Myocardial protection by anesthetic agents against ischemia-reperfusion injury: An update for anesthesiologists

Abstract

P Pu ur rp po os se e: : The aim of this review of the literature was to evaluate the effectiveness of anesthetics in protecting the heart against myocardial ischemia-reperfusion injury.S So ou ur rc ce e: : Articles were obtained from the Medline database (1980-, search terms included heart, myocardium, coronary, ischemia, reperfusion injury, infarction, stunning, halothane, enflurane, desflurane, isoflurane, sevoflurane, opioid, morphine, fentanyl, alfentanil sufentanil, pentazocine, buprenorphine, barbiturate, thiopental, ketamine, propofol, preconditioning, neutrophil adhesion, free radical, antioxidant and calcium).P Pr ri in nc ci ip pa al l f fi in nd di in ng gs s: : Protection by volatile anesthetics, morphine and propofol is relatively well investigated. It is generally agreed that these agents reduce the myocardial damage caused by ischemia and reperfusion. Other anesthetics which are often used in clinical practice, such as fentanyl, ketamine, barbiturates and benzodiazepines have been much less studied, and their potential as cardioprotectors is currently unknown. There are some proposed mechanisms for protection by anesthetic agents: ischemic preconditioning-like effect, interference in the neutrophil/platelet-endothelium interaction, blockade of Ca 2+ overload to the cytosolic space and antioxidant-like effect. Different anesthetics appear to have different mechanisms by which protection is exerted. Clinical applicability of anesthetic agent-induced protection has yet to be explored. C Co on nc cl lu us si io on n: : There is increasing evidence of anesthetic agentinduced protection. At present, isoflurane, sevoflurane and morphine appear to be most promising as preconditioning-inducing agents. After the onset of ischemia, propofol could be selected to reduce ischemia-reperfusion injury. Future clinical application depends on the full elucidation of the underlying mechanisms and on clinical outcome trials. Objectif

Does propofol and isoflurane protect the kidney against ischemia/reperfusion injury during transient hyperglycemia?

“…There is increasing evidence of anesthetic agent-induced protection. At present, isoflurane, sevoflurane and morphine appear to be most promising preconditioning-inducing agents 4 .…”

“…Knowledge on their potential benefits allows physicians to choose the best anesthetic or combination of anesthetics for their patients. It has been demonstrated that halogenated anesthetics, opioids, and propofol can protect against myocardial IRI 4 .…”

Pioglitazone protects the myocardium against ischemia-reperfusion injury in eNOS and iNOS knockout mice

“…However, others suggested that myocardial norepinephrine levels were not increased by ischemic preconditioning in rabbits anesthetized with xylazine-ketamine, whereas they were increased in rabbits anesthetized with pentobarbital sodium (40) and that ketamine deactivates myocardial ATPsensitive potassium channels (35). Most investigators report that ketamine may attenuate preconditioning (24,33,(41)(42)(43). Isoflurane (13,56) and opioid agonists (23) have been shown to protect against ischemia-reperfusion injury and reduce IS.…”

Myocardial ischemia-reperfusion and cardioprotection: a study with microdialysis in a porcine model

“…In studies I-III, it was intended to avoid volatile anaesthetics and propofol as both may have some cardioprotective properties (Kato 2002). Although ketamine may inhibit ischemic preconditioning (Molojavyi 2001), through inhibition of KATP channels, it was used for practical reasons for early anaesthesia induction, but not for maintenance.…”

“…In combination with relatively high doses of fentanyl, which was not used in studies I-III, pancuronium may have a negative effect on myocardial lactate extraction (Gilbert 1990). The opioid fentanyl may have cardioprotective properties (Kato 2002), but probably in higher doses than were used in the studies I-III. Within the studies, the dosing regime was identical in all groups.…”