Choice of Anaesthesia Choice of Anaesthesia

for Patient with for Patient with

Cardiac Disease: Cardiac Disease:

GeneralGeneral versus versus Regional?Regional?

K. LebedinskiK. Lebedinski

St. PetersburgSt. Petersburg

«…«…Epidural anesthesia and analgesia exerted a Epidural anesthesia and analgesia exerted a significant beneficial effect on operative significant beneficial effect on operative outcome in a group of high risk surgical outcome in a group of high risk surgical patients:patients:

• Totally 53 high risk patients, Totally 53 high risk patients,

• Randomized between GA (25) and EAA (28) groupsRandomized between GA (25) and EAA (28) groups

• EAA group had a reduction in:EAA group had a reduction in:

• overall postoperative complication rate (P = 0.002),overall postoperative complication rate (P = 0.002),

• incidence of cardiovascular failure (P = 0.007),incidence of cardiovascular failure (P = 0.007),

• major infectious complications (P = 0.007),major infectious complications (P = 0.007),

• 24-h urinary cortisol excretion (P = 0.025),24-h urinary cortisol excretion (P = 0.025),

• hospital costs (P = 0.02)…hospital costs (P = 0.02)…»» Yeager MP, Glass DD, Neff RK, Brink-Johnsen T. Yeager MP, Glass DD, Neff RK, Brink-Johnsen T.

Epidural Anesthesia and Analgesia in High Risk Surgical Epidural Anesthesia and Analgesia in High Risk Surgical Patients. Patients.

Anesthesiology 1987; 66: 729-36Anesthesiology 1987; 66: 729-36

A retrospective cohort study of 9425 A retrospective cohort study of 9425 consecutive hip fracture patients, aged consecutive hip fracture patients, aged 60 60 yr, who underwent surgical repair at 20 US yr, who underwent surgical repair at 20 US hospitals (1983-1993), divided between GA hospitals (1983-1993), divided between GA (6206) and RA (3219) groups:(6206) and RA (3219) groups:

““The authors were unable to demonstrate The authors were unable to demonstrate that RA was associated with better that RA was associated with better outcome than was GA… These results outcome than was GA… These results suggest that the type of anesthesia used suggest that the type of anesthesia used should depend on factors other than any should depend on factors other than any associated risks of mortality or morbidity.”associated risks of mortality or morbidity.”

O’Hara DA, Duff A, Berlin JA, et al. O’Hara DA, Duff A, Berlin JA, et al.

The effect of anesthetic technique on The effect of anesthetic technique on postoperative outcomes in hip postoperative outcomes in hip fracture repair. fracture repair.

Anesthesiology 2000; 92: 947-57Anesthesiology 2000; 92: 947-57

“…“…Although clinical perceptions and Although clinical perceptions and

theoretic considerations suggest regional theoretic considerations suggest regional anesthesia should be safer than general anesthesia should be safer than general anesthesia in elderly patients, current anesthesia in elderly patients, current studies indicate no difference in outcomes. studies indicate no difference in outcomes. Regional anesthesia may still prove Regional anesthesia may still prove superior to general anesthesia if the right superior to general anesthesia if the right patient population or right endpoints are patient population or right endpoints are identified for comparison.”identified for comparison.”

Roy RC Roy RC

Choosing general versus regional anesthesia for the Choosing general versus regional anesthesia for the elderly. elderly.

Anesthesiology Clinics of North America 2000; 18: 91-104Anesthesiology Clinics of North America 2000; 18: 91-104

Epidural bupivacaine added to GA, despite of Epidural bupivacaine added to GA, despite of mild hypotension, led to severe reduction in mild hypotension, led to severe reduction in blood flow distal to the experimental coronary blood flow distal to the experimental coronary stenosis in swine.stenosis in swine.

Mergner GW, Stolte AL, Frame WB, Lim HJ. Mergner GW, Stolte AL, Frame WB, Lim HJ.

Combined epidural analgesia and general anesthesia Combined epidural analgesia and general anesthesia induce ischemia distal to a severe coronary artery induce ischemia distal to a severe coronary artery stenosis in swine.stenosis in swine.

