pancuronium and Coronary-Disease

It is easy to take for granted the seemingly effortless way cardiovascular surgeons are able to bypass atherosclerotic coronary arteries. The process used today was developed over many years of rigorous study, experimentation, success, and failure. Early cardiac surgery was performed blindly, through small incisions, on a beating heart. Advances in medicine allowed surgery to be performed on hearts stilled by cardioplegic arrest, while the circulation was continued through the use of a cardiopulmonary bypass (CPB) machine. The development of the CPB machine allowed surgeons to perform the delicate work of coronary artery bypass grafting (CABG), first attempted on dogs, and then humans. This article briefly outlines the historical evolution of cardiac surgery that led to the development of the technology necessary to perform off-pump coronary artery bypass grafting (OPCAB). A case report of a 72-year-old female who underwent OPCAB is outlined. Included is a discussion of some of the benefits and potential complications of CABG and OPCAB. Anesthetic considerations for OPCAB procedures also are presented.

Topics: Aged; Anesthesia, Inhalation; Anesthesia, Intravenous; Anesthetics, Inhalation; Anesthetics, Intravenous; Animals; Conscious Sedation; Coronary Artery Bypass, Off-Pump; Coronary Disease; Dogs; Female; Humans; Isoflurane; Midazolam; Monitoring, Intraoperative; Neuromuscular Nondepolarizing Agents; Pancuronium; Perioperative Care; Sufentanil; Treatment Outcome

Different combinations of neuromuscular blockers and opioids have been used in patients with angina pectoris to provide cardiovascular stability and reduce risk of myocardial ischaemia during anaesthesia.. We have compared the haemodynamic effects of high-dose vecuronium (0.3 mg kg-1) with those of a standard dose of pancuronium (0.1 mg kg-1) in patients scheduled for coronary artery bypass grafting during fentanyl-diazepam-nitrous oxide anaesthesia. All patients were receiving beta-adrenergic blocking agents. The given doses of vecuronium and pancuronium are equieffective with respect to duration of neuromuscular blockade.. During a 25-min experimental period following the administration of the randomly selected drug, no significant changes in the haemodynamic parameters were observed in the vecuronium group. The administration of pancuronium, however, resulted in a significant mean increase in heart rate (20%), rate-pressure product (23%) and cardiac index (21%). Following endotracheal intubation in the pancuronium group, we observed an additional significant increase in mean arterial pressure and rate-pressure product.. High-dose administration of vecuronium has minimal haemodynamic effects and may thus offer a better alternative than pancuronium for long-lasting neuromuscular blockade in patients with coronary artery disease during fentanyl-diazepam-nitrous oxide anaesthesia.

Topics: Adrenergic beta-Antagonists; Aged; Anesthesia; Coronary Disease; Diazepam; Female; Fentanyl; Hemodynamics; Humans; Male; Middle Aged; Neuromuscular Nondepolarizing Agents; Nitrous Oxide; Pancuronium; Vecuronium Bromide

The hemodynamic and electrocardiographic (ECG) effects of pancuronium and vecuronium were compared during high-dose fentanyl anesthesia for coronary artery bypass grafting (CABG) surgery. Forty-eight morphine-scopolamine premedicated patients scheduled for elective CABG were anesthetized with fentanyl (100 micrograms/kg) in divided doses, and either of two muscle relaxants, pancuronium (n = 26; 0.10 mg/kg) or vecuronium (n = 22; 0.09 mg/kg). Hemodynamic data, blood gas samples, and ECG tracings were obtained at the following intervals: (1) control; (2) prior to intubation; (3) 1 minute after intubation; (4) prior to sternotomy; and (5) 1 minute after sternotomy. In the pancuronium group, heart rate (HR), cardiac index (CI), and rate-pressure product (RPP) were increased after induction of anesthesia and following intubation. Eleven patients (42.3%) displayed ischemic ST segment changes. Four patients in this group developed tachycardia and hypertension to an extent requiring pharmacological intervention. Vecuronium-treated patients displayed no increases in HR, MAP, and RPP, and a decrease in CI. Only one patient (5.6%) developed evidence of ischemic ECG changes. Four patients in the vecuronium group, all receiving preoperative beta-blocker therapy, became hypotensive and bradycardic after the induction of anesthesia. The present investigation confirms the increased incidence of myocardial ischemia during high-dose fentanyl-pancuronium anesthesia. Although vecuronium was associated with fewer myocardial ischemic changes, the occurrence of bradycardia and hypotension in some patients receiving preoperative beta-adrenergic blocking drugs remains a concern.

Topics: Anesthesia, Intravenous; Atrial Function, Right; Blood Pressure; Cardiac Output; Coronary Artery Bypass; Coronary Disease; Electrocardiography; Female; Fentanyl; Heart Rate; Hemodynamics; Humans; Intubation, Intratracheal; Male; Middle Aged; Pancuronium; Sternum; Stroke Volume; Time Factors; Vascular Resistance; Vecuronium Bromide

