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OPIOID ANAESTHESIA—FACT OR FALLACY?
"I would have everie man write what he knowes and no more."—MONTAIGNE
BRITISH JOURNAL OF ANAESTHESIA VOLUME 54, No. 11
NOVEMBER 1982
EDITORIAL OPIOID ANAESTHESIA—FACT OR FALLACY?
It is now 13 years since the observations of Lowenstein and others (1969) that large doses of morphine produced minimal haemodynamic disturbances when given as a sedative to patients requiring prolonged artificial ventilation. They also showed that morphine 0.5-3.0mgkg" 1 given as a sole agent provided stable anaesthesia for cardiac surgery. As a consequence morphine and, more recently, fentanyl have been widely used for cardiac anaesthesia. It is now appropriate to assess the status of this type of anaesthesia. The apparent cardiovascular stability obtained with morphine anaesthesia for valve surgery was less obvious when this technique was used for coronary artery surgery, with hypotension, hypertension, vasodilatation (from histamine release) and an unacceptable frequency of awareness (Lowenstein, 1971; Rosow et al., 1982). Because of the high degree of cardiovascular stability obtained with large doses of fentanyl (l-2mg kg"1) in the dog (Liu etal., 1976) it was used as an alternative to morphine anaesthesia for both mitral valve and coronary artery operations (Stanley and Webster, 1978; Lunnetal., 1979). The cardiovascular stability obtained with fentanyl 60-70 ng kg"1, particularly during induction and tracheal intubation, even in patients with limited cardiac reserve, has been a main attraction of this technique to cardiac anaesthetists (Sebel et al., 1982; Zuriketal., 1982). However, cardiovascular problems can occur during opioid anaesthesia. Bradycardia is a well known side-effect of opioids, but can be minimized with atropine (Stanley and Webster, 1978) or with pancuronium (Sebel et al., 1982). More troublesome is the occurrence of hypertension which is observed in the period following sternotomy (Edde,
1981). This is more common in patients with coronary artery disease in whom hypertension, resulting in increased heart work and oxygen consumption, is potentially dangerous. These patients have limited ability to increase coronary artery blood flow and a large increase in arterial pressure can compromise their myocardial oxygen supply/demand balance (Waller and Kaplan, 1981). With doses of fentanyl 60-70ngkg" 1 there is a 45-50% frequency of hypertension greater than 20% of the pre-induction value (Sebel et al., 1982); increasing the dose to 125/igkg"1 reduces the frequency to 10% (de Lange, Stanley and Boscoe, 1980). Our own observations are that the most potent stimulus causing hypertension is surgical manipulation of the aortic root and we suggest that this is a result of stimulation of a specific cardiac chemoreflex, possibly involving the chemoreceptor described by James, Isobe and Urthaler (1975). Increased plasma catecholamines (Sebel etal., 1981a) or light anaesthesia (Sebel etal., 1981b) do not appear to play a part in this hypertensive response. Inadequate anaesthesia and a high frequency of awareness was a major disadvantage of morphine anaesthesia (Lowenstein, 1971). This problem does not appear to be as prevalent when fentanyl is used. Despite the widespread use of this anaesthetic technique, particularly in the U.S.A., there have been only isolated reports of awareness (Mummaneni, Rao and Montoya, 1980; Hilgenberg, 1981). Although the true frequency of awareness during fentanyl anaesthesia is unknown, the reported frequency compares favourably with inhalation techniques. Another potential advantage of opioid anaesthetic techniques is the reduction in metabolic and stress responses to surgery (Hall, 1980; Sebel et al.,
Downloaded from http://bja.oxfordjournals.org/ at University of Iowa Libraries/Serials Acquisitions on May 30, 2015
upcfipnt m the arodes triH i hf if In ire t yy o/ the contributor or a^*r'^TTT <~"TW**ITW^ Accordinjrfy, fn n rh*ir that the data rr^H opuuocu p p p jy, d tfae fa editorial d i i l committee and d tti^Tr t^ respective employees, l the publishers and officen and agents accept DO liability whatsoever for the • "itt/T"*Twn of any tachi inaccurate or mt«h-Hmg data, opinion or statement Whilst every effort is made to ensure that drug doaes and other quantities are presented accurately, readers are advised that new methods and techniques involving drug usage, *T*\ described within rhf« Journal, should only be followed m conjurxtian with the drug manufacturer's own published bterature
BRITISH JOURNAL OF ANAESTHESIA
1150
P.S. SebelandJ.G. Bovill
REFERENCES
Edde, R. R. (1981). Hemodynamic changes prior to and after sternotomy in patients anaesthetised with high-dose fentanyl.
