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A comparison of propofol-alfentanil versus midazolam-fentanyl for coronary artery surgery
173 A COMPARISON OF PROPOFOL-ATSFENTANILVERSUS MIDAZOLAM-FENTANYL FOR CORONARY ARTERY SURGERY E. Collard*, M. Gonzalez**, A. Mayne*, V. Delire*, P. Randour*, K. Joucken* mpts of *&aesthesia and i*Intensive Care Gliniques Universitaires U.C.L. de MONT-GODINNE B-5530 YVOIR (BELGIUM)
Bigh dose fentanyl (F) anaesthesia in combinationwith midazolam (H) has been our standard technique for cardiac anaesthesia. As there is increasing interest in early extubation (11, we compared the abovetechnique (groupI) with a combinationof propofol (P) and alfentanil (A) (group II), for haenicdynamic effects and extubation time.
Patients werecomparableaccordingto age, sex and BP (table 1; p > 0.5 ). Table 1 : Dsnographic data. GROUP AGR
The studyprotocolwasapprovedby the local Ethics Caazittee and patients gave informedconsent before entry. Twenty-onepatients have been investigated (10 patients in group I, 11 patients in group II). Patients over 75 or suffering fnxn obesity were excluded. Randonisationof the patients was based on the minimisationprocess (21, wherebythe following criteria were selected : sex, age, ejection fraction [BP), type and severity of coronary artery disease, use of mimetics. Pnznedicationconsisted of lonzetazepam,l-2 mgoral8 y, rmrphine 0.1 mg/kg i.m. and glycopyrrolate 0.2 rcg i.m. ; all were administered one hour before surgery. Concomitant cardiac n&cation wascontinued. IJponarrival in the theatre peripheral venousand arterial as well as pulmonaryartery catheters wereplaced. GroupI : Anaesthesiawas inducedwith a bolus dose of 25 H/kg F and 1.5 to 3 mg H i.v. ; and maintained by a continuous infusion of F at 7 W/kg/h until end of surgery. GroupII : Anaesthesiawas inducedwith an infusion- induction of P at 3-4 rag/kg/hand A at 30 #/kg/h, the latter being maintained until the end of surgery. Supplementarybolus doses of A were administered inroediatelybefore intubation, incision and sternotomy. The infusion rate of P was 1) adjusted afterwardsaccordingto ha&ynamic response, 2) halved at the onset of cardiopulmonarybypass and 3) increased again during the rewarmingphase. Hustle relaxation wasprovidedby pancumniun.All patients were ventilated with a 50 k air/O2 mixture. Hypertensiveperiods (> 20 % increase SAP)were treated in group I with additional bolus doses of F and in group II with supplementaryadministration of A. Bptensive periods were treated with administration of i.v. fluids. Postoperatively in ICU,analgesia wasprovidedby a PCA(Patient Controlled Analgesia) technique and sedation was maintained during approxiiuately4 hours by a K infusion in group I and a P infusion in groupII. The following haemcdynamic parameters were measured : man arterial, mean pulmonaryarterial, pulmonarycapillary wedge, central venous -pressures (WAP,WPAP,PCWP,CVP);heart rate (BR), systemic and pulnionaryvascular resistance (SVR,PVR), cardiac index (CI), left and right ventricular stroke workindex (LVSWI, RVSWI), at the following time points : before induction (A), 1 min before and after intubation (B, C), before incision (D), 1 min before and after steruotcay (E, P), before CPB(G) and after protamineadministration (8). The%n,easuteaentswerecompared betweengroupsat the different time points and analyzedusing AIDVA (p < 0.05 was acceptedas significant difference).
Body
Surface EP,
Uata
Area
(la')
as mean
GRUUP
II
64f7
1.85f0.23
1.94*0.15
62+9
56613
(8)
are expressed
I
66f4
(yr)
+ standard
deviation.
parameters at the different time points were not significantly different between both groups. Raemodynamic parametersare summarized in table 2.
Kamdynamic
Table 2 : Raemodynamic paranteters.
Weantime from end of surgery to extubation was 1095min in groupI and 480min in groupII. This difference reachedstatistical significance (WilcoxonRankSunTest; p = 0.033).
The two techniques showedcomparablehaemodynamic effects in these patients with moderateto goodleft ventricular function. Ourfindings in groupI confirmthose of A.R.WAWARA (3). As was expected with propofol, patients in group II could be weanedfromthe ventilator muchearlier.
