echocardiography: case series]. / Nova cânula orofaríongea de duplo lúmen para sedação em ecocardiografia transesofágica: série de casos.

INTRODUCTION: Currently, transesophageal echodopplercardiography (TEE) is frequently performed under sedation on an outpatient basis. Sedation is related with increase in incidents on airways. Bearing in mind this scenario, we developed a new double lumen oropharyngeal cannula aimed at keeping airway patency, in addition to reducing risks to patients during endoscopy procedures performed under sedation. The main objective of our study was to assess the incidence of oxygen desaturation in a series of cases of adult patients submitted to outpatient TEE exam, under sedation and using the oropharyngeal cannula. METHOD: Thirty patients under sedation with intravenous midazolam and propofol were assessed. After loss of consciousness, the cannula was placed and patients were maintained on spontaneous breathing. Oxygen saturation, capnometry, heart rate and non-invasive arterial blood pressure, in addition to subjective data: airway patency, handling of cannula insertion, and comfort of examiner were analyzed. RESULTS: The incidence of mild desaturation was 23.3%, and there was no severe desaturation in any of the cases. The insertion of the oropharyngeal cannula was considered easy for 29 patients (96.6%), and TEE probe handling was appropriate in 93.33% of exams performed. CONCLUSIONS: TEE exams under sedation aided by the double-lumen oropharyngeal cannula presented a low incidence of desaturation in patients assessed, and allowed analysis of expired CO2 during the exams.

New oropharyngeal double lumen cannula for sedation for transesophageal echocardiography: case series / Nova cânula orofaríongea de duplo lúmen para sedação em ecocardiografia transesofágica: série de casos

Abstract Introduction: Currently, transesophageal echodopplercardiography is frequently performed under sedation on an outpatient basis. Sedation is related with increase in incidents on airways. Bearing in mind this scenario, we developed a new double lumen oropharyngeal cannula aimed at keeping airway patency, in addition to reducing risks to patients during endoscopy procedures performed under sedation. The main objective of our study was to assess the incidence of oxygen desaturation in a series of cases of adult patients submitted to outpatient transesophageal echo exam, under sedation and using the oropharyngeal cannula. Method: 30 patients under sedation with intravenous midazolam and propofol were assessed. After loss of consciousness, the cannula was placed and patients were maintained on spontaneous breathing. Oxygen saturation, capnometry, heart rate and non-invasive arterial blood pressure, in addition to subjective data: airway patency, handling of cannula insertion and, comfort of examiner were analyzed. Results: The incidence of mild desaturation was 23.3%, and there was no severe desaturation in any of the cases. The insertion of the oropharyngeal cannula was considered easy for 29 patients (96.6%), and transesophageal echo probe handling was appropriate in 93.33% of exams performed. Conclusions: Transesophageal echo exams under sedation aided by the double-lumen oropharyngeal cannula presented a low incidence of desaturation in patients assessed, and allowed analysis of expired CO2 during the exams.

Resumo Introdução: Nos dias atuais, exames de ecocardiografia transesofágica (ETE) são realizados de forma frequente sob sedação em regime ambulatorial. A sedação está relacionada com aumento de intercorrências nas vias aéreas. Dentro desse contexto, desenvolvemos uma cânula orofaríngea de duplo-lúmen com finalidade de manutenção da via aérea pérvia, reduzindo riscos aos pacientes durante procedimentos endoscópicos sob sedação. O principal objetivo do nosso estudo foi avaliar a incidência de dessaturação em uma série de casos de pacientes adultos submetidos a ETE ambulatorial sob sedação com o uso da cânula orofaríngea. Métodos: Foram avaliados 30 pacientes sedados com midazolam e propofol intravenoso. A cânula foi inserida após perda da consciência e os pacientes foram mantidos com ventilação espontânea. Analisados saturação de oxigênio, capnometria, frequência cardíaca e pressão arterial não invasiva, além de dados subjetivos: patência das vias aéreas, manuseio e inserção da cânula e conforto ao examinador. Resultados: A incidência de dessaturação leve foi de 23.3% e não houve dessaturação grave em nenhum caso. A inserção da cânula orotraqueal foi considerada fácil em 29 pacientes (96,6%) e o manuseio da sonda de ETE foi adequada em 93,33% dos exames realizados. Conclusões: A realização dos exames de ETE sob sedação com auxílio da cânula orofaríngea de duplo lúmen apresentou baixa incidência de dessaturação nos pacientes avaliados, além de permitir análise do CO2 expirado durante a realização dos exames.

