Response: Is It Reasonable To Discourage Propofol Use in Cardiac Surgery Patients Until Strong Evidence Is Provided?

Abstract

We appreciate that our article1Krzych L.J. Szurlej D. Bochenek A. Rationale for propofol use in cardiac surgery.J Cardiothorac Vasc Anesth. 2009; 23: 878-885Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar was read by Landoni et al2Landoni G. Virzo I. Bignami E. et al.Any rationale for propofol use in cardiac surgery?.J Cardiothorac Vasc Anesth. 2010; 24: 903Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar with such attention. In our article, we attempted to describe a rationale for propofol use in cardiac surgery. We aimed to summarize data from the literature regarding the influence of the agent on the cardiovascular system, vessels, and blood including the inflammatory response.1Krzych L.J. Szurlej D. Bochenek A. Rationale for propofol use in cardiac surgery.J Cardiothorac Vasc Anesth. 2009; 23: 878-885Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar We concluded that propofol could be useful for the induction and maintenance of anesthesia and sedation as well mainly because of its favorable pharmacokinetic properties. However, we emphasized that the benefits of its use are still theoretic, and some advantages in cardiac surgical patients are unconvincing overall.1Krzych L.J. Szurlej D. Bochenek A. Rationale for propofol use in cardiac surgery.J Cardiothorac Vasc Anesth. 2009; 23: 878-885Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar Clinicians should be aware of serious adverse effects of propofol including hemodynamic instability, respiratory depression, and propofol infusion syndrome. On the other hand, propofol may be used as a vasodilator for the treatment of perioperative spasm of coronary artery grafts (including all arterial grafts); further investigations are required to explore the molecular mechanisms of propofol more precisely and possibly would provide wider indications for its use in cardiac anesthetic practice.1Krzych L.J. Szurlej D. Bochenek A. Rationale for propofol use in cardiac surgery.J Cardiothorac Vasc Anesth. 2009; 23: 878-885Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar Furthermore, we attempted neither to assess a rationale for volatile agents use in cardiac surgery nor its superiority over propofol. However, on the basis of current experimental data, propofol usage is not contraindicated in cardiac surgery patients. We agree that the epidemiologic results of Landoni et al3Landoni G. Biondi-Zoccai G.G. Zangrillo A. et al.Desflurane and sevoflurane in cardiac surgery: A meta-analysis of randomized clinical trials.J Cardiothorac Vasc Anesth. 2007; 21: 502-511Abstract Full Text Full Text PDF PubMed Scopus (274) Google Scholar shed light on a rationale for propofol use in cardiac practice. In a meta-analysis of randomized clinical trials involving 1,922 patients, they showed that a total intravenous anesthesia (TIVA) technique in comparison with inhalation anesthesia was associated with significant increases of myocardial infarctions (odds ratio = 0.51; 95% confidence interval, 0.32-0.84) and mortality (odds ratio = 0.31; 95% confidence interval, 0.12-0.8).3Landoni G. Biondi-Zoccai G.G. Zangrillo A. et al.Desflurane and sevoflurane in cardiac surgery: A meta-analysis of randomized clinical trials.J Cardiothorac Vasc Anesth. 2007; 21: 502-511Abstract Full Text Full Text PDF PubMed Scopus (274) Google Scholar In comparison with TIVA, volatile agents were also associated with significant reductions in cardiac troponin I release peak, the need for inotropic support, and a reduction in the length of intensive care unit and in-hospital stay. However, these results should be taken with caution because there was statistically significant heterogeneity between studies.3Landoni G. Biondi-Zoccai G.G. Zangrillo A. et al.Desflurane and sevoflurane in cardiac surgery: A meta-analysis of randomized clinical trials.J Cardiothorac Vasc Anesth. 2007; 21: 502-511Abstract Full Text Full Text PDF PubMed Scopus (274) Google Scholar The same investigators4Bignami E. Biondi-Zoccai G. Landoni G. et al.Volatile anesthetics reduce mortality in cardiac surgery.J Cardiothorac Vasc Anesth. 