Advertisement
Original article| Volume 7, ISSUE 4, P386-395, August 1993

Clonidine improves perioperative myocardial ischemia, reduces anesthetic requirement, and alters hemodynamic parameters in patients undergoing coronary artery bypass surgery

DOI:https://doi.org/10.1016/1053-0770(93)90157-G
Clonidine improves perioperative myocardial ischemia, reduces anesthetic requirement, and alters hemodynamic parameters in patients undergoing coronary artery bypass surgery
Previous ArticleEditorial
Next ArticleMorphine pharmacokinetics in children following cardiac surgery: Effects of disease and inotropic support
      This paper is only available as a PDF. To read, Please Download here.

      Abstract

      The purpose of this study was to determine if clonidine reduces myocardial ischemia or alters anesthetic requirement and perioperative hemodynamic parameters during coronary artery bypass grafting (CABG) surgery. Forty-three patients were randomized in a prospective, double-blind fashion to receive either clonidine (5 μg/kg) or placebo. Anesthetic induction and maintenance was accomplished with intravenous sufentanil-midazolam (S-M) in a 1:20 ratio; up to 1.0% enflurane was added during surgery when repeated boluses of S-M failed to maintain the blood pressure within 20% of preinduction values. Continuous ST segment analysis of leads 11 and V5 was performed throughout surgery with maximal ST segment deflection from baseline recorded every 5 minutes. Catecholamine levels were measured intermittently throughout the perioperative period and myocardial lactate use or excretion was determined just prior to cardiopulmonary bypass (CPB) and at 1, 5, 10, 30, and 60 minutes after release of the aortic cross-clamp. Patients who received clonidine required significantly less sufentanil for their surgical procedure (11.82 ± 0.66 μg/kg v 14.55 ± 0.90 μ/kg, P < 0.05) and also needed less enflurane for blood pressure control, particularly during CPB (P < 0.05). Baseline hemodynamic parameters were similar for both groups prior to induction. In the period between anesthetic induction and the initiation of CPB, patients treated with clonidine had a significantly slower heart rate (HR) (P < 0.01), a lower cardiac output (CO) (P < 0.05), and transiently higher systemic vascular resistance (SVR) (P < 0.05) than placebo-treated patients. Immediately after CPB, patients receiving clonidine continued to have a significantly lower CO (P < 0.01) and a higher SVR (P < 0.01) than placebo-treated patients. Clonidine treatment significantly increased the percentage of patients who required pacing after CPB (P < 0.05). In the intensive care unit, clonidine-treated patients displayed a persistently increased requirement for pacing (P < 0.01), decreased systolic blood pressures, and reduced sodium nitroprusside requirements relative to patients treated with placebo. Epinephrine and norepinephrine levels were lower in clonidine-treated patients throughout the perioperative procedure with significant differences noted immediately following sternotomy and release of the aortic cross-clamp (P < 0.05). Critical ST segment depression was significantly less in clonidinetreated patients for the period from sternotomy until application of the aortic cross-clamp (P < 0.01). Following CPB, absolute deviation of ST segments from isoelectric baseline was significantly less in the clonidine-treated group (P < 0.05). Cumulative myocardial lactate use was significantly increased after CPB in patients treated with clonidine; especially evident at 30 and 60 minutes (P < 0.05). It is concluded that perioperative treatment with clonidine reduced myocardial ischemia and anesthetic requirements in patients undergoing CABG. Clonidine also decreased HR prior to CPB, increased pacing requirement after CPB, and lowered CO throughout the perioperative period.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Journal of Cardiothoracic and Vascular Anesthesia
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Register: Create an account
      Institutional Access: Sign in to ScienceDirect