Anesth Analg 1994; 78: 37-45Anesth Analg 1994; 78: 37-45In 47 healthy parturients, underwent Cesarean In 47 healthy parturients, underwent Cesarean

section under spinal anesthesia, 30% section under spinal anesthesia, 30% demonstrated ST depression due to demonstrated ST depression due to hyperkinetic contractile state.hyperkinetic contractile state.Roy L, Ramanathan S. Roy L, Ramanathan S.

ST-segment depression and myocardial contractility ST-segment depression and myocardial contractility during cesarean section under spinal anesthesiaduring cesarean section under spinal anesthesia..

Can J Anaesth 1999Can J Anaesth 1999;; 46: 46: 5252--5 5

!!

So, where is Truth?...So, where is Truth?...

• The primary event: vasodilation, dose- and The primary event: vasodilation, dose- and level-dependentlevel-dependent

• Compensatory response: cardiac output Compensatory response: cardiac output rise, sometimes reaching >50% from rise, sometimes reaching >50% from baselinebaseline

• Possible limiting factors:Possible limiting factors:

HypovolemiaHypovolemia

High (>Th5) central block levelHigh (>Th5) central block level

““Fixed” cardiac output (e.g., aortic Fixed” cardiac output (e.g., aortic stenosis)stenosis)

Neuraxial BlockNeuraxial Block

!!

The Equilibrium The Equilibrium of Central Neuraxial Block of Central Neuraxial Block

Compensation:Compensation:

• Afterload Afterload decline decline LVESV LVESV decreasesdecreases

• Baroreflex Baroreflex HR rise HR rise

Decompensation:Decompensation:

• Preload decline Preload decline LVEDV LVEDV decreasesdecreases

• Block above Th5 Block above Th5 cardiac cardiac depressiondepression

• The primary event: cardiac output decline, The primary event: cardiac output decline, reaching 25% of baselinereaching 25% of baseline

• Compensatory response: vascular tone riseCompensatory response: vascular tone rise

• Possible limiting factors:Possible limiting factors:

Low initial cardiac outputLow initial cardiac output

Use of vasodilatorsUse of vasodilators

Low central sympathetic outflow - Low central sympathetic outflow - inability to vasoconstrictioninability to vasoconstriction

General AnaesthesiaGeneral Anaesthesia

!!

The Equilibrium The Equilibrium of General Anaesthesia of General Anaesthesia

Compensation:Compensation:

• Vascular tone Vascular tone riserise

• Baroreflex Baroreflex HR rise HR rise

Decompensation:Decompensation:

• Contractility falls Contractility falls VESV increases VESV increases

• Central Central sympathetic sympathetic outflow restricts outflow restricts Vascular tone Vascular tone depressiondepression

Pre-operative Functional TestsPre-operative Functional Tests

• Vladimir A. Schtange (1913):Vladimir A. Schtange (1913):

Inspiratory hold-up test (Schtange test)Inspiratory hold-up test (Schtange test)

• Physical exercise tests (treadmill, Physical exercise tests (treadmill, veloergometer, etc.)veloergometer, etc.)

• Pharmacological stress-testsPharmacological stress-tests

• Pre-op dipyridamol-thallium scintigraphy Pre-op dipyridamol-thallium scintigraphy (Mangano et al.) – ?... (Mangano et al.) – ?...

• Challenges (e.g., physical exercise) are Challenges (e.g., physical exercise) are different from those at the OR!different from those at the OR!

• General conditions are different,General conditions are different,

• Responses are also different,Responses are also different,

• Criteria are based on another endpoints…Criteria are based on another endpoints…

So, at least the challenges So, at least the challenges

must be the same!must be the same!

Why pre-op functional tests are Why pre-op functional tests are unable to predict unable to predict complications?complications?

ModelingModeling

Almost a Almost a universal tool, universal tool,

when the risk is when the risk is high and high and

possible losses possible losses are are

unacceptable:unacceptable:

• Shipbuilding,Shipbuilding,

• Aviation,Aviation,

• Nuclear power,Nuclear power,

• Defense, etc…Defense, etc…

And what about And what about anaesthesiology?anaesthesiology?