In 8 patients with coronary artery disease (CAD) classed as NYHA II or III, anesthesia was induced with high-dose fentanyl (0.05 mg/kg) and pancuronium (0.1 mg/kg). The patients were ventilated normally with the aid of a mask (O2: air 1:1, tidal volume 10 ml/kg with a rate of 10/min) for 5 min and then intubated. In 8 further patients with CAD NYHA class II or III, anesthesia was induced with 0.02 mg/kg flunitrazepam, N2O/O2 1:1 and isoflurane 0.5 vol%; they were relaxed with pancuronium (0.1 mg/kg) in combination with a bolus of 0.005 mg/kg fentanyl. These patients were also ventilated normally for 5 min and then intubated. Measurements of cardiovascular dynamics included cardiac output (CO), heart rate (HR), arterial pressure (AP), pulmonary artery pressure (PAP), pulmonary capillary wedge pressure (PCWP), right atrial pressure (RAP), myocardial blood flow (MBF), and arterial and coronary sinus oxygen and lactate contents. Cardiac index (CI), stroke volume index (SVI), total peripheral resistance (TPR), myocardial oxygen consumption (MVO2), coronary vascular resistance (CVR), coronary perfusion pressure (CPP), myocardial oxygen content difference (AVDO2cor) and myocardial lactate extraction rate (LE) were calculated from standard formulas. Measurements and an electrocardiogram were taken before anesthesia, after induction of anesthesia and after intubation. The hemodynamic parameters HR, AP, CI, CPP were relatively stable in patients anesthetized with high-dose fentanyl and pancuronium, whereas we found greater decreases in these parameters with the balanced anesthesia technique. Determinants of myocardial oxygen demand were higher in the high-dose fentanyl group; therefore, myocardial blood flow and oxygen consumption did not decrease to the same extent as in the balanced anesthesia group.(ABSTRACT TRUNCATED AT 250 WORDS)

Topics: Aged; Coronary Disease; Energy Metabolism; Female; Fentanyl; Hemodynamics; Humans; Male; Middle Aged; Myocardium; Neuroleptanalgesia; Pancuronium

This study was performed to compare the incidence of prebypass myocardial ischemia in patients receiving fentanyl and enflurane for anesthesia along with either pancuronium or vecuronium. Ninety-eight patients with normal left ventricular function were randomly allocated to receive either pancuronium 0.15 mg.kg-1 or vecuronium 0.15 mg.kg-1 in a double-blind manner after fentanyl 40 micrograms.kg-1 for induction of anesthesia for elective coronary artery bypass grafting (CABG). Premedication included diazepam 0.15 mg.kg-1 po, morphine 0.10 mg.kg-1, and scopolamine 0.005 mg.kg-1 im. Two lead Holter monitor recordings (leads V6 and V9) from the time of arrival in the operating suite to institution of cardiopulmonary bypass were analyzed for ischemia by a cardiologist blinded to the choice of muscle relaxant. Intraoperatively, heart rates greater than 90 beats.min-1 and systolic blood pressure +/- 20% of ward values were treated with propranolol, enflurane, or phenylephrine. Nitroglycerin was infused for ECG signs of ischemia or pulmonary hypertension. After induction of anesthesia the heart rate and cardiac index were consistently decreased in patients receiving vecuronium and also lower in these patients compared with those receiving pancuronium. Thirty-two per cent of patients receiving pancuronium received propranolol for heart rates greater than 90 beats.min-1 versus 7% of those who received vecuronium (P approximately 0.01). Eight patients developed 13 episodes of ischemia after administration of the muscle relaxant: four who received pancuronium (n = 44; 9%) and four receiving vecuronium (n = 54; 7%). Four episodes occurred at induction or tracheal intubation, two in each group. There were four perioperative myocardial infarctions as determined by ECG and CPK-MB levels, two in each group.(ABSTRACT TRUNCATED AT 250 WORDS)

Topics: Anesthesia, Inhalation; Clinical Trials as Topic; Coronary Artery Bypass; Coronary Disease; Double-Blind Method; Enflurane; Female; Fentanyl; Humans; Male; Middle Aged; Pancuronium; Random Allocation; Vecuronium Bromide

The effects of the non-depolarizing muscle relaxants pancuronium (Pancuronium) and vecuronium (Norcuron) (0.1 mg/kg) on myocardial blood flow, myocardial oxygen consumption, myocardial lactate balance, cardiovascular dynamics and electrocardiogram were studied in two groups of eight patients undergoing coronary artery bypass surgery. After an introduction of anaesthesia with 0.015-0.02 mg/kg rohypnol, isoflurane (0.5 Vol%) and N2O/O2 neuromuscular blockade was induced with pancuronium or vecuronium combined with a single dose of 0.005 mg/kg fentanyl. Measurements and electrocardiogram were performed before anaesthesia, in steady state of anaesthesia and after relaxation with pancuronium or vecuronium, combined with fentanyl. The measurements consisted of heart rate (HR), cardiac index (CI), stroke volume index (SVI), mean arterial pressure (AP), total peripheral resistance (TPR), pulmonary arterial pressure (PAP), pulmonary capillary wedge pressure (PCWP), right atrium pressure (RAP), myocardial blood flow (MBF), coronary vascular resistance (CVR), myocardial oxygen consumption (MVO2), coronary ateriomixed venous oxygen content difference (AVDO2cor), myocardial lactate extraction (LE) and rate pressure product (RPP). In the vecuronium group heart rate (HR) decreased significantly greater (21%) than in the pancuronium group (9%). Therefore myocardial oxygen consumption (MVO2) and coronary blood flow (CBF) diminished more in the vecuronium (48% resp. 35%) than in the pancuronium group (31% resp. 18%). The higher metabolic demand in the pancuronium group induced a significantly lower coronary vascular resistance (CVR). All the other hemodynamic parameters did not differ significantly in both patients groups. In all the patients we could not observe ST-segment depressions or elevations in the ECG, increases of PCWP or myocardial lactate productions.(ABSTRACT TRUNCATED AT 250 WORDS)