      References

        • Slogoff S.
        • Keats A.S.
        Does perioperative myocardial ischemia lead to postoperative myocardial infarction.
        Anesthesiology. 1985; 62: 107-114
        • Slogoff S.
        • Keats A.S.
        Further observations on perioperative myocardial ischemia.
        Anesthesiology. 1986; 65: 539-542
        • Knight A.A.
        • Hollenberg M.
        • London M.L.
        • et al.
        Perioperative myocardial ischemia: Importance of the preoperative ischemic pattern.
        Anesthesiology. 1988; 68: 681-688
        • Gallagher J.D.
        • Moore R.A.
        • Jose A.B.
        • et al.
        Prophylactic nitroglycerin infusions during coronary artery bypass surgery.
        Anesthesiology. 1986; 64: 785-789
        • Edde R.R.
        Hemodynamic changes prior to and after sternotomy in patients anesthetized with high-dose fentanyl.
        Anesthesiology. 1981; 55: 444-446
        • Hoar P.F.
        • Hickey R.F.
        • Ullyot D.S.
        Systemic hypertension following myocardial revascularization.
        J Thorac Cardiovasc Surg. 1976; 71: 859-864
        • Moffit E.A.
        • Scovil J.E.
        • Barker R.A.
        • et al.
        Myocardial metabolism and hemodynamic responses during high-dose fentanyl anaesthesia for coronary patients.
        Can Anaesth See J. 1984; 31: 611-618
        • Samuelson P.N.
        • Reves J.G.
        • Kirklin J.K.
        • et al.
        Comparison of sufentanil and enflurane-nitrous oxide anesthesia for myocardial revascularization.
        Anesth Analg. 1986; 65: 217-226
        • Stanley T.H.
        • Berman L.
        • Green O.
        • Robertson D.
        Plasma catecholamine and cortisol responses to fentanyl-oxygen anesthesia for coronary artery operations.
        Anesthesiology. 1980; 53: 250-253
        • Waller J.L.
        • Hug C.C.
        • Nagle D.M.
        • Craver J.M.
        Hemodynamic changes during fentanyl-oxygen anesthesia for aortocoronary bypass operation.
        Anesthesiology. 1981; 55: 212-217
        • Walsh E.S.
        • Paterson J.L.
        • O'Riordan J.B.A.
        • Hall G.M.
        Effect of high-dose fentanyl anesthesia on the metabolic and endocrine response to cardiac surgery.
        Br J Anaesth. 1981; 53: 1155-1165
        • Bovill J.G.
        • Sebel P.S.
        • Fiolet J.W.
        • et al.
        The influence of sufentand on endocrine and metabolic responses to cardiac surgery.
        Anesth Analg. 1983; 62: 391-397
        • Wynands J.E.
        • Townsend G.E.
        • Wong P.
        • et al.
        Blood pressure response and plasma fentanyl concentrations during high and very high dose fentanyl anesthesia for coronary artery surgery.
        Anesth Analg. 1983; 62: 661-665
        • Flacke J.W.
        • Bloor B.C.
        • Flacke W.E.
        • et al.
        Reduced narcotic requirement by clonidine with improved hemodynamic and adrenergic stability in patients undergoing coronary bypass surgery.
        Anesthesiology. 1987; 67: 11-19
        • Sonntag H.
        • Larsen R.
        • Hilfiker O.
        • et al.
        Myocardial blood flow and oxygen consumption during high-dose fentanyl anesthesia in patients with coronary artery disease.
        Anesthesiology. 1982; 56: 417-422
        • Butchart E.G.
        • McEnany M.T.
        • Strich G.
        • et al.
        The influence of prearrest factors on the preservation of left ventricular function during cardiopulmonary bypass.
        J Thorac Cardiovasc Surg. 1980; 79: 812-821
        • Frisk-Holmberg M.
        • Edlund P.O.
        • Paalzow L.
        Pharmacokinetics of clonidine and its relation to the hypotensive effect in patients.
        Br J Clin Pharmacol. 1978; 6: 227-232
        • Reid J.L.
        The clinical pharmacology of clonidine and related central antihypertensive agents.