Anathaiohgy, 55, 444. Hall, G. M. (1980). Fentanyl and the metabolic response to surgery. Br. J. Anaath., 52, 561. Hilgenberg, J. C. (1981). Intraoperative awareness during highdose fentanyl oxygen anesthesia. Anesthesiology, 54, 341.
James, T. N., Isobe, J. H., and Urthaler, F. (1975). Analysis of components in a cardiogenic hypertensive reflex. Circulation, 52,179. Lange, S. de, Stanley, T. H., and Boscoe, M. J. (1980). Fentanyl-oxygen anaesthesia: comparison of anaesthetic requirements and cardiovascular responses in Salt Lake City, Utah and Leiden, the Netherlands 7th World Congress of Anaestesiologists Hamburg, F.R.G. Amsterdam: Excerpta Medico, Abstract no. 646, p. 313. Liu.W. S.,Bidwai, A. W., Stanley, T. H.,andIsern-Aramel,J. (1976). Cardiovascular dynamics after large doses of fentanyl and fentanyl plus nitrous oxide in the dog. Antsth. Analg. (Clew), 55,168. Lowenstein, E. (1971). Morphine anesthesia—a perspective. Anesthatology, 35, 563. Hallowell, P., Levine, F. H., Daggett, W. M., Austin, G., and Laver, M. B. (1969). Cardiovascular responses to large doses of intravenous morphine in man. N. Engl. J. Med., 281, 1389. Lunn, J. K., Stanley, T. H., Eisler, J., Webster, L., and Woodward, A. (1979). High-dose fentanyl anesthesia for coronary artery sugery: plasma fentanyl concentrations and influence of nitrous oxide on cardiovascular responses. Anath. Analg. (CUvt.), 58, 390. Merin, R. G. (1981). Is anesthesia beneficial for the ischemic heart? Anesthtstology, 55, 341. Mummaneni, N., Rao, T. L. K., and Montoya, A. (1980). Awareness and recall with high-dose fentanyl-oxygen anesthesia. Anetth. Analg. (One.), 59, 948. Rosow, C E., Moss, J., Philbin, D. M., and Savarese, J. J. (1982). Histamine release during morphine and fentanyl anesthesia. Anathesiology, 56, 93. Sebel, P. S., Bovill, J. G., Schellekens, A. P. M., and Hawker, C. D. (1981a). Hormonal responses to high-dose fentanyl anaesthesia. Br. J. Anaath. 53,941. Wauquier, A., and Rog, P. (1981b). Effects of highdose anesthesia on the electroencephalogram. Antsthestology, 55,203. ' " Boekhorst, R. A. A., and Rog, N. (1982). Cardiovascular effects of high-dose fentanyl anaesthesia. Acta Anatithesiol. Scand., 26,308. Stanley, T. H., and Webster, L. R. (1978). Anesthetic requirements and cardiovascular effects of fentanyl-oxygen and fentanyl-diazepam-oxygen anesthesia in man. Anath.
Analg. (One.), 57,411. Waller, J. L., and Kaplan, J. A. (1981). Anaesthesia for patients with coronary artery disease. Br. J. Anaath., 53, 757. Zurick, A. M., Urzua, J., Yared, J.-P., and Estafanous, F. G. (1982). Comparison of hemodynamic and hormonal effects of large single-dose fentanyl anesthesia and halothane/nitrous oxide anesthesia for coronary artery surgery. Antsth. Analg.
(CUvt.),61,S2l.
Downloaded from http://bja.oxfordjournals.org/ at University of Iowa Libraries/Serials Acquisitions on May 30, 2015
1981a). Although theoretically beneficial, it has never been demonstrated that this produces a clinical advantage to the patient. There are currently two schools of thought on the best anaesthetic technique for cardiac anaesthesia: inhalation or i.v. The myocardial depressant action of inhalation drugs has generally been considered a disadvantage in patients with limited cardiovascular reserve. While this may be true for the more severely ill patient, there is recent evidence to suggest that halothane increases coronary vascular reserve (Merin, 1980) and may thus be beneficial for the ischaemic heart. Waller and Kaplan (1981) recommended the use of inhalation drugs, which produce controllable myocardial depression, for patients with good left ventricular function undergoing coronary artery surgery, and the use of opioids for patients with diminished cardiac reserve. It is likely that the cardiac anaesthetist of the future may be more selective in his choice of anaesthetic technique based on improved pharmacological data. There is a definite need for large well-controlled clinical trials comparing the two methods of anaesthesia; opioid v. inhalation. In our opinion, opioid anaesthesia has an important role in the anaesthetic management of the cardiac patient. The lack of cardiovascular depression and the attenuation of metabolic responses are potentially most beneficial in patients with severely compromised left ventricular function.
