Clinical Studies (Cardio)


Kliniska Studier Hjärta


Isoflurane Sedation on the ICU in Cardiac Arrest Patients Treated With Targeted Temperature Management: An Observational Propensity-Matched Study

Author
Krannich et al
Critical Care Medicine 2017

Objective
Targeted temperature management after cardiac arrest requires deep sedation to prevent shivering and discomfort. Compared to IV sedation, volatile sedation has a shorter half-life and thus may allow more rapid extubation and neurologic assessment.

Findings
A matched pairs analysis revealed that time on ventilator (difference of median, 98.5 hr; p = 0.003) and length of ICU stay (difference of median, 4.5 d; p = 0.006) were significantly shorter in patients sedated with isoflurane when compared with IV sedation although no differences in neurologic outcome (45% of patients with cerebral performance category 1–2 in both groups) were observed. Significant hypercapnia occurred more frequently during anesthetic conserving device use (6.4% vs 0%; p = 0.021).

Conclusion
Volatile sedation is feasible in cardiac arrest survivors. Prospective controlled studies are necessary to confirm the beneficial effects on duration of ventilation and length of ICU stay observed in our study. Our data argue against a major effect on neurologic outcome. Close monitoring of PaCO2 is necessary during sedation via anesthetic conserving device.

To evaluate the differences in extubation times in a group of cardiac surgical patients who were anesthetized and sedated with either IV propofol or inhaled volatile anaesthetic agents.

Author
Jerath et al
Critical Care Medicine 2015

Objective
To evaluate the differences in extubation times in a group of cardiac surgical patients who were anesthetized and sedated with either IV propofol or inhaled volatile anaesthetic agents.

Findings
This was a prospective randomized controlled trial performed between September 2009 and August 2011. Cardiovascular ICU within a tertiary referral university-affiliated teaching hospital. One hundred forty-one patients undergoing coronary artery bypass graft surgery with normal or mildly reduced left ventricular systolic function. Participants were randomly assigned to receive anaesthesia and postoperative sedation using IV propofol (n = 74) or inhaled volatile (isoflurane or sevoflurane) anaesthetic agent (n = 67). Patients sedated using inhaled volatile agent displayed faster readiness to extubation time at 135 minutes (95-200 min) compared with those receiving IV propofol at 215 minutes (150-280 min) (p < 0.001). Extubation times were faster within the volatile group at 182 minutes (140-255 min) in comparison with the propofol group at 291 minutes (210-420 min) (p < 0.001). The volatile group showed a higher prevalence of vasodilatation with hypotension and higher cardiac outputs necessitating greater use of vasoconstrictors. There was no difference in postoperative pain scores, opioid consumption, sedation score, ICU or hospital length of stay, or patient mortality.

Conclusion
Inhaled volatile anaesthesia and sedation facilitates faster extubation times in comparison with IV propofol for patient undergoing coronary artery bypass graft surgery.

Inhaled Isoflurane Sedation during Therapeutic Hypothermia after Cardiac Arrest: A Case Series

Author
Hellström et al
Crit Care of Med – Vol 42 No 2 2014

Objective
Volatile anaesthetics have been reported to provide protection against ischemia-reperfusion injury and have been safely used in the ICU to provide sedation in trials with shorter wake-up times. There are no clinical studies in this setting. We describe a case series and discuss potential benefits.

Findings
Ten-bed ICU, university hospital. Twelve patients resuscitated from cardiac arrest with Glasgow Coma Scale score less than or equal to 4. Isoflurane sedation with the AnaConDa during 24 hours of therapeutic hypothermia, until rewarming. Data were extracted from the computerized ICU chart/monitors, hospital and prehospital charts, and the national death index. Patients were 49-76 years old. Median return of spontaneous circulation was 14 minutes. Glasgow Coma Scale scores were assessed within 24 hours from reaching normal body temperature and compared with outcomes at 6 months: six patients had poor Glasgow Coma Scale scores (< 8) that remained low and all died before 6-month follow-up, whereas another six patients had high scores (> 8) and survived to 6 months with good Cerebral Performance Category. In the ICU, four of the survivors were directly extubated after rewarming while two were once more sedated due to pneumonia requiring invasive ventilator therapy. All patients required norepinephrine to maintain adequate mean arterial pressure. Isoflurane sedation was changed to midazolam in two non-surviving patients because of hemodynamic instability, which persisted despite the change.

Conclusion
Sedation with volatile anaesthetics during therapeutic hypothermia may be a feasible short-acting option with potential post conditioning effects protecting vital organs from ischemia-reperfusion injury. Its measurability and insignificant drug accumulation could facilitate early neurologic assessment. Prospective clinical trials are warranted.

Volatile-Based Short-Term Sedation in Cardiac Surgical Patients: A Prospective Randomized Controlled Trial

Author
Jerath et al
Critical Care Medicine 2015

Objective
To evaluate the differences in extubation times in a group of cardiac surgical patients who were anesthetized and sedated with either IV propofol or inhaled volatile anaesthetic agents.

Findings
This was a prospective randomized controlled trial performed between September 2009 and August 2011. Cardiovascular ICU within a tertiary referral university-affiliated teaching hospital. One hundred forty-one patients undergoing coronary artery bypass graft surgery with normal or mildly reduced left ventricular systolic function. Participants were randomly assigned to receive anaesthesia and postoperative sedation using IV propofol (n = 74) or inhaled volatile (isoflurane or sevoflurane) anaesthetic agent (n = 67). Patients sedated using inhaled volatile agent displayed faster readiness to extubation time at 135 minutes (95-200 min) compared with those receiving IV propofol at 215 minutes (150-280 min) (p < 0.001). Extubation times were faster within the volatile group at 182 minutes (140-255 min) in comparison with the propofol group at 291 minutes (210-420 min) (p < 0.001). The volatile group showed a higher prevalence of vasodilatation with hypotension and higher cardiac outputs necessitating greater use of vasoconstrictors. There was no difference in postoperative pain scores, opioid consumption, sedation score, ICU or hospital length of stay, or patient mortality.

Conclusion
Inhaled volatile anaesthesia and sedation facilitates faster extubation times in comparison with IV propofol for patient undergoing coronary artery bypass graft surgery.

Late pharmacologic conditioning with volatile anaesthetics after cardiac surgery

Author
Beatrice Beck-Schimmer et al
Critical Care 2012

Objective
The aim of this randomized controlled trial was to investigate whether volatile anaesthetics used for postoperative sedation have any beneficial effects on myocardial injury in cardiac patients after on-pump valve replacements. Anaesthesia was performed with propofol.

Findings
Sevoflurane was administered via the AnaConDa in 46 patients for at least 4 hours postoperatively. Concentration of troponin T as the most sensitive marker for myocardial injury at first postoperative day was significantly lower in the sevoflurane group compared to the propofol group. Sevoflurane was started at a dose of MAC 0,5 and was then titrated to balance sedation. The ventilator was set at maintaining a PaCO2 of 5-6 kPa. In 4 cases, the AnaConDa device had to be removed because of sedation problems, and sedation was continued with propofol.

Conclusion
Late post conditioning with sevoflurane might mediate cardiac protection, even with late, brief, and low-dose application.