The Impact of Morphine and Fentanyl on Recovery of Ventricular Function After Cardiopulmonary Bypass - PowerPoint PPT Presentation

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The Impact of Morphine and Fentanyl on Recovery of Ventricular Function After Cardiopulmonary Bypass

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Opioids protect the myocardium from ischemic injury. Morphine produces a more potent cardioprotective effect than fentanyl ... Infarct size reduced from 56 ... – PowerPoint PPT presentation

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Title: The Impact of Morphine and Fentanyl on Recovery of Ventricular Function After Cardiopulmonary Bypass


1
The 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
2
Object
  • Opioids protect the myocardium from ischemic
    injury
  • Morphine produces a more potent cardioprotective
    effect than fentanyl
  • Choice of intraoperative opioid

3
Material 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)
4
Results
  • MPI was increased in fentanyl group--
  • a significant worsening of global left
    ventricular function
  • MPI was improved in morphine group

5
Conclusions
  • In patients undergoing CPB, global ventricular
    function is enhanced by the administration of
    morphine prior to the ischemic insult of
    cardioplegic arrest.

6
Anesthetic 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

7
METHODS
  • 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

8
Induction
  • 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

9
Maintenance
  • Hypertension
  • isoflurane or nitroglycerin
  • Hypotension
  • volume replacement or phenylephrine
  • Inotropic agents
  • dobutamine 5 µg/kg/min
  • Mean pressures of 50 to 70 mmHg

10
Echocardiographic 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

11
Systolic Function
12
Diastolic Function
DT prolong poor LV relaxation
13
Diastolic Function and MPI
14
Discussion
  • 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
15
Morphine 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)
16
Mitochondrial 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

17
Morphine 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

18
Fentanyl Group
  • The peak A wave velocity increased
  • The deceleration time increased
  • A greater degree of impaired relaxation
  • The diastolic dysfunction class remained
    unchanged

19
Myocardial 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

20
Brain 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
    ?

21
Brain natriuretic peptide concentrations (pg/mL)
22
Troponin 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
23
Troponin I concentrations (ng/mL)
24
Some important limitations
  • Balance anesthesia, more practical?
  • Plasma concentration?
  • Limitation for early extubation

25
Fast-Track Cardiac Anesthesia
26
(No Transcript)
27
A 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
28
The 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.
29
Outcome Measures
  • Primary outcome was 30-day all-cause mortality
  • Secondary outcomes were major morbidities

30
No significant difference between groups with
respect to major morbidity
31
Clinical Outcome?
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