BRITISH JOURNAL OF ANAESTHESIA VOLUME 54, No. 11
NOVEMBER 1982
EDITORIAL OPIOID ANAESTHESIA—FACT OR FALLACY?
It is now 13 years since the observations of Lowenstein and others (1969) that large doses of morphine produced minimal haemodynamic disturbances when given as a sedative to patients requiring prolonged artificial ventilation. They also showed that morphine 0.5-3.0mgkg" 1 given as a sole agent provided stable anaesthesia for cardiac surgery. As a consequence morphine and, more recently, fentanyl have been widely used for cardiac anaesthesia. It is now appropriate to assess the status of this type of anaesthesia. The apparent cardiovascular stability obtained with morphine anaesthesia for valve surgery was less obvious when this technique was used for coronary artery surgery, with hypotension, hypertension, vasodilatation (from histamine release) and an unacceptable frequency of awareness (Lowenstein, 1971; Rosow et al., 1982). Because of the high degree of cardiovascular stability obtained with large doses of fentanyl (l-2mg kg"1) in the dog (Liu etal., 1976) it was used as an alternative to morphine anaesthesia for both mitral valve and coronary artery operations (Stanley and Webster, 1978; Lunnetal., 1979). The cardiovascular stability obtained with fentanyl 60-70 ng kg"1, particularly during induction and tracheal intubation, even in patients with limited cardiac reserve, has been a main attraction of this technique to cardiac anaesthetists (Sebel et al., 1982; Zuriketal., 1982). However, cardiovascular problems can occur during opioid anaesthesia. Bradycardia is a well known side-effect of opioids, but can be minimized with atropine (Stanley and Webster, 1978) or with pancuronium (Sebel et al., 1982). More troublesome is the occurrence of hypertension which is observed in the period following sternotomy (Edde,
1981). This is more common in patients with coronary artery disease in whom hypertension, resulting in increased heart work and oxygen consumption, is potentially dangerous. These patients have limited ability to increase coronary artery blood flow and a large increase in arterial pressure can compromise their myocardial oxygen supply/demand balance (Waller and Kaplan, 1981). With doses of fentanyl 60-70ngkg" 1 there is a 45-50% frequency of hypertension greater than 20% of the pre-induction value (Sebel et al., 1982); increasing the dose to 125/igkg"1 reduces the frequency to 10% (de Lange, Stanley and Boscoe, 1980). Our own observations are that the most potent stimulus causing hypertension is surgical manipulation of the aortic root and we suggest that this is a result of stimulation of a specific cardiac chemoreflex, possibly involving the chemoreceptor described by James, Isobe and Urthaler (1975). Increased plasma catecholamines (Sebel etal., 1981a) or light anaesthesia (Sebel etal., 1981b) do not appear to play a part in this hypertensive response. Inadequate anaesthesia and a high frequency of awareness was a major disadvantage of morphine anaesthesia (Lowenstein, 1971). This problem does not appear to be as prevalent when fentanyl is used. Despite the widespread use of this anaesthetic technique, particularly in the U.S.A., there have been only isolated reports of awareness (Mummaneni, Rao and Montoya, 1980; Hilgenberg, 1981). Although the true frequency of awareness during fentanyl anaesthesia is unknown, the reported frequency compares favourably with inhalation techniques. Another potential advantage of opioid anaesthetic techniques is the reduction in metabolic and stress responses to surgery (Hall, 1980; Sebel et al.,
Downloaded from http://bja.oxfordjournals.org/ at University of Iowa Libraries/Serials Acquisitions on May 30, 2015
upcfipnt m the arodes triH i hf if In ire t yy o/ the contributor or a^*r'^TTT <~"TW**ITW^ Accordinjrfy, fn n rh*ir that the data rr^H opuuocu p p p jy, d tfae fa editorial d i i l committee and d tti^Tr t^ respective employees, l the publishers and officen and agents accept DO liability whatsoever for the • "itt/T"*Twn of any tachi inaccurate or mt«h-Hmg data, opinion or statement Whilst every effort is made to ensure that drug doaes and other quantities are presented accurately, readers are advised that new methods and techniques involving drug usage, *T*\ described within rhf« Journal, should only be followed m conjurxtian with the drug manufacturer's own published bterature
BRITISH JOURNAL OF ANAESTHESIA
1150
P.S. SebelandJ.G. Bovill
REFERENCES
Edde, R. R. (1981). Hemodynamic changes prior to and after sternotomy in patients anaesthetised with high-dose fentanyl.
