Monitoring tissue oxygenation of the heart after myocardial revascularization

Felypressin, but not epinephrine, reduces myocardial oxygen tension after an injection of dental local anesthetic solution at routine doses

PURPOSE

The aim of this study was to evaluate the effect of epinephrine (Epi) or felypressin (Fely) contained in dental local anesthetics on myocardial oxygen balance.

MATERIALS AND METHODS

Male Japanese White tracheotomized rabbits were anesthetized with isoflurane. Three doses of 0.18, 0.36, and 0.72 mL of 2% lidocaine hydrochloride containing 1:80,000 Epi or 3% prilocaine hydrochloride containing Fely 0.03 IU/mL were injected into the rabbit tongue muscle. These doses were equivalent to 2, 4, and 8 of dental local anesthetic cartridges in humans weighing 50 kg by body weight correction, respectively. Heart rate, blood pressure, aortic blood flow, myocardial tissue blood flow, and myocardial tissue oxygen tension were continuously monitored. Data were recorded immediately before and 10, 20, 30, and 60 minutes after the injection.

RESULTS

Heart rate decreased in the Fely group. Systolic blood pressure increased in the Epi group, and diastolic blood pressure increased in both groups. Aortic blood flow and myocardial tissue blood flow increased, whereas myocardial tissue oxygen tension did not change in the Epi group. In contrast, aortic blood flow, myocardial tissue blood flow, and myocardial tissue oxygen tension decreased in the Fely group.

CONCLUSION

It is suggested that Fely, but not Epi, decreases myocardial oxygen tension and aggravates myocardial oxygen demand/supply balance even after an injection of dental local anesthetic solution at routine doses.

High thoracic epidural blockade increases myocardial oxygen availability in coronary surgery patients

BACKGROUND

High thoracic epidural techniques are increasingly being used in patients scheduled for cardiothoracic surgery, including coronary artery bypass grafting. In the present study, we evaluated the acute effects of the epidural blockade on myocardial oxygen availability by means of tissue oxygen pressure monitoring in patients submitted for surgical revascularization.

METHODS

Fifty adult patients were included in a prospective, randomized, double-blind study. After placement of an epidural catheter in thoracic space T1-T2, and under general anesthesia, 5-10 ml of either normal saline or 0.3% ropivacaine was injected through the epidural catheter. Hemodynamic parameters and the intramyocardial oxygen partial pressure were recorded before and 20 min after the epidural injection.

RESULTS

There were no demographic or hemodynamic differences between the groups before intervention. A significant increase in intramyocardial partial oxygen pressure was observed in the ropivacaine group (14.6 mmHg vs. 25.1 mmHg, P < 0.0005).

CONCLUSION

High thoracic epidural blockade with 5-10 ml of 0.3% ropivacaine increases myocardial oxygen availability in coronary diseased patients prior to surgical revascularization without deleterious hemodynamic disturbances.

Effects of local injection of prilocaine-felypressin on the myocardial oxygen balance in dogs

The authors investigated the effects of felypressin (Fely), a non-adrenergic vasoconstrictor, used together with prilocaine on myocardial oxygen balance. Six open-chest dogs were studied under urethane and alpha-chloralose anesthesia. Systolic arterial pressure, diastolic arterial pressure, mean pulmonary arterial pressure and pulmonary capillary wedge pressure, heart rate, coronary blood flow (CBF), internal and external myocardial oxygen tension (int- or ext-PmO2), and cardiac output were observed. Three doses of Citanest-Octapressin, which contains 3% prilocaine and 0.03 IU ml(-1) Fely (Pri-Fely) - 0.09, 0.18, and 0.3 ml kg(-1)- were injected into the tongue. Observations were performed up to 60 min after the injection. The CBF and int-PmO2 was reduced following the injection of each of the three doses of Pri-Fely. There were negative correlations between the Pri-Fely dose per body weight and the maximum reductions in CBF (r = -0.52, P < 0.05), in int-PmO2 (r = -0.78, P < 0.05), and in ext-PmO2 (r = -0.55, P < 0.05), respectively [corrected]. These results suggest that an administration of Fely at doses more than 2.7-5.4 mIU kg(-1) (3-6 cartridges of Pri-Fely) may induce an imbalance between the oxygen supply and demand in myocardial tissues of patients with cardiovascular diseases.

Postoperative monitoring of myocardial oxygen tension: experience in 51 coronary artery bypass patients

Following a preliminary feasibility report, polarographic monitoring of myocardial tissue O2 tension (Pmo2) in 51 coronary bypass patients has been accomplished. In this context, the influence of rapid atrial pacing (RAP), O2 inhalation, and intra-aortic balloon assistance (IAB) was statistically analyzed using Wilcoxon sign-rank and Student's t-tests. Electrodes were implanted in revascularized and nonrevascularized areas for comparison (24.0 +/- 1.1; and 26.3 +/- 1.8 mmHg Pmo2, p, not significant). Increasing myocardial O2 demand with RAP caused a 6% PmO2 drop (p less than 0.01). A 70% O2 inhalation increased Pmo2 by 30% (p less than 0.01). In 5 cases the benefit of IAB was confirmed by a 41% increase in Pmo2 (p = 0.02). These data support the clinical usefulness of polarographic Pmo2 as a measure of regional myocardial oxygenation. In addition to early recognition of intraoperative or postoperative graft failure previously reported, the efficacy of various therapeutic interventions can be more precisely determined.

Improved oxygenation of ischemic myocardium by hemodilution with stroma-free hemoglobin solution

Experiments were conducted in anesthetized open-chest dogs subjected to occlusion of the left anterior descending coronary artery for three hours. The oxygenation of myocardial tissue was monitored by a polarographic technique capable of recording simultaneously the oxygen tension (Po2) of myocardial tissue and electrograms. Ischemic injury was monitored by means of ST-segment elevations on myocardial and epicardial electrograms. The volume of the myocardial infarct was measured at the end of each experiment by incubation of transverse slices of left ventricle in a solution of nitroblue tetrazolium and by separation of the unstained (ischemic) from the stained (normal) portions. In one group of dogs, hemodilution was performed after 15 minutes of ischemia by exchanging blood with a stroma-free hemoglobin solution (from a hematocrit reading of 45 +/- 3 percent to 23 +/- 2 percent). Changes occurring in this group were compared with those occurring in dogs that did not undergo hemodilution, underwent hemodilution with dextran 75, or were transfused with whole blood. Hemodilution with hemoglobin reduced aortic and left ventricular filling pressures while increasing coronary blood flow, increased myocardial Po2 from 2 +/- 2 mm Hg to 8 +/- 2 mm Hg (P less than 0.005), lowered the ST-segment elevation of both myocardial and epicardial electrograms, and reduced the volume of the myocardial infarct. These effects were unmatched by hemodilution with dextran or infusion of whole blood.