Cardiopulmonary bypass (CPB) with extracorporeal circulation produces changes in the immune system accompanied by an increase in proinflammatory cytokines and a decrease in anti-inflammatory cytokines. We hypothesize that dexmedetomidine (DEX) as an anesthetic adjuvant modulates the inflammatory response after coronary artery bypass graft surgery with mini-CPB. In a prospective, randomized, blind study, 12 patients (4 females and 8 males, age range 42-72) were assigned to DEX group and compared with a conventional total intravenous anesthesia (TIVA) group of 11 patients (4 females and 7 males). The endpoints used to assess inflammatory and biochemical responses to mini-CPB were plasma interleukin (IL)-1, IL-6, IL-10, interferon (INF)-γ, tumor necrosis factor (TNF)-α, C-reactive protein, creatine phosphokinase, creatine phosphokinase-MB, cardiac troponin I, cortisol, and glucose levels. These variables were determined before anesthesia, 90 min after beginning CPB, 5 h after beginning CPB, and 24 h after the end of surgery. Endpoints of oxidative stress, including thiobarbituric acid reactive species and delta-aminolevulinate dehydratase activity in erythrocytes were also determined. DEX+TIVA use was associated with a significant reduction in IL-1, IL-6, TNF-α, and INF-γ (P<0.0001) levels compared with TIVA (two-way ANOVA). In contrast, the surgery-induced increase in thiobarbituric acid reactive species was higher in the DEX+TIVA group than in the TIVA group (P<0.01; two-way ANOVA). Delta-aminolevulinate dehydratase activity was decreased after CPB (P<0.001), but there was no difference between the two groups. DEX as an adjuvant in anesthesia reduced circulating IL-1, IL-6, TNF-α, and INF-γ levels after mini-CPB. These findings indicate an interesting anti-inflammatory effect of DEX, which should be studied in different types of surgical interventions.
Despite the fact that coronary artery bypass grafting surgery (CABG) with cardiopulmonary bypass (CPB) prolongs life and reduces symptoms in patients with severe coronary artery diseases, these benefits are accompanied by increased risks. Morbidity associated with cardiopulmonary bypass can be attributed to the generalized inflammatory response induced by blood-xenosurfaces interactions during extracorporeal circulation and the ischemia/reperfusion implications, including exacerbated inflammatory response resembling the systemic inflammatory response syndrome (SIRS). The use of specific anesthetic agents with anti-inflammatory activity can modulate the deleterious inflammatory response. Consequently, anti-inflammatory anesthetics may accelerate postoperative recovery and better outcomes than classical anesthetics. It is known that the stress response to surgery can be attenuated by sympatholytic effects caused by activation of central (α-)2-adrenergic receptor, leading to reductions in blood pressure and heart rate, and more recently, that they can have anti-inflammatory properties. This paper discusses the clinical significance of the dexmedetomidine use, a selective (α-)2-adrenergic agonist, as a coadjuvant in general anesthesia. Actually, dexmedetomidine use is not in anesthetic routine, but this drug can be considered a particularly promising agent in perioperative multiple organ protection.
INTRODUÇÃOO estudo compara dois grupos de pacientes submetidas à videolaparoscopia ginecológica, anestesiadas com dexmedetomidina (DEX) ou com remifentanil (REM), ambos em infusão contínua, associados ao propofol. MÉTODOSApós aprovação pelo Comitê de Ética da Universidade Federal de Santa Maria, 30 pacientes em estado físico P1 e P2 (antigos ASA I e II) (22-56 anos), submetidas à videolaparoscopia ginecológica, deram seu consentimento informado, sendo anestesiadas com DEX ou REM em infusão contínua, associados ao propofol em infusão alvo-controlada. Parâmetros hemodinâmicos (freqüência cardíaca-FC, pressão arterial média-PAM, pressão arterial sistólica-PAS e diastólica-PAD) foram anotados antes da indução anestésica (T1), 5 minutos após intubação orotraqueal (IOT) (T2) e 30 minutos após incisão cirúrgica (T3). Amostras de sangue venoso foram coletadas nesses tempos, para determinação da glicemia e cortisol sérico. Registraram-se tempos para extubação, orientação e alta da sala de recuperação pós-anestésica (SRPA), bem como incidência de náuseas e vômitos, necessidade de analgésicos no pós-operatório e efeitos colaterais. RESULTADOSO cortisol sérico decresceu em função do tempo no grupo REM, enquanto no grupo DEX diminuiu na segunda coleta (T2) e retornou aos níveis basais. A glicemia aumentou em função do tempo em ambos os grupos, sendo esse aumento maior no grupo DEX. A análise da PAM e PAD mostrou diferenças entre os grupos, com maior diminuição observada aos 5 minutos após IOT em ambos os grupos. Aos 30 minutos após a incisão cirúrgica, a PAM e PAD retornaram aos valores basais no grupo DEX, enquanto mantiveram-se significativamente mais baixas no grupo REM. Houve diferenças significativas quanto à PAS e FC entre os grupos em T2 e T3, sendo os valores mais baixos no grupo REM. Os tempos para extubação e orientação foram significativamente maiores no grupo DEX, se comparados ao grupo REM, porém, sem diferenças nos tempos para alta da SRPA. DISCUSSÃONão houve diferença na incidência de náuseas e vômitos, bem como da necessidade de analgésicos entre os grupos. Ocorreu um caso de bradicardia na SRPA em paciente do grupo DEX, que respondeu ao uso de atropina. CONCLUSÃOA DEX mostrou-se uma droga clinicamente eficaz como substituto ao REM em AIVT durante procedimentos videolaparoscópicos ginecológicos. REFERÊNCIAS 1. Ebert TI, et al. The effects of increasing plasma concentrations of dexmedetomidine in human. Anesth. 2000;93:382-94. 2. Hall, et al. Sedative, amnestic and analgesic properties of small-dose dexmedetomidine infusions. Anesth Analg. 2000;90:699-705. Endereço para correspondência:
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