Development of a prototype anti-pollution filter for volatile anesthetics.

INTRODUCTION: The use of volatile agents during cardiopulmonary bypass allows a "single drug anesthesia" and is associated with reduced peak postoperative troponin levels. Connecting the exhaust systems to the oxygenator's gas outlet port is mandatory and allows to prevent operating room (but not atmospheric) pollution by volatile agents. The aim of this study was to create a prototype filter for volatile agents and to test its adsorption efficacy during an ex-vivo simulated conventional cardiopulmonary bypass test. METHODS: We carried out bench tests to conceive a prototype filter that could prevent room and environment pollution without damaging membrane oxygenators. We performed the tests at the Engineering Center for Circulatory Assistance Laboratory, Dante Pazzanese Institute of Cardiology, São Paulo, Brazil. Bench tests included simulation of integral adsorption tests, filter dimensions and design, flow versus pressure curve, sizing, and tightness. RESULTS: Calgon AT 410 was the best kind of activated charcoal granules for adsorption of sevoflurane, isoflurane, and desflurane. Filter dimension tests showed that a chamber of 30-cm width over 10-cm diameter filled with 200 g of the Calgon AT410 granules was the minimum required to fully adsorb sevoflurane for 90 min. Adsorption tests showed that the prototype filter fully adsorbed isoflurane in 100 ± 2.3 min, sevoflurane in 95 ± 3.4 min, and desflurane in 95 ± 4.3 min. CONCLUSION: The new version of our prototype filter adsorbed most of the volatile anesthetics agents during an ex-vivo simulated conventional cardiopulmonary bypass test.

Inhalational anesthesia maintenance with the Janus facial mask for transcatheter aortic-valve replacement: a case series / Manutenção da anestesia inalatória com a máscara facial Janus para substituição de válvula aórtica transcateter: uma série de casos

Abstract Background and objectives Aortic stenosis is the most common type of heart valve disease. Percutaneous aortic valve replacement has become the alternative for patients considered at high risk for surgery. Controlled mechanical ventilation with tracheal intubation has been the choice for this type of procedure, however the use of noninvasive ventilation in cardiac patients has shown to be beneficial. Janus is a novel full-face mask that allows application of noninvasive ventilation support during anesthesia. Our main objective was to evaluate the feasibility of transcatheter aortic valve replacement with prolonged transesophageal echocardiographic monitoring under deep inhalational sedation delivered through a new mask for noninvasive ventilation. Methods A case series observational study that included five patients with critical aortic stenosis that underwent inhalational anesthesia with sevoflurane for transcatheter aortic valve replacement in a hybrid room of a teaching hospital. Standard monitors and bispectral index were used, followed by inhalational induction and placement of the Janus mask. Anesthesia was maintained with sevoflurane. Patients were transferred to intensive care unit after the procedure. Complications related to the mask use, transesofageal echocardiography accessibility and respiratory implications to the patients were recorded. Results All procedures were uneventful and no major complications were observed intraoperatively. One patient presented CO2 retention (50 mmHg) and sevoflurane leak around the central opening of the mask, both without clinical significance. Conclusions The use of inhalational anesthesia with the facial mask Janus is a safe and efficient alternative to general anesthesia with tracheal intubation for transcatheter aortic valve replacement and can easily accommodate the use of transesophageal echocardiography intraoperatively.