        Br J Clin Pharmacol. 1981; 12: 295-302
        • Ceremuzynski L.
        • Zaleska T.
        • Lada W.
        • Zalewski A.
        Clonidine effect in chronic angina pectoris.
        Eur J Cardiol. 1987; 10: 415-427
        • Heusch G.
        • Schipke J.
        • Thamer V.
        Clonidine prevents the sympathetic initiation and aggravation of poststenotic myocardial ischemia.
        J Cardiovasc Pharmacol. 1985; 7: 1176-1182
        • Zochowski R.J.
        • Lada W.
        Intravenous clonidine in Acute myocardial infarction in men.
        Int J Cardiol. 1984; 6: 189-201
        • Bloor B.C.
        • Flacke W.E.
        Reduction in halothane anesthetic requirement by clonidine, an alpha-adrenergic agonist.
        Anesth Analg. 1982; 61: 741-745
        • Kavkinen S.
        • Pyykko K.
        The potentiation of halothane anesthesia by clonidine.
        Acta Anaesthesiol Scand. 1979; 23: 1007-1111
        • Ghignone M.
        • Noe C.
        • Calvillo O.
        • Quintin L.
        Anesthesia for ophthalmic surgery in the elderly: The effects of clonidine on intraocular pressure, perioperative hemodynamics and anesthetic requirement.
        Anesthesiology. 1988; 68: 707-716
        • Ghignone M.
        • Calvillo O.
        • Quintin L.
        Anesthesia and hypertension: The effect of clonidine on perioperative hemodynamics and isoflurane requirements.
        Anesthesiology. 1987; 67: 3-10
        • Engelman E.
        • Lipszyc M.
        • Gilbart E.
        • et al.
        Effects of clonidine on anesthetic drug requirements and hemodynamic response during aortic surgery.
        Anesthesiology. 1989; 71: 178-187
        • Ghignone M.
        • Quintin L.
        • Duke P.C.
        • et al.
        Effects of clonidine on narcotic requirements and hemodynamic response during induction of fentanyl anesthesia and endotracheal intubation.
        Anesthesiology. 1986; 64: 36-42
        • Burns M.
        • Downs W.
        Clinical evaluation of a bedside ST-segment monitor.
        IEEE. 1989; 37: 97-100
        • Bloor B.C.
        • Finander L.S.
        • Flacke W.E.
        • Van Etten A.
        Effect of clonidine on sympathoadrenal response during sodium nitroprusside hypotension.
        Anesth Analg. 1986; 65: 469-474
        • Feigl E.O.
        Carotid sinus reflex control of coronary blood flow.
        Circ Res. 1968; 23: 223-237
        • Mitchell H.C.
        • Pettinger W.A.
        The hypernoradrenergic state in vasodilator drug-treated hypertensive patients: Effect of clonidine.
        J Cardiovasc Pharmacol. 1980; 2: 1-7
        • Mudge G.H.
        • Goldberg S.
        • Gunther S.
        • et al.
        Comparison (it metabolic and vasoconstrictor stimuli on coronary vascular resistance in man.
        Circulation. 1979; 59: 544-550
        • Karlsberg R.P.
        • Penkoske P.A.
        • Cryer P.E.
        • et al.
        Rapid activation of the sympathetic nervous system following coronary artery occlusion: Relationship to infarct size. site, and hemodynamic impact.
        Cardiovasc Res. 1979; 13: 523-531
        • Opic L.H.
        Metabolism of free fatty acids, glucose and cateeholamines in acute myocardial infarction. Relation to myocardial ischemia and infarct size.
        Am J Cardiol. 1975; 36: 938-948
        • Vatner S.F.
        • McRitchie R.J.
        • Maroko P.R.
        • et al.
        Effects of catecholamines, exercise and nitroglycerin on the normal and ischemic myocardium in conscious dogs.
        J Clin Invest. 1974; 54: 563-576
        • Opie L.H.
        • Thandroyen F.T.
        • Muller C.
        • Brieknell O.L.
        Adrenaline-induced “oxygen-wastage” and enzyme release from working rat heart. Effects of calcium antagonism. B blockade. nicotinic acid and coronary artery ligation.
        J Mol Cell Cardiol. 1979; 11: 1073-1094
