Intravenous Anesthesia for the Patient with Left Ventricular Dysfunction

Abstract

Patients with heart failure have a diminished cardiac reserve capacity that may be further compromised by anesthesia. In addition to depression of sympathetic activity, most anaesthetics interfere with cardiovascular performance, either by a direct myocardial depression or by modifying cardiovascular control mechanisms. Etomidate causes the least cardiovascular depression. It is popular for induction of anesthesia in cardiac-compromised patients; however, it is not suitable for maintenance of anesthesia because it depresses adrenocortical function. Ketamine has a favorable cardiovascular profile related to central sympathetic stimulation and inhibition of neuronal catecholamine uptake. These counteract its direct negative inotropic effect. In patients with a failing myocardium, however, the negative inotropic effects may be unmasked, resulting in deterioration in cardiac performance and cardiovascular instability. Propofol is the most popular intravenous anesthetic for maintenance of anesthesia. It does have a negative inotropic effect, but the net effect on myocardial contractility is insignificant at clinical concentrations, probably because of a simultaneous increase in the sensitivity of the myofilaments to Ca2+. Propofol protects the myocardium against ischemia-reperfusion injury, an action derived from its antioxidant and free-radical-scavenging properties as well as the related inhibition of the mitochondrial permeability transition pore. For intravenous anesthesia, propofol is always combined with an opioid. Opioids have relatively few cardiovascular side effects and, in particular, do not cause myocardial depression. Indeed, they are cardioprotective, with antiarrhythmic activity, and induce pharmacologic preconditioning of the myocardium by a mechanism similar to the inhalational anesthetics.

Effect of Propofol Preconditioning on Hypoxic-Cultured Human Osteoblast

“…Propofol is extensively used for the induction and maintenance of anesthesia during surgery and for ICU sedation [32][33][34]. It has recently focused greater attention due to its anti-apoptosis capability and antioxidant property [35][36][37][38].…”

Propofol attenuates intestinal mucosa injury induced by intestinal ischemia-reperfusion in the rat

“…Propofol is an iv anesthetic with antioxidant properties 7,8 that is commonly used during cardiac surgery and postoperative sedation. [9][10][11] Propofol has been shown to enhance tissue antioxidant capacity in various tissues in a rat model. 12 Interestingly, low-dose propofol sedation attenuates the formation of ROS in tourniquet-induced ischemia-reperfusion injury in humans.…”

Comparison of pre treatment with Ondansetron and Lignocaine over Pain on Etomidate Injection. A double blind prospective non randomised study

“…Although etomidate cause adrenocortical suppression, a single injection which is used to induce anaesthesia will only produce a transient and clinically insignificant interference with adrenocortical function. Because of its Hemodynamic stability it is preferred agent to induce anaesthesia in patients with ischemic heart disease, valvular heart disease, patients with cardiomyopathy and with any patients with poor ventricular function [5][6][7][8]. However, its use is limited by two major side effects, pain on injection and involuntary movements [14][15].…”

“…Etomidate is a hypnotic drug without analgesic property [1][2][3]. The intravenous administration of up to 0.6mg/kg of Etomidate to patients with severe cardiovascular disease has little or no effect on myocardial metabolism, cardiac output, peripheral circulation or pulmonary circulation [5][6][7]. Etomidate is rapidly metabolised in the liver.…”