Resumo Justificativa e objetivos A estenose aórtica é o tipo mais comum de doença valvular cardíaca. A substituição percutânea de válvula aórtica tornou-se a alternativa para pacientes cirúrgicos considerados de alto risco. A ventilação mecânica controlada com intubação traqueal tem sido a escolha para esse tipo de procedimento; porém, o uso de ventilação não invasiva em pacientes cardíacos mostrou ser benéfico. Janus é uma nova máscara facial que permite a aplicação de suporte à VNI durante a anestesia. Nosso objetivo primário foi avaliar a viabilidade da substituição transcateter de valva aórtica com monitoração ecocardiográfica transesofágica prolongada sob sedação inalatória profunda através de uma nova máscara para ventilação não invasiva. Métodos Estudo observacional de série de casos que incluiu cinco pacientes com estenose aórtica em fase crítica, submetidos à anestesia inalatória com sevoflurano para substituição transcateter de valva aórtica em uma sala híbrida de um hospital universitário. Monitores padrão e índice bispectral foram usados, seguidos de indução inalatória e colocação da máscara Janus. A anestesia foi mantida com sevoflurano. Os pacientes foram transferidos para a unidade de terapia intensiva após o procedimento. As complicações relacionadas ao uso da máscara, a acessibilidade da ecocardiografia transesofágica e as implicações respiratórias para os pacientes foram registradas. Resultados Todos os procedimentos transcorreram sem incidentes e não foram observadas complicações maiores no intraoperatório. Um paciente apresentou retenção de CO2 (50 mmHg) e vazamento de sevoflurano em torno da abertura central da máscara, ambos sem significância clínica. Conclusões O uso de anestesia inalatória com a máscara facial Janus é uma opção segura e eficiente à anestesia geral com intubação traqueal para substituição transcateter de valva aórtica e pode facilmente acomodar o uso de ecocardiografia transesofágica no intraoperatório.

[Inhalational anesthesia maintenance with the Janus facial mask for transcatheter aortic-valve replacement: a case series]. / Manutenção da anestesia inalatória com a máscara facial Janus para substituição de válvula aórtica transcateter: uma série de casos.

BACKGROUND AND OBJECTIVES: Aortic stenosis is the most common type of heart valve disease. Percutaneous aortic valve replacement has become the alternative for patients considered at high risk for surgery. Controlled mechanical ventilation with tracheal intubation has been the choice for this type of procedure, however the use of noninvasive ventilation in cardiac patients has shown to be beneficial. Janus is a novel full-face mask that allows application of noninvasive ventilation support during anesthesia. Our main objective was to evaluate the feasibility of transcatheter aortic valve replacement with prolonged transesophageal echocardiographic monitoring under deep inhalational sedation delivered through a new mask for noninvasive ventilation. METHODS: A case series observational study that included five patients with critical aortic stenosis that underwent inhalational anesthesia with sevoflurane for transcatheter aortic valve replacement in a hybrid room of a teaching hospital. Standard monitors and bispectral index were used, followed by inhalational induction and placement of the Janus mask. Anesthesia was maintained with sevoflurane. Patients were transferred to intensive care unit after the procedure. Complications related to the mask use, transesofageal echocardiography accessibility and respiratory implications to the patients were recorded. RESULTS: All procedures were uneventful and no major complications were observed intraoperatively. One patient presented CO2 retention (50mmHg) and sevoflurane leak around the central opening of the mask, both without clinical significance. CONCLUSIONS: The use of inhalational anesthesia with the facial mask Janus is a safe and efficient alternative to general anesthesia with tracheal intubation for transcatheter aortic valve replacement and can easily accommodate the use of transesophageal echocardiography intraoperatively.

Vasodilator Agents in Pediatric Cardiac Surgery with Cardiopulmonary Bypass

Surgical management of congenital heart disease has become regularly performed in tertiary hospitals worldwide. Although routinely needed, cardiopulmonary bypass (CPB) deleteriously affects physiological processes being among the main causes of increased morbidity in cardiac surgery, especially in neonates and children.Recent studies have shown that vasodilator agents’ use during CPB improved peripheral tissue perfusion while maintaining high flow during bypass. Hence, an improvement in perfusion and oxygenation of the skin, musculature and intestinal mucosa has been demonstrated, with favorable result throughout the postoperative period.These agents, by reducing systemic vascular resistance (SVR), lead to greater peripheral blood flow, improvement in peripheral perfusion, decreased base deficit and lactic acidosis and therefore improved respiratory and circulatory status.The present article reviews the main aspects of vasodilator agents most commonly used in pediatric cardiac surgery with CPB, including: chlorpromazine, phentolamine, phenoxybenzamine, sodium nitroprusside, volatile anesthetic agents, calcium channel blockers, angiotensin blockers and inodilators.