Topics: Aged; Anesthesia, General; Coronary Artery Bypass; Coronary Circulation; Coronary Disease; Electrocardiography; Female; Fentanyl; Hemodynamics; Humans; Lactates; Lactic Acid; Male; Middle Aged; Myocardium; Oxygen Consumption; Pancuronium; Vecuronium Bromide

A study was carried out to see whether the administration of a small dose of midazolam determined a reduction of the dose of fentanyl necessary for induction of anaesthesia. Sixteen patients undergoing coronary artery bypass surgery were randomly allocated to either of two groups. Patients in group M received 0.075 mg.kg-1 midazolam intravenously 3 to 5 min prior to induction with fentanyl (5 micrograms.kg-1.min-1), whereas patients in group P only received placebo. The mean dose of fentanyl administered to obtain complete loss of reaction to a painful stimulus was 20 +/- 3 micrograms.kg-1 in group M and 21.5 +/- 2.5 micrograms.kg-1 in group P (NS). However the small dose of midazolam associated with fentanyl caused a significant drop in blood pressure by 20%. After the administration of pancuronium (0.15 mg.kg-1), the patients in group P showed a significant increase in heart rate (+ 14 b.min-1), accompanied by an increase in cardiac index (+0.45 l.min-1.m-2). Pretreatment with midazolam seemed to protect the patient from this undesirable reaction. It was concluded that induction with a combination of a small dose of midazolam and fentanyl did not lead to a reduction in the dose of fentanyl necessary to obtain profound analgesia. However, it gave rise to a haemodynamic pattern quite distinct from that seen during induction with fentanyl alone.

Topics: Anesthesia, General; Clinical Trials as Topic; Coronary Disease; Double-Blind Method; Fentanyl; Hemodynamics; Humans; Intubation, Intratracheal; Midazolam; Middle Aged; Pancuronium

Thirty patients with ischaemic heart disease scheduled for coronary artery bypass grafting were randomly allocated to three equal groups. Following morphine, hyoscine and pentobarbitone premedication, anaesthesia was induced with diazepam 0.3 mg kg-1. Five minutes later neuromuscular blockade was induced with pancuronium 0.1 mg kg-1, vecuronium 0.1 mg-1 or atracurium 0.5 mg kg-1, followed after 6 min by fentanyl 25 micrograms kg-1. Pancuronium and atracurium caused significant increases in heart rate, while vecuronium induced little change. Systemic vascular resistance decreased significantly from 1515 dyn s cm-5 to 1200 dyn s cm-5 following atracurium. Cardiac index was increased transiently in the atracurium group, but a more sustained increase was observed following pancuronium. Nine patients in the atracurium group showed skin flushing and one developed skin weals.

Topics: Atracurium; Coronary Artery Bypass; Coronary Disease; Female; Hemodynamics; Humans; Male; Middle Aged; Pancuronium; Vecuronium Bromide

To compare haemodynamic responses associated with equipotent doses of muscle relaxants and high dose fentanyl (50 micrograms X kg-1), 40 non-hypertensive patients who were receiving beta adrenergic and calcium channel blocker therapy and undergoing coronary bypass surgery were randomized to four study groups receiving the following: (1) atracurium: 0.4 mg X kg-1, (2) pancuronium: 0.12 mg X kg-1, (3) vecuronium: 0.12 mg X kg-1, or (4) pancuronium-metocurine mixture: (0.4 mg + 1.6 mg X ml-1):1 ml/10 kg. Neuromuscular blockers were injected with fetanyl at induction. Haemodynamics were recorded with the patients awake (baseline), at two minutes post-induction, and at two and five minutes after intubation. Pancuronium was the only drug associated with significant increases in HR; no other significant changes occurred within each group when compared to their respective baseline haemodynamics. HR increased more after induction with pancuronium when compared to atracurium (23 vs. 4 per cent, p less than 0.05) and to vecuronium (23 vs. 2 per cent, p less than 0.05), and when compared to vecuronium after intubation (29 vs. 7 per cent, p less than 0.05). The pancuronium-metocurine mixture caused tachycardia which was less than, though not significantly different than with pancuronium; however, HR returned to baseline by five minutes with the mixture, but remained elevated with pancuronium (3 vs. 18 per cent, p less than 0.05). SVR fell more on induction with atracurium when compared to vecuronium (-18 vs. 1 per cent, p less than 0.05). These changes in HR or SVR were not accompanied by ECG signs of ischaemia.(ABSTRACT TRUNCATED AT 250 WORDS)

Topics: Anesthesia; Coronary Artery Bypass; Coronary Disease; Electrocardiography; Female; Fentanyl; Hemodynamics; Humans; Male; Middle Aged; Neuromuscular Nondepolarizing Agents; Pancuronium; Tubocurarine; Vecuronium Bromide

