Isoflurane compared with fentanyl-midazolam-based anesthesia in patients undergoing heart transplantation

Abstract

Inhalation anesthetics provide myocardial protection for cardiac surgery. This study was undertaken to compare the perioperative effects between isoflurane and fentanyl-midazolam-based anesthesia for heart transplantation. A retrospective cohort study was conducted by reviewing the medical records of heart transplantation in a single medical center from 1990 to 2013. Patients receiving isoflurane or fentanyl-midazolam-based anesthesia were included. Those with preoperative severe pulmonary, hepatic, or renal comorbidities were excluded. The perioperative variables and postoperative short-term outcomes were analyzed, including blood glucose levels, urine output, inotropic use, time to extubation, and length of stay in the intensive care units. After reviewing 112 heart transplantations, 18 recipients with fentanyl-midazolam-based anesthesia, and 29 receiving isoflurane anesthesia with minimal low-flow technique were analyzed. After cessation of cardiopulmonary bypass, recipients with isoflurane anesthesia had a significantly lower mean level and a less increase of blood glucose, as compared with those receiving fentanyl-based anesthesia. In addition, there was less use of dobutamine upon arriving the intensive care unit and a shorter time to extubation after isoflurane anesthesia. Compared with fentanyl-midazolam-based anesthesia, isoflurane minimal low-flow anesthesia maintained better perioperative homeostasis of blood glucose levels, less postoperative use of inotropics, and early extubation time among heart-transplant recipients without severe comorbidities.

Effects of midazolam co-induction to general anesthesia: A randomized clinical trial

“…[22] Conflicting results have been reported regarding the effects of individual anesthetics used in GA on perioperative and postoperative glycemia. Some authors have shown better glycemic control with isoflurane compared to TIVA with midazolam in cardiac surgery, [23] while other studies did not find significant differences between TIVA with midazolam and balanced anesthesia, [24] or between TIVA with propofol or midazolam. [25] Our study did not find significant glycemic differences between the study groups.…”

Cerebral Oximetry-Monitored Nitroglycerin Infusion and Tissue Perfusion during Rewarming of Cardiopulmonary Bypass in Cardiac Surgery: A Prospective Randomized Trial

“…Patients receiving normothermic CPB according to the surgeon's decision during operation were also excluded. Before the commencement of this study, statistical power analyses performed with G*Power [13] revealed that a sample size of 27 patients per group was required to achieve 80% power for an effect size of 0.78 in the primary endpoint of post-CPB blood glucose levels [14] because we did not find any previously published data on lactate levels following nitroglycerin infusion during rewarming of CPB. A total of 80 patients were enrolled to allow for patient dropout.…”

“…However, its dosedependent vasodilatory effects on cerebral oxygenation, heparin reversal, and metabolic homeostasis, such as blood glucose and lactate levels, were scarcely reported in previous studies when we commenced this prospective study. Therefore, the significantly different glucose levels in our previous study [14] were substituted for lactate levels as the primary endpoint of tissue perfusion for the calculation of the sample size. However, based on the present results from more than 30 patients in each group, we observed that most clinical variables were closely comparable.…”

Renal effects of general anesthesia from old to recent studies

“…Fentanyl and sufentanil may pose hemodynamic effects by regulating the release of norepinephrine from the adrenal glands (Thomson, Hudson, Rosenbloom, & Torchia, ). Fentanyl significantly elevates the blood glucose level (Hsu et al, ) and heart rate, and on the other hand, dampens the cardiovascular response (Kirvela, Scheinin, & Lindgren, ). An adjuvant of fentanyl with midazolam and fluanisone has a direct effect on blood glucose, C‐lactate, and pyruvate (due to renal metabolism) and renal mean transit time, perhaps because of compromised renal function.…”