Determinação das substâncias reativas ao ácido tiobarbitúrico como indicador da peroxidação lipídica em ratos tratados com sevoflurano / Thiobarbituric acid reactive substances as an index of lipid peroxidation in sevoflurane-treated rats

JUSTIFICATIVA E OBJETIVOS: O sevoflurano é um éter fluorado de baixa solubilidade sangüínea e sua biotransformação ocorre por meio do sistema enzimático hepático oxidativo que envolve o citocromo P450 2E1. A peroxidação lipídica ocorre durante o processo de biotransformação dos éteres sob ação do citocromo P450, um dos possíveis mecanismos de toxicidade hepática e renal promovida por esses compostos. O objetivo deste estudo foi determinar os níveis de substâncias reativas ao ácido tiobarbitúrico (SRAT), como indicador da peroxidação lipídica, em ratos que receberam sevoflurano, previamente tratados ou não com isoniazida, indutor enzimático do citocromo P450 2E1. MÉTODO: Foram utilizados 42 animais, distribuídos aleatoriamente em 4 grupos que receberam respectivamente: G1 - oxigênio a 100 por cento 1 l.min-1/60 minutos por 5 dias consecutivos; G2 - sevoflurano a 4 por cento em oxigênio a 100 por cento, 1 l.min-1/60 minutos por 5 dias consecutivos; G3 - isoniazida (50 mg.kg-1.dia) por via intraperitoneal durante 4 dias consecutivos, em seguida foi tratado como o G1, no G4 - isoniazida 50 mg.kg-1.dia por via intraperitoneal durante 4 dias consecutivos, sendo tratado, posteriormente, como o G2. Após 12 horas do último tratamento, sacrificaram-se os animais e foi coletado o plasma para a análise das SRAT, sendo removido o lobo esquerdo do fígado e os rins para exame histológico. RESULTADOS: Os resultados mostraram aumento nas taxas de SRAT no G3 e G4, com elevação discreta em G2. O estudo histológico revelou necrose focal no fígado de ratos pré-tratados com isoniazida (G3). CONCLUSÕES: O sevoflurano promoveu peroxidação lipídica apenas quando associado à isoniazida.

[Thiobarbituric acid reactive substances as an index of lipid peroxidation in sevoflurane-treated rats.]. / Determinação das substâncias reativas ao ácido tiobarbitúrico como indicador da peroxidação lipídica em ratos tratados com sevoflurano.

BACKGROUND AND OBJECTIVES: Sevoflurane is a fluorinated ether with low blood solubility and biotransformed by an oxidative enzymatic liver system involving cytochrome P450 2E1. Lipid peroxidation occurs during ethers biotransformation process under action of cytochrome P450, a possible mechanism for liver and kidney toxicity promoted by such compounds. This study aimed at determining the levels of substances reactive to thiobarbituric acid (TBARS), as an index for lipid peroxidation in sevoflurane-treated rats, previously treated or not with isoniazid, enzymatic inducer of cytochrome P450 2E1. METHODS: Forty two male Wistar rats were randomly distributed in 4 groups receiving respectively: G1 - 1 L.min-1/60 minutes of 100% oxygen for 5 consecutive days; G2 - 4% sevoflurane in 1 L.min-1/60 minutes of 100% oxygen for 5 consecutive days; G3 - intraperitoneal isoniazid (50 mg.kg-1/day) for 4 consecutive days and then treated as G1; G4 - intraperitoneal isoniazid (50 mg.kg-1/day) for 4 consecutive days and then treated as G2. Animals were sacrificed 12 hours after the last treatment, plasma was collected for TBARS analysis and the liver left lobe and both kidneys were removed for histological evaluation. RESULTS: Results have shown increased TBARS levels in G3 and G4, with mild increase in G2. Histological evaluation has revealed focal liver necrosis in rats pretreated with isoniazid (G3). CONCLUSION: Sevoflurane has promoted lipid peroxidation only when associated to isoniazid.