......

Our aim was to elaborate clinical prognostic Our aim was to elaborate clinical prognostic models to substantiate the individual models to substantiate the individual choice of anaesthesia based on specific choice of anaesthesia based on specific patients’ response to physiological patients’ response to physiological challenges, similar to those of the challenges, similar to those of the anaesthesiaanaesthesia

The first step was … The first step was … Systemic Vasodilation with p.o. Systemic Vasodilation with p.o.

Nitroglycerin as a Prognostic Test Nitroglycerin as a Prognostic Test for Hypotension after Spinal for Hypotension after Spinal

BlockBlock

to investigate the possibility of individual prognosis based on the analogy between local (spinal block) and systemic (nitroglycerin p.o.) vasodilation

Aim of the study:

Problem:

severe hypotension under spinal block

• 58 ASA I-III patients aged 22—89

• Monitoring: ECG, SpO2, NIBP

• Impedance cardiography: CI, SVRI

• LV Power Index (Wm-2) = 0.0022CImean BP

• Nitroglycerin test: 500 mkg p.o.Nitroglycerin test: 500 mkg p.o.

• Crystalloid fluid loading 6.23.8 mlkg–1

• Spinal anesthesia: L3-L4, isobaric Spinal anesthesia: L3-L4, isobaric bupivacaine 0.2bupivacaine 0.20.05 mg0.05 mgkgkg–1–1

• Mean sensory block level: T8Mean sensory block level: T8

• Hypotension: mean BP <75% of base Hypotension: mean BP <75% of base level, requiring ephedrinelevel, requiring ephedrine

Materials and methods:

• Normotensive (N) group: 44 patients

• Hypotensive (H) group: 14 patients

• No difference between N and H: age, gender, body weight and length, nitroglycerin and bupivacaine doses, time interval between test and puncture, sensory block level

• Similar response to test and SA

• Test CI rise (P=5.510-5): N-group 42.9%

H-group 22.2%

• Test LVPI changes (P=10-6): N-group +29.7%

H-group –0.77%

Results:

Hemodynamic Hemodynamic Response Response To To

Nitroglycerin TestNitroglycerin Test

Preoperative systemic vasodilation test with p.o. nitroglycerin may be used as simple, fast, safe and relevantprognostic test for severe hypotension after spinal block

Conclusion:

Lebedinski K, Shevkulenko D Eur J Anaesth 2006; 23, Suppl. Lebedinski K, Shevkulenko D Eur J Anaesth 2006; 23, Suppl. 37: A40837: A408

Our next steps… Our next steps…

Esmolol i.v. bolus as a Prognostic Test Esmolol i.v. bolus as a Prognostic Test for Hemodynamic Response for Hemodynamic Response

to General Anaesthesia to General Anaesthesia

Postural Tests as a Prognostic Tool Postural Tests as a Prognostic Tool for Hemodynamic Responses for Hemodynamic Responses

during Surgery and Anaesthesia during Surgery and Anaesthesia

From From á prioriá priori choice of anaesthesia – choice of anaesthesia –

to modeling-based choice!to modeling-based choice!

The Choice of Anaesthesia The Choice of Anaesthesia for Patient with for Patient with Cardiac Disease:Cardiac Disease:

Brief SummaryBrief SummaryPeripheral neuraxial block Peripheral neuraxial block

– – if sufficient regarding surgery – if sufficient regarding surgery –

the superior choice anyway!the superior choice anyway!

If there are no direct contraindications If there are no direct contraindications to central neuraxial block – to central neuraxial block –

choice between RA and GA choice between RA and GA

based on prognostic modeling testsbased on prognostic modeling tests

Our specialty develops more Our specialty develops more

and more methods of and more methods of anaesthesia – ingenious, anaesthesia – ingenious, elegant and effective.elegant and effective.

But we should always But we should always remember, that the aim of remember, that the aim of our patient is to survive our patient is to survive surgery, but not to confirm surgery, but not to confirm any paradigm – even those any paradigm – even those reported just now!…reported just now!…

Thank youThank you for the for the

attention!attention!