The purpose of this study was to evaluate intravenous nitroglycerin given during induction of anesthesia as a means for prevention of myocardial ischemia and hemodynamic changes associated with induction, laryngoscopy, and intubation, in patients with stable angina scheduled for vascular operations of moderate duration. Forty-six patients were randomly assigned to receive either fentanyl, 3 micrograms/kg (group 1, n = 6), fentanyl, 8 micrograms/kg (group 2, n = 20), or fentanyl 3 micrograms/kg plus a continuous intravenous nitroglycerin infusion, 0.9 microgram X kg-1 X min-1 (group 3, n = 20), in addition to thiopental-pancuronium anesthetic induction, prior to laryngoscopy and intubation. The criteria for recognizing myocardial ischemia were the following: horizontal or downsloping ST segment depression equal to or greater than 1 mV, and/or ventricular arrhythmia, on CM5 recording. In group 1, myocardial ischemia occurred during laryngoscopy and intubation in four patients, and mean blood pressure (MBP), heart rate, and mean pulmonary wedge pressure (PCWP) increased significantly (P less than 0.05). Despite greater stability in MBP and heart rate in group 2, myocardial ischemia still occurred in four patients (not significantly different from group 1). Nitroglycerin added to low-dose fentanyl (group 3) produced significant reduction in myocardial ischemia (1/20) when compared with group 1 (P less than 0.01), and significantly greater stability in PCWP during laryngoscopy and intubation in comparison to groups 1 and 2. In patients with stable angina undergoing operations of short duration, the use of nitroglycerin infusion and low-dose fentanyl significantly decreases the incidence of myocardial ischemia associated with induction of anesthesia and tracheal intubation.

Topics: Aged; Anesthesia, Local; Blood Pressure; Coronary Disease; Electrocardiography; Female; Fentanyl; Heart Rate; Humans; Laryngoscopy; Male; Middle Aged; Morphine; Nitroglycerin; Pancuronium; Preanesthetic Medication; Pulmonary Wedge Pressure; Stroke Volume; Thiopental; Vascular Resistance

The effects of prophylactic infusion of 1 microgram X kg-1 X min-1 nitroglycerin (NTG) on the incidence of ischemia, hypertension, hypotension and perioperative myocardial infarction were studied in 81 patients during coronary artery bypass grafting (CABG). Forty-one patients (Group 1) received NTG and 40 patients (Group 2) received placebo. All patients received fentanyl for anesthesia and pancuronium. Mean arterial pressure (MAP), pulmonary capillary wedge pressure (PCWP), heart rate (HR), and cardiac output (CO) were measured before and after induction of anesthesia, after intubation, before and after chest incision, after sternotomy, after the pericardium was opened, and during normothermic cardiopulmonary bypass. Myocardial ischemia and infarction were diagnosed from the ECG, hypertension was defined as a 20% increase in MAP, and hypotension was defined as a 20% decrease in MAP compared with preinduction values. No significant differences between Groups 1 and 2 in HR, PCWP, or CO were seen. MAP was significantly lower in Group 1 than Group 2 (P less than 0.05) before chest incision, but increased to levels equal to Group 2 after sternotomy. Hypertension occurred in 32 Group 2 patients and 25 Group 1 patients (0.05 less than P less than 0.1). Group 1 patients had 0.95 +/- 0.14 episodes per patient of hypertension, while Group 2 patients had 2.10 +/- 0.31 episodes (P less than 0.05). Hypotension occurred in 20 Group 1 patients but only six Group 2 patients (P less than 0.05). There was no difference in the incidence of ischemia. In Group 1, nine patients (22%) had ECG changes of ischemia, while 12 patients in Group 2 (30%) had ischemia.(ABSTRACT TRUNCATED AT 250 WORDS)

Topics: Anesthesia; Cardiac Output; Coronary Artery Bypass; Coronary Disease; Creatine Kinase; Electrocardiography; Fentanyl; Heart Rate; Humans; Hypertension; Hypotension; Nitroglycerin; Pancuronium; Pulmonary Wedge Pressure; Tachycardia

Using a randomized double-blind protocol, the authors prospectively compared three nondepolarizing muscle relaxants with respect to their influence on hemodynamics and on the electrocardiogram. Thirty-three patients undergoing elective coronary artery bypass grafting (CABG) with high-dose (100 micrograms/kg) fentanyl anesthesia were studied. Patients received 1.5 X ED95 of either pancuronium (n = 12), metocurine (n = 9), or a metocurine-pancuronium combination (4:1 ratio by weight) (n = 12) for muscle relaxation. Heart rate and rate pressure product (RPP) were significantly higher postinduction in the pancuronium group. Myocardial ischemia, indicated by new ECG ST-segment depression occurred significantly more frequently, and exclusively, in the pancuronium group. The authors' data suggest that since pancuronium is associated with tachycardia and an increased incidence of myocardial ischemia, it is best avoided in patients with severe coronary artery disease undergoing CABG with high-dose fentanyl. Either metocurine or the metocurine-pancuronium combination provides greater hemodynamic stability, without precipitating myocardial ischemia, and can be safely and effectively substituted for pancuronium.

