15 de abril de 2011

Optimization of the volemic status of cardiosurgical patients before initial anesthesia

Anesteziol Reanimatol. 2008 Sep-Oct;(5):26-9.
Tolstova IA, Aksel'rod BA, Shmyrin MM, Iavorovskiĭ AG.


Twenty-six patients with coronary heart disease who had undergone aortocoronary bypass surgery were examined. In all the patients, central hemodynamic parameters were monitored by transpulmonary thermodilution. The patients were divided into 2 groups. In Group 1 (n = 14), routine initial anesthesia was made without a preliminary volumetric loading test. In Group 2 (n = 12), a controlled volumetric loading test was carried out before induction; a decision on whether it might be made was taken on the basis of the results of a loading test for passive leg raise. The patients from both groups were hypovolemic at baseline, as suggested by the low values of central venous pressure (CVP) and global end-diastolic volume index (GEDVI). By the initiation of initial anesthesia, in Group 2 the mean blood pressure (BPmean), CVP, stroke index (SI), and GEDVI were significantly higher and total peripheral vascular resistance index (TPVRS) was significantly lower than in Group I (p < 0.05), as achieved via preliminary loading tests. After the maximum hypnotic effect being achieved in Group 1, there were reductions in BPmean, SI, GEDVI, dPmax, and TPVRS (p < 0.05). In Group 1, 50% of the patients were observed to have hypotension episodes requiring the patient to be placed in Trendelenburg's position and to be given colloids as jets, and 3 patients received bolus vasopressors. After achieving the maximum hypnotic effect, BPmean, SI, GEDVI, and dPmax also decreased in Group 2 patients (p < 0.05). However, due to preliminary loading tests, these variables remained to be in the normal ranges and were significantly higher than in Group 1 (p < 0.05). IOPSS objectively reflects the preload status at all stages of initial anesthesia and the leg raising test enables prediction of a cardiovascular response to a volumetric load. When infusion therapy is performed, it is advisable to take into account a relationship between altered preload (GEDVI) and cardiac performance (SI). This volumetric loading testing tactics before induction promotes GEDVI to be maintained in the normal ranges throughout the initial anesthesia and minimizes hemodynamic disorders at this stage.

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