1. KertzbergLB,Glass DD.Wanagement of ventilation. KaplanJR. Cardiac Anaesthesia. 2nd ed. Orlando : Gruneand Stratton, 1987: 1049-51. 2. Stuart J. Pocock. Clinical Trials. A practical approach. 1986,JohnWilley and SonsLtd., DA. 3. WanaraA.R., HonkC.R., Bolsin S.N. and Prys-RobertsC. Total I.V.anaesthesia with propofol and alfentanil for CABG. BJA 66; 716-718,1991.
Bigh dose fentanyl (F) anaesthesia in combinationwith midazolam (H) has been our standard technique for cardiac anaesthesia. As there is increasing interest in early extubation (11, we compared the abovetechnique (groupI) with a combinationof propofol (P) and alfentanil (A) (group II), for haenicdynamic effects and extubation time.
Patients werecomparableaccordingto age, sex and BP (table 1; p > 0.5 ). Table 1 : Dsnographic data. GROUP AGR
The studyprotocolwasapprovedby the local Ethics Caazittee and patients gave informedconsent before entry. Twenty-onepatients have been investigated (10 patients in group I, 11 patients in group II). Patients over 75 or suffering fnxn obesity were excluded. Randonisationof the patients was based on the minimisationprocess (21, wherebythe following criteria were selected : sex, age, ejection fraction [BP), type and severity of coronary artery disease, use of mimetics. Pnznedicationconsisted of lonzetazepam,l-2 mgoral8 y, rmrphine 0.1 mg/kg i.m. and glycopyrrolate 0.2 rcg i.m. ; all were administered one hour before surgery. Concomitant cardiac n&cation wascontinued. IJponarrival in the theatre peripheral venousand arterial as well as pulmonaryartery catheters wereplaced. GroupI : Anaesthesiawas inducedwith a bolus dose of 25 H/kg F and 1.5 to 3 mg H i.v. ; and maintained by a continuous infusion of F at 7 W/kg/h until end of surgery. GroupII : Anaesthesiawas inducedwith an infusion- induction of P at 3-4 rag/kg/hand A at 30 #/kg/h, the latter being maintained until the end of surgery. Supplementarybolus doses of A were administered inroediatelybefore intubation, incision and sternotomy. The infusion rate of P was 1) adjusted afterwardsaccordingto ha&ynamic response, 2) halved at the onset of cardiopulmonarybypass and 3) increased again during the rewarmingphase. Hustle relaxation wasprovidedby pancumniun.All patients were ventilated with a 50 k air/O2 mixture. Hypertensiveperiods (> 20 % increase SAP)were treated in group I with additional bolus doses of F and in group II with supplementaryadministration of A. Bptensive periods were treated with administration of i.v. fluids. Postoperatively in ICU,analgesia wasprovidedby a PCA(Patient Controlled Analgesia) technique and sedation was maintained during approxiiuately4 hours by a K infusion in group I and a P infusion in groupII. The following haemcdynamic parameters were measured : man arterial, mean pulmonaryarterial, pulmonarycapillary wedge, central venous -pressures (WAP,WPAP,PCWP,CVP);heart rate (BR), systemic and pulnionaryvascular resistance (SVR,PVR), cardiac index (CI), left and right ventricular stroke workindex (LVSWI, RVSWI), at the following time points : before induction (A), 1 min before and after intubation (B, C), before incision (D), 1 min before and after steruotcay (E, P), before CPB(G) and after protamineadministration (8). The%n,easuteaentswerecompared betweengroupsat the different time points and analyzedusing AIDVA (p < 0.05 was acceptedas significant difference).
Body
Surface EP,
Uata
Area
(la')
as mean
GRUUP
II
64f7
1.85f0.23
1.94*0.15
62+9
56613
(8)
are expressed
I
66f4
(yr)
+ standard
deviation.
parameters at the different time points were not significantly different between both groups. Raemodynamic parametersare summarized in table 2.
Kamdynamic
Table 2 : Raemodynamic paranteters.
Weantime from end of surgery to extubation was 1095min in groupI and 480min in groupII. This difference reachedstatistical significance (WilcoxonRankSunTest; p = 0.033).
The two techniques showedcomparablehaemodynamic effects in these patients with moderateto goodleft ventricular function. Ourfindings in groupI confirmthose of A.R.WAWARA (3). As was expected with propofol, patients in group II could be weanedfromthe ventilator muchearlier.
1. KertzbergLB,Glass DD.Wanagement of ventilation. KaplanJR. Cardiac Anaesthesia. 2nd ed. Orlando : Gruneand Stratton, 1987: 1049-51. 2. Stuart J. Pocock. Clinical Trials. A practical approach. 1986,JohnWilley and SonsLtd., DA. 3. WanaraA.R., HonkC.R., Bolsin S.N. and Prys-RobertsC. Total I.V.anaesthesia with propofol and alfentanil for CABG. BJA 66; 716-718,1991.