Anathaiohgy, 55, 444. Hall, G. M. (1980). Fentanyl and the metabolic response to surgery. Br. J. Anaath., 52, 561. Hilgenberg, J. C. (1981). Intraoperative awareness during highdose fentanyl oxygen anesthesia. Anesthesiology, 54, 341.
James, T. N., Isobe, J. H., and Urthaler, F. (1975). Analysis of components in a cardiogenic hypertensive reflex. Circulation, 52,179. Lange, S. de, Stanley, T. H., and Boscoe, M. J. (1980). Fentanyl-oxygen anaesthesia: comparison of anaesthetic requirements and cardiovascular responses in Salt Lake City, Utah and Leiden, the Netherlands 7th World Congress of Anaestesiologists Hamburg, F.R.G. Amsterdam: Excerpta Medico, Abstract no. 646, p. 313. Liu.W. S.,Bidwai, A. W., Stanley, T. H.,andIsern-Aramel,J. (1976). Cardiovascular dynamics after large doses of fentanyl and fentanyl plus nitrous oxide in the dog. Antsth. Analg. (Clew), 55,168. Lowenstein, E. (1971). Morphine anesthesia—a perspective. Anesthatology, 35, 563. Hallowell, P., Levine, F. H., Daggett, W. M., Austin, G., and Laver, M. B. (1969). Cardiovascular responses to large doses of intravenous morphine in man. N. Engl. J. Med., 281, 1389. Lunn, J. K., Stanley, T. H., Eisler, J., Webster, L., and Woodward, A. (1979). High-dose fentanyl anesthesia for coronary artery sugery: plasma fentanyl concentrations and influence of nitrous oxide on cardiovascular responses. Anath. Analg. (CUvt.), 58, 390. Merin, R. G. (1981). Is anesthesia beneficial for the ischemic heart? Anesthtstology, 55, 341. Mummaneni, N., Rao, T. L. K., and Montoya, A. (1980). Awareness and recall with high-dose fentanyl-oxygen anesthesia. Anetth. Analg. (One.), 59, 948. Rosow, C E., Moss, J., Philbin, D. M., and Savarese, J. J. (1982). Histamine release during morphine and fentanyl anesthesia. Anathesiology, 56, 93. Sebel, P. S., Bovill, J. G., Schellekens, A. P. M., and Hawker, C. D. (1981a). Hormonal responses to high-dose fentanyl anaesthesia. Br. J. Anaath. 53,941. Wauquier, A., and Rog, P. (1981b). Effects of highdose anesthesia on the electroencephalogram. Antsthestology, 55,203. ' " Boekhorst, R. A. A., and Rog, N. (1982). Cardiovascular effects of high-dose fentanyl anaesthesia. Acta Anatithesiol. Scand., 26,308. Stanley, T. H., and Webster, L. R. (1978). Anesthetic requirements and cardiovascular effects of fentanyl-oxygen and fentanyl-diazepam-oxygen anesthesia in man. Anath.
Analg. (One.), 57,411. Waller, J. L., and Kaplan, J. A. (1981). Anaesthesia for patients with coronary artery disease. Br. J. Anaath., 53, 757. Zurick, A. M., Urzua, J., Yared, J.-P., and Estafanous, F. G. (1982). Comparison of hemodynamic and hormonal effects of large single-dose fentanyl anesthesia and halothane/nitrous oxide anesthesia for coronary artery surgery. Antsth. Analg.
(CUvt.),61,S2l.
Downloaded from http://bja.oxfordjournals.org/ at University of Iowa Libraries/Serials Acquisitions on May 30, 2015
1981a). Although theoretically beneficial, it has never been demonstrated that this produces a clinical advantage to the patient. There are currently two schools of thought on the best anaesthetic technique for cardiac anaesthesia: inhalation or i.v. The myocardial depressant action of inhalation drugs has generally been considered a disadvantage in patients with limited cardiovascular reserve. While this may be true for the more severely ill patient, there is recent evidence to suggest that halothane increases coronary vascular reserve (Merin, 1980) and may thus be beneficial for the ischaemic heart. Waller and Kaplan (1981) recommended the use of inhalation drugs, which produce controllable myocardial depression, for patients with good left ventricular function undergoing coronary artery surgery, and the use of opioids for patients with diminished cardiac reserve. It is likely that the cardiac anaesthetist of the future may be more selective in his choice of anaesthetic technique based on improved pharmacological data. There is a definite need for large well-controlled clinical trials comparing the two methods of anaesthesia; opioid v. inhalation. In our opinion, opioid anaesthesia has an important role in the anaesthetic management of the cardiac patient. The lack of cardiovascular depression and the attenuation of metabolic responses are potentially most beneficial in patients with severely compromised left ventricular function.