Abstract
BackgroundGeneral anesthesia induction with the initiation of positive pressure ventilation creates a vulnerable phase for patients. The impact of positive intrathoracic pressure on cardiac performance has been studied but remains controversial. 3D echocardiography is a valid and MRI-validated bed-side tool to evaluate the right ventricle (RV). The aim of this study was to assess the impact of anesthesia induction (using midazolam, sufentanil and rocuronium, followed by sevoflurane) with positive pressure ventilation (PEEP 5, tidal volume 6–8 ml/kg) on 2D and 3D echocardiography derived parameters of RV function.MethodsA prospective observational study on fifty-three patients undergoing elective cardiac surgery in a tertiary care university hospital was designed. Transthoracic echocardiography exams were performed before and immediately after anesthesia induction and were recorded together with hemodynamic parameters and ventilator settings.ResultsAfter anesthesia induction TAPSE (mean difference − 1.6 mm (95% CI − 2.6 mm to − 0.7 mm; p = 0.0013) as well as the Tissue Doppler derived tricuspid annulus peak velocity (TDITVs’) were significantly reduced (mean difference − 1.9% (95% CI: − 2.6 to − 1.2; p < 0.0001), but global right ventricular ejection fraction (RVEF; p = 0.1607) and right ventricular stroke volume (RVSV; p = 0.1838) did not change.ConclusionsThis data shows a preserved right ventricular ejection fraction and right ventricular stroke volume after anesthesia induction and initiation of positive pressure ventilation. However, the baso-apical right ventricular function is significantly reduced. Larger studies are needed in order to determine the clinical impact of these findings especially in patients presenting with impaired right ventricular function before anesthesia induction.Trial registrationRetrospecitvely registered, 6th June 2016, ClinicalTrials.gov Identifier NCT02820727.
Highlights
General anesthesia induction with the initiation of positive pressure ventilation creates a vulnerable phase for patients
The controversy of whether an increase in intrathoracic pressure during intermittent positive pressure ventilation (IPPV) leads to an decreased right ventricular function and ejection fraction remains unclear, as some studies did not find a decrease in right ventricular filling pressures or right ventricle (RV) function after the application of high positive end expiratory pressure (PEEP) levels [5, 6]
Right ventricular function was assessed by real time threedimensional transthoracic echocardiography (TTE) immediately before anesthesia induction under spontaneous ventilation and as soon as possible after achieving hemodynamic stability after anesthesia induction and endotracheal intubation under controlled IPPV with constant PEEP
Summary
General anesthesia induction with the initiation of positive pressure ventilation creates a vulnerable phase for patients. The impact of positive intrathoracic pressure on cardiac performance has been studied but remains controversial. The aim of this study was to assess the impact of anesthesia induction (using midazolam, sufentanil and rocuronium, followed by sevoflurane) with positive pressure ventilation (PEEP 5, tidal volume 6–8 ml/kg) on 2D and 3D echocardiography derived parameters of RV function. Anesthesia induction and initiation of intermittent positive pressure ventilation (IPPV) can lead to hemodynamic impairment due to several factors. All anesthetic agents used for the induction and maintenance of general anesthesia have varying degrees of impact on systemic vascular resistance and cardiac contractility and can, potentially impair right ventricular function [4]. Other factors that contribute to hemodynamic changes during anesthesia induction are therapeutic measures, e.g. fluid administration and vasopressor therapy
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