Do Elderly Patients With Diastolic Dysfunction Require Higher Doses of Norepinephrine During General Anesthesia for Noncardiac Surgeries? A Prospective Observational Study

Abstract

BACKGROUND: Diastolic dysfunction is a risk factor for postoperative major cardiovascular events. During anesthesia, patients with diastolic dysfunction might experience impaired hemodynamic function and worsening of diastolic function, which in turn, might be associated with a higher incidence of postoperative complications. We aimed to investigate whether patients with diastolic dysfunction require higher doses of norepinephrine during general anesthesia. Furthermore, we aimed to examine the association between the grade of diastolic dysfunction and the E/e’ ratio during anesthesia. A high E/e’ ratio corresponds to elevated filling pressures and is an important measure of impaired diastolic function. METHODS: We conducted a prospective observational cohort study at a German university hospital from February 2017 to September 2018. Patients aged ≥60 years and undergoing general anesthesia (ie, propofol and sevoflurane) for elective noncardiac surgery were enrolled. Exclusion: mitral valve disease, atrial fibrillation, and implanted mechanical device. The primary outcome parameter was the administered dose of norepinephrine within 30 minutes after anesthesia induction (μg·kg−1 30 min−1). The secondary outcome parameter was the change of Doppler echocardiographic E/e’ from ECHO1 (baseline) to ECHO2 (anesthesia). Linear models and linear mixed models were used for statistical evaluation. RESULTS: A total of 247 patients were enrolled, and 200 patients (75 female) were included in the final analysis. Diastolic dysfunction at baseline was not associated with a higher dose of norepinephrine during anesthesia (P = .6953). The grade of diastolic dysfunction at baseline was associated with a decrease of the E/e’ ratio during anesthesia (P < .001). CONCLUSIONS: We did not find evidence for an association between diastolic dysfunction and impaired hemodynamic function, as expressed by high vasopressor support during anesthesia. Additionally, our findings suggest that diastolic function, as expressed by the E/e’ ratio, does not worsen during anesthesia.

Postoperative norepinephrine versus dopamine in patients undergoing noncardiac surgery: a propensity-matched analysis using a nationwide intensive care database

“…All rights reserved. conducted [30][31][32][33]. However, our findings indicate that norepinephrine may not decrease mortality compared with dopamine in the noncardiac postoperative setting in populations with relatively low expected mortality.…”

Pre-Operative Point-of-Care Assessment of Left Ventricular Diastolic Dysfunction, an Observational Study

“…[30] In another recent study no association between diastolic dysfunction and need of intra-operative norepinephrine was observed. [31] Notwithstanding, patients with higher grade diastolic dysfunction have an impaired capacity to manage haemodynamic alterations and are at an increased peri-operative risk. [1] Thus, for elderly and/or patients with risk factors or symptoms, especially in intermediate or high-risk surgery, pre-operative echocardiographic screening conducted by anesthesiologists would allow for a proactive anesthesia plan to minimize intra-operative hemodynamic instability and perioperative complications.…”

Pre-operative point-of-care assessment of left ventricular diastolic dysfunction, an observational study

“…On the other side, in a recently published retrospective study on the prevalence of diastolic dysfunction and postoperative outcomes, no significant association was found between diastolic dysfunction and in-hospital mortality or acute kidney injury [ 33 ]. In another recent study no association between diastolic dysfunction and need of intra-operative norepinephrine was observed [ 34 ]. Notwithstanding, patients with higher grade diastolic dysfunction have an impaired capacity to manage haemodynamic alterations and are at an increased peri-operative risk [ 1 ].…”