Topics: Anesthesia; Coronary Artery Bypass; Coronary Disease; Double-Blind Method; Female; Fentanyl; Hemodynamics; Humans; Male; Middle Aged; Pancuronium; Prospective Studies; Random Allocation; Tubocurarine

Twenty patients undergoing coronary artery bypass grafting under fentanyl-pancuronium anesthesia were studied. Continuous electrocardiographic (ECG) recording by a Holter Monitor was utilized to determine the incidence of ECG changes of myocardial ischemia during the precardiopulmonary bypass period and to determine the efficacy of an intravenous nitroglycerin (iv NTG) infusion for preventing ischemic ECG changes. Patients in Group 1 (n = 9) received a 0.5 microgram . kg-1 . min-1 iv NTG infusion 20 min prior to induction of anesthesia and throughout the study. Patients in Group 2 (n = 11) received placebo. A randomized double-blind protocol was employed. Anesthesia was induced with fentanyl 3 micrograms . kg-1 . min-1. After fentanyl 25 micrograms/kg and pancuronium 0.1 microgram/kg, the trachea was intubated. After fentanyl 50 micrograms/kg surgery commenced. Prior to induction of anesthesia, iv NTG caused significant decreases in mean arterial pressure and pulmonary capillary wedge pressure, whereas placebo had no effect. However, subsequent to induction of anesthesia, hemodynamics in the two groups were identical. Fifty per cent of patients developed ECG changes of myocardial ischemia during the period from induction of anesthesia to commencement of cardiopulmonary bypass. The incidence of ischemic ECG changes was virtually identical in Group 1 (5/9) and Group 2 (5/11). Ischemic ECG changes were associated with increases in heart rate, mean arterial pressure, and rate pressure product, and decreases in the endocardial viability ratio (DPTI/SPTI). Increases in pulmonary capillary wedge pressure were not associated with myocardial ischemia. Fentanyl-pancuronium anesthesia, as administered in this study, was associated with a high incidence of myocardial ischemia.(ABSTRACT TRUNCATED AT 250 WORDS)

Topics: Anesthesia; Coronary Artery Bypass; Coronary Disease; Electrocardiography; Fentanyl; Hemodynamics; Humans; Injections, Intravenous; Intraoperative Complications; Middle Aged; Nitroglycerin; Pancuronium; Pulmonary Wedge Pressure

Cardiovascular effects of neuromuscular blocking agents mainly guide the choice of these relaxants in patients with cardiovascular disease. The purpose of this study was to compare the hemodynamic effects of fazadinium (1 mg . kg-1), pancuronium (0,08 mg . kg-1) and alcuronium (0,2 mg . kg-1) in 30 coronary patients without beta-blocking therapy. No hemodynamic changes were observed after pancuronium. Fazadinium induced at the fifth minute a mean five p. 100 decrease in mean arterial pressure, cardiac index, stroke volume and systemic vascular resistance. At the fifth minute with alcuronium, mean arterial pressure decreased (22 p. 100) (p less than 0.01) with a decrease in cardiac index (12 p. 100), stroke volume (8 p. 100) and systemic vascular resistance (10 p. 100). This study shows that pancuronium and fazadinium are well tolerated. Alcuronium induces at the fifth minute a significant decrease in arterial pressure. This effect does not seem to be deleterious in normovolemic patient with coronary artery disease without beta-blocking therapy.

Topics: Aged; Alcuronium; Blood Pressure; Coronary Disease; Heart; Hemodynamics; Humans; Middle Aged; Neuromuscular Blocking Agents; Pancuronium; Pyridinium Compounds; Vascular Resistance

The haemodynamic effects of large bolus doses of metocurine 0.45 mg kg-1 and pancuronium 0.1 mg kg-1 were compared in patients with coronary artery disease anaesthetized with diazepam, anileridine and nitrous oxide. Hypotension occurred more frequently after metocurine and was a result of a decrease in systemic vascular resistance. After pancuronium there was no increase in arterial pressure or heart rate, but a small increase in cardiac index. The decrease in heart rate after metocurine was the principal cause of the statistically significant difference in cardiac index between the two groups. Contrary to previous findings, metocurine did not attenuate circulatory responses to tracheal intubation. During surgical stimulation, two of the 10 patients of the pancuronium group developed significant ST segment depression and three patients had a rate-pressure product greater than 12 000 mm Hg beat min-1. However, the difference in rate-pressure product between the groups was not statistically significant.

Topics: Anesthesia, General; Coronary Artery Bypass; Coronary Disease; Female; Hemodynamics; Humans; Male; Middle Aged; Pancuronium; Tubocurarine

Topics: Aluminum Silicates; Anesthesia, Inhalation; Anesthesia, Intravenous; Anesthetics, Inhalation; Anesthetics, Intravenous; Angina Pectoris; Coronary Disease; Fentanyl; Heart Ventricles; Holmium; Humans; Isoflurane; Laser Therapy; Male; Midazolam; Middle Aged; Myocardial Revascularization; Neuromuscular Nondepolarizing Agents; Oxygen; Pancuronium; Yttrium

To determine the incidence, triggers, and timing of myocardial injury during reoperation for coronary artery bypass surgery.. Prospective observational.. One tertiary care university hospital.. 15 patients undergoing reoperation.. Multilead electrocardiographic monitoring approximately every 3 minutes during surgery.. The occurrence of a new ischemic ST elevation or depression on the electrocardiogram (ECG) was determined. A major deterioration in ventricular function after cardiopulmonary bypass (CPB) also was determined. Peak creatine kinase myocardial band (CK-MB) > or = 25 IU/L was considered to be the marker of myocardial injury. Seven patients demonstrated myocardial injury, all intraoperatively. Five of these patients had new ST elevation episodes before CPB. Three of the episodes were temporally associated with an abrupt increase in the heart rate. The other two episodes were temporally associated with surgical manipulation of the heart and the old grafts. The sixth patient had a significant deterioration of ventricular function during CPB. One of the patients who had ST elevation before CPB and the seventh patient developed ST elevation towards the end of protamine administration.. In patients undergoing reoperation, the intraoperative incidence of myocardial injury, especially before CPB, was found to be substantially higher than that previously reported.

