The effects of anesthesia induction and positive pressure ventilation on right-ventricular function: an echocardiography-based prospective observational study

Abstract

BackgroundGeneral anesthesia induction with the initiation of positive pressure ventilation creates a vulnerable phase for patients. The impact of positive intrathoracic pressure on cardiac performance has been studied but remains controversial. 3D echocardiography is a valid and MRI-validated bed-side tool to evaluate the right ventricle (RV). The aim of this study was to assess the impact of anesthesia induction (using midazolam, sufentanil and rocuronium, followed by sevoflurane) with positive pressure ventilation (PEEP 5, tidal volume 6–8 ml/kg) on 2D and 3D echocardiography derived parameters of RV function.MethodsA prospective observational study on fifty-three patients undergoing elective cardiac surgery in a tertiary care university hospital was designed. Transthoracic echocardiography exams were performed before and immediately after anesthesia induction and were recorded together with hemodynamic parameters and ventilator settings.ResultsAfter anesthesia induction TAPSE (mean difference − 1.6 mm (95% CI − 2.6 mm to − 0.7 mm; p = 0.0013) as well as the Tissue Doppler derived tricuspid annulus peak velocity (TDITVs’) were significantly reduced (mean difference − 1.9% (95% CI: − 2.6 to − 1.2; p < 0.0001), but global right ventricular ejection fraction (RVEF; p = 0.1607) and right ventricular stroke volume (RVSV; p = 0.1838) did not change.ConclusionsThis data shows a preserved right ventricular ejection fraction and right ventricular stroke volume after anesthesia induction and initiation of positive pressure ventilation. However, the baso-apical right ventricular function is significantly reduced. Larger studies are needed in order to determine the clinical impact of these findings especially in patients presenting with impaired right ventricular function before anesthesia induction.Trial registrationRetrospecitvely registered, 6th June 2016, ClinicalTrials.gov Identifier NCT02820727.

Regional Right Ventricular Function Assessed by Intraoperative Three-Dimensional Echocardiography Is Associated With Short-Term Outcomes of Patients Undergoing Cardiac Surgery

“…Assessment of systolic RV function by intraoperative TEE is crucial. The induction of general anesthesia and positive pressure ventilation have distinct effects on RV function ( 21 ), and the application of goal-directed therapies by the anesthesiologist—such as vasopressor infusions to achieve predefined mean arterial pressures—could help to equilibrate loading conditions. Baseline reductions in RV function are associated with perioperative RV dysfunction and adverse outcomes following cardiac surgery ( 22 ), but the sensitivities of traditional echocardiographic measures are potentially insufficient ( 23 ).…”

Bedside Ultrasound for Hemodynamic Monitoring in Cardiac Intensive Care Unit

“…In addition, all anesthetic agents used for the induction and maintenance of general anesthesia have varying degrees of impact on systemic vascular resistance and cardiac contractility and can, hence, potentially impair RV function [72]. In a prospective study on 53 patients undergoing anesthesia and positive pressure ventilation, a significant reduction of TAPSE and free wall strain was described, without changes in RVEF and SV measured with 3D echocardiography [73].…”

Einfluss der perioperativen Echokardiografie auf das chirurgische Management

“…Andererseits sollte bei der Evaluation der ventrikulären Funktion in Narkose der Einfluss der Anästhetika und der Überdruckbeatmung auf die Herzfunktion berücksichtigt werden. So kann sich beispielsweise die rechtsventrikuläre Funktion, wenn man sie ausschließlich anhand der longitudinalen Kontraktion untersucht, schlechter als präoperativ darstellen [5]. Ob diese beobachtete "Verschlechterung" einen Einfluss auf die Hämodynamik oder gar das Patienten-Outcome hat, ist bisher nicht untersucht.…”