RESUMEN
OBJECTIVES: To compare the incidence of delirium and early (at 1 week) postoperative cognitive dysfunction (POCD) between propofol-based total intravenous anesthesia (TIVA) and volatile anesthesia with sevoflurane in adult patients undergoing elective coronary artery bypass graft surgery (CABG) with cardiopulmonary bypass (CPB). DESIGN: This was a prospective randomized single-blinded study. SETTING: The study was conducted at a single institution, the Sree Chitra Tirunal Institute for Medical Sciences and Technology, a tertiary care institution and university-level teaching hospital. PARTICIPANTS: Seventy-two patients undergoing elective CABG under CPB participated in this study. INTERVENTIONS: This study was conducted on 72 adult patients (>18 years) undergoing elective CABG under CPB who were randomized to receive propofol or sevoflurane. Anesthetic depth was monitored to maintain the bispectral index between 40 and 60. Delirium was assessed using the Confusion Assessment Method for the Intensive Care Unit. Early POCD was diagnosed when there was a reduction of >2 points in the Montreal Cognitive Assessment score compared to baseline. Cerebral oximetry changes using near-infrared spectroscopy (NIRS), atheroma grades, and intraoperative variables were compared between the 2 groups. MEASUREMENTS & MAIN RESULTS: Seventy-two patients were randomized to receive propofol (n = 36) or sevoflurane (n = 36). The mean patient age was 59.4 ± 8.6 years. The baseline and intraoperative variables, including atheroma grades, NIRS values, hemoglobin, glycemic control, and oxygenation, were comparable in the 2 groups. Fifteen patients (21.7%) patients developed delirium, and 31 patients (44.9%) had early POCD. The incidence of delirium was higher with sevoflurane (n = 12; 34.2%) compared to propofol (n = 3; 8.8%) (odds ratio [OR], 1.72; 95% confidence interval [CI], 1.13-2.62; p = 0.027)*. POCD was higher with sevoflurane (n = 20; 57.1%) compared to propofol (n = 11; 32.3%) (OR, 1.63; 95% CI, 1.01-2.62; p = 0.038)*. In patients aged >65 years, delirium was higher with sevoflurane (7/11; 63.6%) compared to propofol (1/7; 14.2%) (p = 0.03)*. CONCLUSIONS: Propofol-based TIVA was associated with a lower incidence of delirium and POCD compared to sevoflurane in this cohort of patients undergoing CABG under CPB. Large-scale, multicenter randomized trials with longer follow-up are needed to substantiate the clinical relevance of this observation.
Asunto(s)
Anestesia Intravenosa , Anestésicos por Inhalación , Anestésicos Intravenosos , Puente de Arteria Coronaria , Propofol , Sevoflurano , Humanos , Sevoflurano/administración & dosificación , Sevoflurano/efectos adversos , Propofol/administración & dosificación , Propofol/efectos adversos , Masculino , Femenino , Persona de Mediana Edad , Método Simple Ciego , Estudios Prospectivos , Puente de Arteria Coronaria/efectos adversos , Puente de Arteria Coronaria/métodos , Anestésicos por Inhalación/efectos adversos , Anestésicos por Inhalación/administración & dosificación , Anestesia Intravenosa/métodos , Anestesia Intravenosa/efectos adversos , Anestésicos Intravenosos/efectos adversos , Anestésicos Intravenosos/administración & dosificación , Anciano , Delirio/epidemiología , Delirio/etiología , Anestesia por Inhalación/métodos , Anestesia por Inhalación/efectos adversos , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/diagnóstico , Complicaciones Posoperatorias/etiologíaAsunto(s)
Paro Cardíaco , Implantación de Prótesis de Válvulas Cardíacas , Prótesis Valvulares Cardíacas , Humanos , Válvula Mitral/diagnóstico por imagen , Válvula Mitral/cirugía , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Prótesis Valvulares Cardíacas/efectos adversos , Paro Cardíaco/cirugía , Unidades de Cuidados IntensivosAsunto(s)
