Original contribution
Fentanyl-induced hemodynamic changes after esophagectomy or cardiac surgery

https://doi.org/10.1016/j.jclinane.2005.04.004Get rights and content

Abstract

Study Objective

The goal of this study was to characterize the hemodynamic response to propofol vs propofol with fentanyl when used for sedation after esophagectomy or cardiac surgery.

Design

Prospective, randomized, controlled study.

Setting

University Hospital, Intensive Care Unit.

Patients

Thirty patients undergoing elective cardiac surgery and 26 patients undergoing esophagectomy were examined.

Intervention

Patients were randomized to receive propofol (0.5 mg/kg bolus over 10 minutes, followed by continuous infusion at 1 mg/kg per hour) with or without fentanyl (2.0 μg/kg per hour) to achieve sedation overnight while in the intensive care unit. Randomization was performed in a double-blind manner.

Measurement

Mean arterial pressure (MAP) was monitored throughout the treatment period, and sedation level was measured. Sedation level was targeted to achieve a Ramsay score of 4.

Main Results

The number of patients experiencing a greater than 20% drop in baseline MAP was higher in cardiac patients receiving propofol alone (11 of 15 patients, 73%) than in cardiac patients receiving propofol with fentanyl (4 of 15 patients, 27%). Furthermore, the time of optimal sedation was lower in the cardiac patients who received propofol than in cardiac patients who received propofol with fentanyl group (propofol alone, 79%; propofol with fentanyl, 88%). In contrast, there was no difference in the number of esophagectomy patients experiencing a greater than 20% drop in baseline MAP or in the mean time of optimal sedation when comparing the 2 treatment regimens.

Conclusions

Propofol has a differential effect on hemodynamics and sedation when comparing patients after cardiac surgery and esophagectomy.

Introduction

Sedation in patients undergoing mechanical ventilation in the intensive care unit (ICU) reduces the stress response, provides anxiolysis, and facilitates nursing care [1], [2]. Ideal properties of a sedative agent include rapid onset of sedation and recovery, high efficacy at producing the desired level of sedation, and a low level of adverse effects [1].

Propofol is a sedative agent that is widely used in the ICU and has rapid onset of action and recovery [1], [2]. However, propofol may also produce undesirable changes in hemodynamics, namely, hypotension [3], [4], [5], [6], [7], [8], [9]. For example, Higgins et al [4] reported a transient 20 mm Hg mean decrease in mean arterial pressure (MAP) when using propofol in patients after elective coronary artery bypass graft (CABG) surgery. In contrast, Boyd et al [9] found no decrease in MAP during propofol infusion in patients who underwent elective repair of an abdominal aortic aneurysm. Ostermann et al [10] noted that conflicting results in studies of propofol on hemodynamics may result from the heterogeneous study populations, including patients in medical ICUs, cardiac surgery units, trauma units, and other surgical ICUs.

Soliman et al [2] reported that the concomitant use of sedative and analgesic agents was common in ICU patients. Common combinations include midazolam with fentanyl, propofol with morphine, and midazolam with morphine.

Thus, the goal of this study was to characterize the hemodynamic response to propofol vs propofol with fentanyl when used for sedation after esophagectomy or cardiac surgery.

Section snippets

Patients and methods

From 2002 to 2003, 30 patients undergoing elective cardiac surgery and 26 patients undergoing esophagectomy were examined. This study was performed on the second and third postoperative days. All patients were alert when enrolled in this study and were expected to require mechanical ventilation for at least 3 days after surgery because of preexisting pulmonary dysfunction.

Patient demographic data are summarized in Table 1. Informed consent was obtained from all patients or their

Results

Demographic data of patients treated with propofol alone or propofol with fentanyl are summarized in Table 1. There were no significant differences in age, height, weight, and baseline hemodynamics when comparing patients who underwent cardiac surgery vs those that underwent esophagectomy.

Among the cardiac surgery patients, there was no difference in the duration of awake period or the sedation time when comparing patients who received propofol/fentanyl vs propofol alone. However, propofol

Discussion

The American College of Critical Care Medicine of the Society of Critical Care Medicine practice parameters for the optimal use of sedatives and analgesics were published in 1995 and revised in 2000, and recommended a tiered approach to the use of sedatives and analgesics [1]. This guideline recommended that the drugs of choice in patients older than 12 years, requiring prolonged sedation and analgesia during mechanical ventilation, included morphine and fentanyl for intravenous opiate

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Cited by (4)

This study was supported by grants to Dr Yuji Kadoi (155919914) and to Center of Excellence (COE) Program of Gunma University from the Japanese Ministry of Science, Education and Culture.

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