        • Raab W.
        The nonvascular metabolic myocardial vulnerability factor in “coronary heart disease”.
        Am Heart J. 1963; 66: 685-706
        • Waldenstrom A.P.
        • Hjalmarson A.C.
        • Thornell L.
        A possible role of noradrenaline in the development of myocardial infarction.
        Am Heart J. 1978; 95: 43-51
        • Guyenet P.G.
        The cocruleospinal noradrenergic neurons: Anatomical and electrophysiological studies in the rat.
        Brain Res. 1980; 189: 121-133
        • Spaulding T.C.
        • Fielding S.
        • Venatro J.J.
        • Lal H.
        Antinocicepfive activity of clonidine and its potentiation of morphine analgesia.
        Eur J Pharmacol. 1979; 58: 19-25
        • Calvillo O.
        • Ghignone M.
        Presynaptic effect of clonidine in spinal uociceptive pathways.
        in: Fed Proc. 44. 1985: 890-899
        • Guyenet P.G.
        • Cabot J.B.
        Inhibition of sympathetic preganglionic neurons by catecholamines and clonidine: Mediation by an alpha-adrenergic receptor.
        J Neurosci. 1981; 1: 908-917
        • Fleetwood-Walker S.M.
        • Mitchell R.
        • Hope P.J.
        • et al.
        An alpha2-receptor mediates the selective inhibition by noradrenaline of nociceptive responses of identified dorsal horn neurons.
        Brain Res. 1985; 334: 243-254
        • Calvillo O.
        • Ghignone M.
        Pre-synaptic effect of clonidine on unmyelinated afferent fibers in the spinal cord of the cat.
        Neurosci Lett. 1986; 64: 335-339
        • Reis D.J.
        • Granata A.R.
        • Joh T.H.
        • et al.
        Brain stem catecholamine mechanisms in tonic and reflex control of blood pressure.
        Hypertension. 1984; 6: 7-15
        • Mathias C.J.
        • Reid J.L.
        • Wing L.M.H.
        • et al.
        Antihypertensive effects of clonidine in tetraplegic subjects devoid of central sympathetic control.
        Clin Sci. 1979; 57: 425s-428s
        • Cavero I.
        • Roach A.G.
        Effects of clonidine on canine cardiac neuroeffector structures controlling heart rate.
        Br J Pharmacol. 1980; 70: 269-276
        • Kobinger W.
        • Pichler L.
        Localization in the CNS of adrenoceptors which facilitate a cardioinhibitory reflex.
        Naunyn Schmiedebergs Arch Pharm. 1975; 286: 371-377
        • Quintin L.
        • Viale J.P.
        • Annat G.
        • et al.
        Oxygen uptake after major abdominal surgery: Effect of clonidine.
        Anesthesiology. 1991; 74: 236-241
        • Coffman J.D.
        • Cohen R.A.
        Role of alpha-adrenoceptor subtypes mediating sympathetic vasoconstriction in human digits.
        Eur J Clin Invest. 1988; 18: 309-313
        • Baines A.D.
        • Ho P.
        Specific alpha 1, alpha 2 and beta responses to norepinephrine in pyruvate-perfused rat kidneys.
        Am J Physiol. 1987; 252: 170-176
        • Bloor B.C.
        • Flacke J.W.
        • Flacke W.E.
        Perioperative clonidine withdrawal syndrome.
        in: Reves J.G. Common Problems in Cardiac Anesthesia. Yearbook Medical, Chicago, IL1986: 397-405

      Article info

      Footnotes

      ☆From the University of Washington School of Medicine, Seattle, WA USA

      ☆☆Supported by a grant from the Society of Cardiovascular Anesthesiologists.

      Identification

      DOI: https://doi.org/10.1016/1053-0770(93)90157-G

      Copyright

      © 1993 Published by Elsevier Inc.

      ScienceDirect

      Access this article on ScienceDirect
      We use cookies to help provide and enhance our service and tailor content. To update your cookie settings, please visit the for this site.
      Copyright © 2023 Elsevier Inc. except certain content provided by third parties. The content on this site is intended for healthcare professionals.


      RELX