Topics: Aged; Arrhythmias, Cardiac; Cardiopulmonary Bypass; Case-Control Studies; Coronary Artery Bypass; Coronary Disease; Creatine Kinase; Electrocardiography; Female; Heart Rate; Heparin Antagonists; Humans; Incidence; Intraoperative Complications; Intubation, Intratracheal; Isoenzymes; Male; Middle Aged; Monitoring, Intraoperative; Myocardial Ischemia; Neuromuscular Nondepolarizing Agents; Pancuronium; Prospective Studies; Protamines; Reoperation; Ventricular Dysfunction

Topics: Analgesics, Opioid; Coronary Disease; Drug Combinations; Humans; Length of Stay; Pancuronium; Piperidines; Propofol; Remifentanil; Retrospective Studies

Topics: Anesthetics; Blood Pressure; Cardiac Output; Coronary Disease; Drug Interactions; Heart; Heart Rate; Humans; Myocardial Ischemia; Narcotics; Neuromuscular Nondepolarizing Agents; Norepinephrine; Pancuronium; Pipecuronium

Topics: Anesthesia, General; Coronary Disease; Energy Metabolism; Fentanyl; Hemodynamics; Humans; Myocardium; Neuroleptanalgesia; Pancuronium

Although not unanimously accepted, high-dose fentanyl anesthesia has been associated with hemodynamic stability and little derangement of myocardial oxygen balance. This apparent inconsistency inspired us to investigate the effects on cardiac function and myocardial metabolism of stepwise increasing doses of fentanyl, accumulating to 15, 30, and 50 micrograms.kg-1, with the least possible interference from other drugs. Subjects were unpremedicated patients with ischemic cardiac disease scheduled for coronary artery bypass grafting or major vascular surgery. In an initial study employing succinylcholine for muscle relaxation, we found that heart rate (HR), coronary sinus blood flow (CSF) and coronary vascular resistance (CVR) remained unchanged, while systemic arterial pressure (SBP), rate-pressure product (RPP), coronary perfusion pressure (CPP) and left ventricular work (LVW) decreased. Myocardial uptake of oxygen (MVO2) and free fatty acids (FFA) both decreased in a dose-dependent manner. Arterial lactate concentration and myocardial lactate uptake both increased. These findings opposed the postinduction myocardial ischemia noted by some other investigators. In most of these studies pancuronium bromide had been used for muscle relaxation. Since the latter agent has been claimed to increase cardiac work, a second group of correspondingly diseased patients was studied in which succinylcholine was replaced by pancuronium bromide. In this group HR, RPP, CSF and MVO2 all increased at the lowest dose of fentanyl and HR additionally also at 30 micrograms.kg-1. The cardiac index was higher in the pancuronium group at the lowest and middle dose steps of fentanyl. Lactate uptake decreased with higher doses of fentanyl and relative myocardial lactate extraction declined.(ABSTRACT TRUNCATED AT 250 WORDS)

Topics: Anesthesia, Intravenous; Blood Pressure; Coronary Circulation; Coronary Disease; Energy Metabolism; Fatty Acids, Nonesterified; Fentanyl; Heart Rate; Humans; Lactates; Middle Aged; Myocardium; Oxygen Consumption; Pancuronium; Stroke Volume; Succinylcholine

Topics: Coronary Disease; Fentanyl; Humans; Middle Aged; Pancuronium; Propranolol; Tachycardia; Verapamil

It has been suggested that sufentanil is a superior anesthetic to fentanyl for patients undergoing myocardial revascularization. This study was performed to determine the incidence of prebypass myocardial ischemia using sufentanil, 20 micrograms/kg for patients undergoing coronary artery bypass grafting (CABG). Twenty-seven patients with normal left ventricular function, scheduled for elective CABG, were studied. Anesthesia was induced with sufentanil, 10 micrograms/kg; and pancuronium, 0.1 mg/kg, was given for muscle relaxation. Further increments of sufentanil, 5 micrograms/kg, were given before skin incision and sternotomy. All patients had ECG leads V6 and V9 recorded continuously with a Holter monitor from arrival in the operating room until the start of bypass. Hemodynamic profiles were recorded at specific intervals in the prebypass period. Seven patients (25.9%) developed prebypass myocardial ischemia, three at intubation, and three at aortic dissection. Fourteen patients developed hypertension and 14 had hypotension, defined as increases or decreases greater than 20% from baseline values, respectively. Only five patients had neither hypotension nor hypertension. Three patients (11.1%) had perioperative myocardial infarctions, two of whom had prebypass myocardial ischemia. It is concluded that the incidence of prebypass ischemia with sufentanil anesthesia approximates 26%, which is similar to other studies using sensitive ECG monitoring techniques for the detection of ST segment changes. Hemodynamic instability, in the form of bradycardia, hypertension and hypotension, but not tachycardia, may have contributed to the incidence of prebypass ischemia.

Topics: Aged; Anesthetics; Coronary Artery Bypass; Coronary Disease; Female; Fentanyl; Hemodynamics; Humans; Male; Middle Aged; Oxygen; Pancuronium; Sufentanil

The hemodynamic effects of vecuronium 0.2 mg/kg were investigated in 11 patients with coronary artery disease. Vecuronium, at a dose double the ED90, produced 90% neuromuscular block in a mean time of 163 +/- 7 s, and was not associated with any significant hemodynamic changes. The results suggest that vecuronium can safely be used in cardiac patients.

