TIVA and inhalation anesthesia

1. JOURNAL READING

2. Background
Cardioprotective properties of volatile
anaesthetics : clearly demonstrated on a
laboratory basis.
Experimental evidence to clinical studies :
suggests a benefit in postoperative outcomes.

3. Background ~cont.
Recent international consensus conference : volatile
anesthetics  might be associated with mortality
reduction.18
Recommended by the most recent ACC/AHA
guidelines in CABG surgery / non-cardiac surgery in
patients at risk for myocardial ischemia.

4. Objective of study
To study the effects of volatile agents in
patients undergoing high-risk cardiac surgery
with a long-term follow-up.
Primary endpoints : mortality, prolonged ICU
stay (>2days), or both

5. Past studies about TIVA and
volatile anesthetics
1.Small number of patients
2.Predominance of single-centre studies,
3.Low-risk isolated CABG surgery setting
4.Short-term follow- up

6. Study design
• Multicenter RCT ( 2 medical center in Italy )
• Sevoflurane v.s. Propofol-based TIVA
• High-risk cardiac surgery, defined as
combined valvular surgery and CABG
(Short-term mortality ~5%)

7. Study design ~ intervention
• Continue preoperative beta-blocker.
• No other drug continued routinely for cardiac
protection.
• Premedication : morphine 0.1 mg/kg s.c. and
scopolamine 0.25 mg i.m.

8. Study design ~intervention
Induction :
IV midazolam (0.15–0.25
mg/kg) or Thiopental (3–6
mg/kg)
NMBA (rocuronium 0.6–1.2
mg/kg).
Opioid (fentanyl 5–10
mcg/kg)
•Maintenance :
•Opioid (fentanyl 3–5 mg
/kg‧h in repeated boluses)
•NMBA (rocuronium 10
mg/kg‧min) infusion
Sevoflurane Propofol TIVA

9. Study design ~participants

10. Study design
~primary endpoints
• Mortality rate (30 days and 1 year )
• Prolonged ICU stay ( > 2 days )
• ICU discharge criteria
SpO2>94% with FiO2<50% Hemodynamics stable
Chest tube drainage< 50 ml/h Urine output > 0.5 ml/kg/h
No i.v. inotropics or vasopressors > dopamine 5 mcg/kg/min

11. Study design
~other measurements
• Intraoperative measurements
• Biomarkers of organ damage ( Tr-I, Cr., BNP )
• Neurological assessment
• Acute kidney injury / failure
• Re-hospitalization rate

12. Result ~patient enrolled

13. Result ~patient enrolled

14. Result ~intraoperative

15. Result ~primary endpoints

16. Result ~other outcome data

17. Result
~biomarke
rs

18. Discussion
• Strength of study :
• First multicenter RCT.
• Targeted group : high-risk cardiac surgery

19. Discussion
• Cardioprotective effect might be limited to the
isolated low-risk CABG surgery, and do not
apply to high-risk cardiac surgery.
• High-risk cardiac surgery : mechanisms of
cardiac damage might only in part be due
to ischaemia/reperfusion injury.

20. Limitation
• Sample size and assumption for risk reduction.
• Anesthesiologists not blinded to intervention.
• May not powered to detect a difference in mortality at 30
days and at the 1 yr follow-up.
• Effectiveness of cardioprotective effect in a broader cardiac
surgical population not in this study.

21. Conclusion
Results shows No difference between
sevoflurane anesthesia and propofol TIVA on
prolonged ICU stay, mortality, or both.