2009; 23: 594-599Abstract Full Text Full Text PDF PubMed Scopus (92) Google Scholar also showed that risk-adjusted mortality may be reduced by the use of volatile agents in patients undergoing coronary artery bypass graft surgery (β = −1.172, p = 0.035). We believe that the results mentioned earlier should encourage anesthesiologists to use volatile agents, as this technique has already been recommended by the American College of Cardiology/American Heart Association.5ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Non-Cardiac Surgery A report of the American College of Cardiology/American Heart Association task force on practice guidelines.J Am Coll Cardiol. 2007; 50: e159-e241Abstract Full Text Full Text PDF PubMed Scopus (336) Google Scholar However, some countries still experience technical problems because of the lack of vaporizers suitable to deliver volatile anesthetics during cardiopulmonary bypass. On the other hand, we believe that the results of Landoni et al3Landoni G. Biondi-Zoccai G.G. Zangrillo A. et al.Desflurane and sevoflurane in cardiac surgery: A meta-analysis of randomized clinical trials.J Cardiothorac Vasc Anesth. 2007; 21: 502-511Abstract Full Text Full Text PDF PubMed Scopus (274) Google Scholar, 4Bignami E. Biondi-Zoccai G. Landoni G. et al.Volatile anesthetics reduce mortality in cardiac surgery.J Cardiothorac Vasc Anesth. 2009; 23: 594-599Abstract Full Text Full Text PDF PubMed Scopus (92) Google Scholar should not discourage use of propofol on cardiac surgery patients. There are still not enough convincing data from studies on humans regarding this issue, but some in vitro investigations suggest that propofol has vasodilating effects on radial or internal mammary arteries.1Krzych L.J. Szurlej D. Bochenek A. Rationale for propofol use in cardiac surgery.J Cardiothorac Vasc Anesth. 2009; 23: 878-885Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar We previously revealed that propofol might elicit weak and endothelium-dependent relaxation in a precontracted internal mammary artery.6Szurlej D. Golba K. Deja M. et al.Effect of propofol on reactivity of isolated internal mammary artery grafts.Eur J Anesthesiol. 2002; 19: 1-8Crossref PubMed Google Scholar We also consider that in the article by Bignami et al4Bignami E. Biondi-Zoccai G. Landoni G. et al.Volatile anesthetics reduce mortality in cardiac surgery.J Cardiothorac Vasc Anesth. 2009; 23: 594-599Abstract Full Text Full Text PDF PubMed Scopus (92) Google Scholar the spectrum of recruited subjects did not reflect real-life patient characteristics (eg, only 20.9% of women or 2.7% of those with ejection fraction <30%). The data of Landoni et al3Landoni G. Biondi-Zoccai G.G. Zangrillo A. et al.Desflurane and sevoflurane in cardiac surgery: A meta-analysis of randomized clinical trials.J Cardiothorac Vasc Anesth. 2007; 21: 502-511Abstract Full Text Full Text PDF PubMed Scopus (274) Google Scholar describing mortality reduction by the use of volatile agents were explained only in 0.5% to 13.5% (values of coefficients of determination), so the determination of the remaining reduction (86.5% up to 99.5%) in the statistic model is unknown. In conclusion, we believe that until more is known about molecular mechanisms of propofol and its detailed effects on the human body, the decision not to use the agent in cardiac surgery is unclear. Rationale for Propofol Use in Cardiac SurgeryJournal of Cardiothoracic and Vascular AnesthesiaVol. 23Issue 6PreviewPROPOFOL IS A COMMONLY USED intravenous anesthetic agent. Chemically, propofol is a lipophilic, sterically hindered alkylated phenol that is a very weak acid.1,2 Pharmacokinetic and pharmacodynamic properties make propofol a useful drug in everyday anesthesia with rapid and clear emergence, precise control of the level of sedation, and lack of cumulative effects even after prolonged administration.1-4 Although the terminal half-life of propofol is long, recovery is rapid because of the slow mobilization from the highly lipophilic tissue compartment. Full-Text PDF Any Rationale for Propofol Use in Cardiac Surgery?Journal of Cardiothoracic and Vascular AnesthesiaVol. 24Issue 5PreviewWe read with interest the article by Krzych et al1 regarding propofol use in cardiac surgery. We agree with the authors that propofol is widely used in cardiac surgery worldwide for the induction and maintenance of general anesthesia and for sedation in intensive care units. We disagree that there is any evidence-based rationale to support its use in cardiac surgery when patients' clinically relevant outcomes are considered. Full-Text PDF