Cardiopatías Congénitas , Atresia Pulmonar , Tabique Interventricular , Ecocardiografía , Ecocardiografía Transesofágica , Cardiopatías Congénitas/diagnóstico por imagen , Cardiopatías Congénitas/cirugía , Ventrículos Cardíacos/diagnóstico por imagen , Ventrículos Cardíacos/cirugía , Humanos , Atresia Pulmonar/diagnóstico por imagen , Atresia Pulmonar/cirugía , Resultado del TratamientoRESUMEN
OBJECTIVE: To evaluate the feasibility of intraoperative real time three-dimensional echocardiography (RT3DE) for identification and quantification of transient and persistent regional wall motion abnormalities (RWMAs) in patients with ischemic cardiomyopathy undergoing coronary artery bypass grafting (CABG). DESIGN: A prospective observational study SETTING: Single-center study in an academic tertiary care hospital PARTICIPANTS: A series of 42 patients undergoing elective CABG over a 2-year period were included. INTERVENTION: After induction of anesthesia, a comprehensive transesophageal echocardiography (TEE) examination was performed to evaluate regional wall motion using two-dimensional wall motion score index (WMSI) and RT3D echocardiographic parameters at three specific time points during the operative phase. MEASUREMENTS AND MAIN RESULTS: The 3D assessment of LV function was based on the quantification of change in LV chamber volume over time from each segment excursion. Patients were divided into two groups and subgroups based on TEE findings. There was significant mechanical dyssynchrony in patients with RWMAs (WMSI > 1; systolic dyssynchrony index [SDI] = 7.0 ± 3.66) as compared to the patients having normal wall motion (WMSI = 1; SDI = 2.0 ± 0.95; P = .001). Patients with contractile dysfunction were found to have low values of segmental excursion and high values of negative excursion on parametric imaging. Persistent RWMAs due to hibernating myocardium showed significant resolution of mechanical dyssynchrony after revascularization. Parametric imaging could detect transient RWMAs due to stunning and graft dysfunction. Early activating segments (EAS) on "timing bull's-eye" may represent hypercontractile segments and may influence inotrope administration. CONCLUSION: The RT3DE is a valuable modality for precise quantification of regional wall motion during revascularization procedure.
Asunto(s)
Puente de Arteria Coronaria/métodos , Ecocardiografía Tridimensional/métodos , Ecocardiografía Transesofágica/métodos , Monitoreo Intraoperatorio/métodos , Disfunción Ventricular Izquierda/diagnóstico por imagen , Disfunción Ventricular Izquierda/fisiopatología , Femenino , Ventrículos Cardíacos/diagnóstico por imagen , Ventrículos Cardíacos/fisiopatología , Humanos , Masculino , Persona de Mediana Edad , Estudios ProspectivosRESUMEN
PURPOSE: We report a case of bispectral index (BIS) falling to zero during absolute alcohol embolization of an intracranial arteriovenous malformation (AVM) under anesthesia. This case highlights the unusual effect of a therapeutic dose of parenteral alcohol on the central nervous system using BIS monitoring. CLINICAL FEATURES: A 29-yr-old male with a left parieto-occipital arteriovenous malformation underwent neuroendovascular embolization under general anesthesia. During injection of absolute alcohol injection into the AVM nidus, the patient developed hypertension and tachycardia coincident with a profound and sustained reduction of BIS values to zero, despite a stable level of anesthesia. Immediate angiography revealed no evidence of hemorrhage or new changes in the patient's cerebral vasculature. Post-procedure, the patient remained drowsy for several hours with signs of alcohol intoxication. He had full neurological recovery. CONCLUSIONS: In the presence of normal cerebral angiographic findings, suppression of BIS values may serve as an early indicator of CNS responses to intracranial injection of absolute alcohol for embolization of an arteriovenous malformation.