Topics: Blood Pressure; Cardiac Output; Coronary Artery Bypass; Coronary Disease; Diazepam; Heart Rate; Hemodynamics; Humans; Middle Aged; Neuromuscular Blocking Agents; Pancuronium; Stroke Volume; Vascular Resistance; Vecuronium Bromide

Topics: Anesthesia, General; Coronary Disease; Drug Administration Schedule; Fentanyl; Humans; Intraoperative Period; Nitroglycerin; Pancuronium

Topics: Anesthesia; Coronary Artery Bypass; Coronary Disease; Hemodynamics; Humans; Pancuronium; Research Design

Thirteen patients with good left ventricular function undergoing coronary artery revascularization were studied to determine the cardiovascular effects of verapamil, 75-150 micrograms X kg-1, after a large dose (100 micrograms X kg-1) of fentanyl, with pancuronium for muscle relaxation. The patients were continued on their usual cardiovascular medications until the time of surgery, which included nitrates, beta adrenergic blockers, and nifedipine. Anaesthesia with fentanyl was associated with decreases in mean arterial blood pressure, systemic vascular resistance, left ventricular stroke work index, and circulating catecholamine levels. Mean values were not further changed by verapamil, but individual patients had additional modest decreases in blood pressure and systemic vascular resistance. Cardiac index, however, was well maintained. Plasma catecholamines remained depressed after verapamil under the study condition. Thus, in patients with good left ventricular function, clinically relevant doses of verapamil were well tolerated even in the presence of an anaesthetic that included large doses of fentanyl, with suppression of circulating catecholamine levels.

Topics: Adult; Aged; Anesthesia, General; Blood Pressure; Coronary Artery Bypass; Coronary Disease; Diazepam; Epinephrine; Fentanyl; Hemodynamics; Humans; Middle Aged; Norepinephrine; Pancuronium; Propranolol; Pulmonary Circulation; Stroke Volume; Vascular Resistance; Verapamil

Topics: Anesthetics; Coronary Disease; Coronary Vessels; Female; Fentanyl; Hemodynamics; Humans; Male; Middle Aged; Neuromuscular Blocking Agents; Pancuronium; Sufentanil; Tubocurarine

Topics: Anesthesia, General; Coronary Disease; Fentanyl; Humans; Infusions, Parenteral; Intraoperative Complications; Nitroglycerin; Pancuronium

Topics: Adult; Anesthesia, General; Coronary Disease; Diazepam; Fentanyl; Hemodynamics; Humans; Male; Middle Aged; Pancuronium; Preanesthetic Medication

Intramuscular injection of levomepromazine (0.5 mg/kg) 30 min before intravenous injection of 10 mg/kg pentobarbital sodium induces a good surgical anaesthesia in dogs artificially ventilated with 50% N2O and 50% O2 and given 0.01 mg/kg atropine and 0.1 mg/kg pancuronium intravenously before left thoracotomy. This protocol is suitable for the study of the arrhythmogenic effects of acute one-stage coronary artery ligation in anaesthetized dogs. In fact, minor interference with the autonomic nervous system appears to be involved since heart rate is maintained slow and mean aortic pressure is kept within normal limits, as pH, PaO2, anc PaCO2 during subsequent periods. Acute circumflex coronary arterio-venous pedicle ligation close to the left main trunk division resulted in this model in a high incidence of ventricular fibrillation (10 out of 15 dogs) early (7 +/- 4 min) after occlusion. Specific interventions aimed at reducing the incidence of early post-ischemic life-threatening ventricular arrhythmias might be tested in this model.

Topics: Anesthesia, General; Animals; Arrhythmias, Cardiac; Atropine; Coronary Disease; Coronary Vessels; Disease Models, Animal; Dogs; Electrocardiography; Female; Ligation; Male; Methotrimeprazine; Pancuronium; Pentobarbital; Preanesthetic Medication

The hemodynamic effects of diazepam (0.2 mg/kg)--vecuronium (0.2 mg/kg)--fentanyl (10 micrograms/kg) sequence was investigated when used for induction of anesthesia and tracheal intubation in eleven patients undergoing CABG. The parameters monitored included HR, SBP, PAP and PCWP. Also, EKG was monitored via a modified V5 lead and C.O was measured by thermodilution. SVR, PVR and SV were computed from the measured parameters. Following induction of anesthesia by diazepam-vecuronium-fentanyl sequence, there was a decrease in SBP by 20.0% (P less than 0.05), in HR by 15.7% (P less than 0.001) in C.O by 13.3% (P less than 0.01) and in SVR by 13.6% (P less than 0.05) of control value. There were no changes in PAP, PCWP, PVR and SV. Coronary perfusion pressure and heart rate product were both decreased following this induction sequence. However, the percentage decrease in PR was higher than that of CPP, affecting favorably the myocardial oxygen supply-demand balance. Orotracheal intubation was followed by an increase of HR by 10.7% (P less than 0.05), SVR by 13% (P less than 0.05) and PCWP by 26% (P less than 0.05) of preceding value. However, all these values did not reach the control awake values. It was concluded that diazepam (0.2 mg/kg)--vecuronium (0.2 mg/kg)--fentanyl (10 micrograms/kg) sequence does not produce serious hemodynamic changes when used for induction of anesthesia and tracheal intubation in patients undergoing coronary artery bypass surgery.

