Title: The Impact of Morphine and Fentanyl on Recovery of Ventricular Function After Cardiopulmonary Bypass
1The Impact of Morphine and Fentanyl onRecovery
of Ventricular Function After Cardiopulmonary
Bypass
Murphy, Glenn S et al. Journal of Cardiothoracic
and Vascular Anesthesia, Vol 20, No 4 (August),
2006 pp 493-502
2Object
- Opioids protect the myocardium from ischemic
injury - Morphine produces a more potent cardioprotective
effect than fentanyl - Choice of intraoperative opioid
3Material and Methods
- Prospective, randomized study, University
hospital - 46 patients undergoing CABG surgery
- Morphine(40mg)or fentanyl(1,000µg) before CPB
- Using the myocardial performance index (MPI)
single number that reflects global systolic and
diastolic function of the ventricle (higher
numbers indicating worsening function)
4Results
- MPI was increased in fentanyl group--
- a significant worsening of global left
ventricular function - MPI was improved in morphine group
5Conclusions
- In patients undergoing CPB, global ventricular
function is enhanced by the administration of
morphine prior to the ischemic insult of
cardioplegic arrest.
6Anesthetic Preconditioning
- Brief periods of exposure of the heart to an
anesthetic agent - Opening of the mitochondrial adenosine
triphosphate-sensitive K channel (KATP channel) - Opioid receptor(µ)KATP channel-linked mechanism
7METHODS
- CABG patients (age of 18-79 )
- Exclusion criteria
- 1.concurrent valvular surgery
- 2.reoperative procedures,
- 3.unstable angina or elevated cardiac enzymes
- 4.ejection fraction lt40
- 5.the need for an IABP or inotropic agents
- 6.CRI(creatinine gt1.6 mg/dL)
- 7.preoperative use of drugs affecting the
KATP - channel
8Induction
- Midazolam, Etomidate, Rocuronium
- A bolus dose of 50 mL of the study infusion
(morphine or fentanyl) - Deliver the study opioid at 25 mL/h over the next
2 hours - Deliver the total dose of opioid
- (Morphine 40mg or fentanyl 1,000µg )
- before placement of the aortic cross-
- clamp.
- maintained with isoflurane
-
9Maintenance
- Hypertension
- isoflurane or nitroglycerin
- Hypotension
- volume replacement or phenylephrine
- Inotropic agents
- dobutamine 5 µg/kg/min
- Mean pressures of 50 to 70 mmHg
-
10Echocardiographic data
- After Induction
- 15 minutes after separation from CPB
- At the end of the operation
- 3 consecutive cardiac cycles, off-line analysis
- Systolic function
- ?fractional area change, FAC (LVEDA-
- LVESA)/LVEDA)
- ?ejection fraction, EF
- Diastolic function
-
-
11Systolic Function
12Diastolic Function
DT prolong poor LV relaxation
13Diastolic Function and MPI
14Discussion
- High-dose fentanyl produced less histamine
release and soon replaced morphine as a primary
anesthetic - Morphine in doses of 0.6 to 1.0 mg/kg results in
minimal histamine release - Morphine may protect the myocardium from ischemic
injury during cardiac surgery.
Opiate drugs andd-receptor-mediated myocardial
protection. Circulation 100II357-II360, 1999
15Morphine mimics the cardioprotective effect of
ischemic preconditioning via a glibenclamidesensit
ive mechanism in the rat heart
- Anesthetized rats
- 3 brief infusions of morphine (100 µg/kg)
- 30-minute left coronary artery occlusion
- Infarct size reduced from 56?12
- Abolished by the administration of naloxone or
glibenclamide(KATP-channel antagonist)
(Circ Res 781100-1104, 1996)
16Mitochondrial KATP channel
- Naltrindole selectived-receptor antagonist
- Naltrindole completely abolished the protective
effects of morphine - d-receptor plays an important role in
opioid-induced cardioprotection - End-effector of morphine-induced cardioprotection
is the - Mitochondrial KATP channel
17Morphine better than Fentanyl?
- Morphine has a greater affinity for the dopioid
receptor than fentanyl - Morphine, in contrast to fentanyl, can activate
KATP channels in neuron tissue
18Fentanyl Group
- The peak A wave velocity increased
- The deceleration time increased
- A greater degree of impaired relaxation
- The diastolic dysfunction class remained
unchanged
19Myocardial performance index (MPI)
- Single number that reflects global systolic and
diastolic function of the ventricle (higher
numbers indicating worsening function) - Independent of preload, afterload, and heart rate
- Predictive of poor outcome in the setting of CHF
and acute MI or after mitral valve surgery
20Brain natriuretic peptide
- ????
- biochemical markers of left ventricular
dysfunction after CPB - Not significantly different ?
- Indirect measures of ventricular function
- Samples were collected during the postoperative
period - Cardioprotective effect of morphine was transient
?
21Brain natriuretic peptide concentrations (pg/mL)
22Troponin I
- Most sensitive and specific biochemical marker
- No significant differences ?
- Influenced to a greater extent by surgical
factors than by anesthetic protective strategies. - Preconditioning on postoperative troponin I
elevations remains controversial
Anesthesiology 981315-1327, 2003 Anesthesiology
9742-49, 2002
23Troponin I concentrations (ng/mL)
24Some important limitations
- Balance anesthesia, more practical?
- Plasma concentration?
- Limitation for early extubation
25Fast-Track Cardiac Anesthesia
26(No Transcript)
27A Comparison of Fentanyl, Sufentanil, and
Remifentanil for Fast-Track Cardiac Anesthesia
- We conclude that the more expensive but
shorter-acting opioids, sufentanil and
remifentanil, produced equally rapid extubation,
similar stays, and similar costs to fentanyl,
indicating that any of these opioids can be
recommended for fast-track cardiac surgery
Anesthesia Analgesia. 93(4)859-64, 2001 Oct
28The Efficacy and Resource Utilization of
Remifentanil and Fentanyl in Fast-Track Coronary
Artery Bypass Graft Surgery
- We conclude that both anesthesia techniques
permit early and similar times until tracheal
extubation, less intense monitoring, ICU and
hospital discharge, and reduced resource
utilization after coronary artery bypass graft
surgery.
Anesthesia Analgesia. 92(5)1094-102, 2001 May.
29Outcome Measures
- Primary outcome was 30-day all-cause mortality
- Secondary outcomes were major morbidities
30No significant difference between groups with
respect to major morbidity
31Clinical Outcome?