Topics: Anesthesia; Coronary Artery Bypass; Coronary Disease; Diazepam; Fentanyl; Hemodynamics; Humans; Middle Aged; Pancuronium; Vecuronium Bromide

Vecuronium is a new nondepolarizing muscle relaxant which has been shown to cause no significant cardiovascular effects. Utilizing invasive monitoring in patients undergoing coronary artery bypass grafting, the authors compared the cardiovascular effects of vecuronium (0.28 mg/kg) in seven anesthetized patients with those of pancuronium (0.1 mg/kg) in five anesthetized patients. This dose of pancuronium represents three times its ED90 (dose producing a 90% depression of evoked twitch tension), while the vecuronium dose represents twelve times its ED90. This relatively large dose of vecuronium was chosen deliberately in an attempt to manifest any possible cardiovascular effects. Following administration of vecuronium, cardiac output increased 9% and systemic vascular resistance decreased 12%, while pancuronium produced a significantly greater 17% increase in cardiac output without change in systemic vascular resistance. Heart rate and systemic mean arterial pressure did not change following vecuronium, while increasing 22% and 24%, respectively, following pancuronium. The authors conclude that large doses of vecuronium have minimal cardiovascular effects and thus offer an advantage over pancuronium in patients anesthetized for coronary artery surgery.

Topics: Adrenergic beta-Antagonists; Adult; Coronary Artery Bypass; Coronary Disease; Halothane; Hemodynamics; Humans; Intraoperative Complications; Nitrous Oxide; Pancuronium; Vecuronium Bromide

Topics: Abdomen; Adult; Alfentanil; Anesthetics; Coronary Disease; Drug Evaluation; Fentanyl; Humans; Lorazepam; Middle Aged; Mitral Valve Insufficiency; Muscle Contraction; Pancuronium; Preanesthetic Medication; Thorax; Time Factors

Topics: Coronary Disease; Female; Humans; Middle Aged; Pancuronium; Pulmonary Edema; Tourniquets

Fentanyl in doses of 50-60 microgram/kg has been reported to produce anesthesia with remarkable hemodynamic stability in patients with coronary artery disease (CAD). Because the authors had observed hypertension and tachycardia in response to noxious stimulation during aortocoronary bypass (ACB) operations in patients so anesthetized, they studied the hemodynamic changes and anesthetic conditions produced by fentanyl/O2/relaxant anesthesia in patients undergoing elective ACB. Twelve patients with left ventricular (LV) ejection fractions greater than 0.4 were maintained on propranolol until 10 hours before operation and were premedicated with fentanyl, diazepam, and scopolamine. Cannulae were inserted before the study commenced for measurement of intravascular pressures, arterial blood gases, and thermodilution cardiac output. The patients breathed 100 per cent oxygen throughout the study. Controlled ventilation aided by succinylcholine to reduce truncal rigidity maintained PaCO2 at 30-45 torr. Measurements were made after each of the following: breathing oxygen (control), 10 microgram/kg fentanyl, 50 microgram/kg fentanyl, and 0.1 mg/kg pancuronium, tracheal intubation, skin incision, and sternotomy. Fentanyl alone produced no significant hemodynamic changes. Fentanyl and pancuronium in combination produced increased heart rate and reduced stroke volume. Significant and progressively greater increases in mean arterial pressure and systemic vascular resistance followed intubation, skin incision, and sternotomy. Chest rigidity occurred in every patient at a lower fentanyl dose than did unresponsiveness. While fentanyl, 62.4 +/- 2.9 microgram/kg (SE), produced minor hemodynamic changes, it failed to block hemodynamic responses to noxious stimulation. Such changes resulted in increased cardiac work, and could have affected myocardial oxygen balance unfavorably. In eight of the 12 patients, following the last set of measurements, supplementary anesthetic agents were required to maintain hemodynamic stability during the surgical procedure. The authors suggest that this fentanyl/O2/relaxant technique should be modified for patients with severe CAD and reasonably good LV function.

Topics: Blood Pressure; Coronary Artery Bypass; Coronary Disease; Fentanyl; Heart Rate; Hemodynamics; Humans; Middle Aged; Oxygen; Pancuronium; Stroke Volume

An anaesthetic technique comprising a combination of phenoperidine (0.1 mg . kg-1), diazepam (0.06 mg . kg-1) and pancuronium bromide (0.1 mg . kg-1) with controlled ventilation was evaluated in 12 patients with severe coronary artery disease. The heart rate, cardiac output and mean arterial blood pressure did not change significantly between the preinduction and postinduction measurements. The right atrial pressure and pulmonary capillary wedge pressure decreased significantly by 33% and 36%, respectively, probably due to the influence of positive-pressure ventilation. There was no depression of the left ventricular performance.

Topics: Adult; Aged; Anesthesia, General; Blood Pressure; Cardiac Output; Coronary Artery Bypass; Coronary Disease; Diazepam; Heart Rate; Hemodynamics; Humans; Hydrogen-Ion Concentration; Middle Aged; Pancuronium; Partial Pressure; Phenoperidine; Vascular Resistance

Topics: Adult; Anesthesia; Coronary Artery Bypass; Coronary Disease; Halothane; Hemodynamics; Humans; Male; Nitrous Oxide; Pancuronium; Propranolol

Topics: Anesthesia, Endotracheal; Blood Pressure; Coronary Disease; Electrocardiography; Heart; Heart Rate; Humans; Myocardial Contraction; Myocardium; Neuromuscular Blocking Agents; Oxygen Consumption; Pancuronium; Time Factors; Tubocurarine