Comparison of the Hemodynamic Effects of the Induction Agents Ketamine, Etomidate and Sevoflurane Using the Model of Electrical Velocimetry Based Cardiac Output Monitoring in Pediatric Cardiac Surgical Patients

Suruchi Hasija^1*, Sandeep Chauhan¹, Neeti Makhija¹, Sarvesh Pal Singh¹, Sanjay Kumar¹, Arin Choudhury¹, Sachin Talwar², Usha Kiran¹

¹Department of Cardiac Anaesthesiolgy, All India Institute of Medical Sciences, New Delhi, India.
²Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi, India.

DOI: 10.4236/wjcs.2014.410024                

Abstract

Objective: To compare the haemodynamic effects of the induction agents ketamine, etomidate and sevoflurane using the model of electrical velocimetry based cardiac output monitoring in paediatric cardiac surgical patients. Design: Prospective randomized study. Setting: Tertiary care hospital. Participants: 60 children < 2 years age undergoing cardiac surgery. Interventions: The patients were randomized into 3 equal groups to receive 1.5-2.5 mg/kg iv ketamine (group K), 0.2-0.3 mg/kg iv etomidate (group E) or upto 8% sevoflurane (group S) as the induction agent. Hemodynamic parameters were noted before and after induction of anaesthesia utilizing a noninvasive cardiac monitor based on the model of electrical velocimetry. Measurements and Main Results: The demographic characteristics of the patients were similar in the three groups. The HR decreased in all groups, least in group E (P ≤ 0.01) but the MAP decreased only in group S (P ≤ 0.001). In group S, the stroke volume improved from 9 ± 3.2 ml to 10 ± 3.2 ml (P ≤ 0.05) and the stroke volume variation decreased from 25% ± 6.4% to 13% ± 6.2% (P ≤ 0.001). The stroke index and systemic arterial saturation improved in all groups (P ≤ 0.01). The cardiac index and index of contractility were unchanged. The transthoracic fluid content reduced in groups E and S, but did not change in group K (P ≤ 0.05). Conclusions: Etomidate appeared to provide the most stable conditions for induction of anesthesia in children undergoing cardiac surgery, followed by ketamine and sevoflurane.

Keywords

Anesthesia Induction Agents, Electrical Velocimetry, Noninvasive Hemodynamic Monitoring, Pediatric Cardiac Surgery

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1]	Morray, J.P., Lynn, A.M., Stamm, S.J., Herndon, P.S., Kawabori, I. and Stevenson, J.G. (1984) Hemodynamic Effects of Ketamine in Children with Congenital Heart Disease. Anesthesia Analgesia, 63, 895-899. http://dx.doi.org/10.1213/00000539-198410000-00004
[2]	Oklü, E., Bulutcu, F.S., Yalcin, Y., Ozbek, U., Cakali, E. and Bayindir, O. (2003) Which Anesthetic Agent Alters the Hemodynamic Status during Pediatric Catheterization? Comparison of Propofol versus Ketamine. Journal of Cardiothoracic and Vascular Anesthesia, 7, 686-690. http://dx.doi.org/10.1053/j.jvca.2003.09.009
[3]	Berman Jr., W., Fripp, R.R., Rubler, M. and Alderete, L. (1990) Hemodynamic Effects of Ketamine in Children Undergoing Cardiac Catheterization. Pediatric Cardiology, 11, 72-76. http://dx.doi.org/10.1007/BF02239565
[4]	Sungur Ulke, Z., Kartal, U., Orhan Sungur, M., Camci, E. and Tugrul, M. (2008) Comparison of Sevoflurane and Ketamine for Anesthetic Induction in Children with Congenital Heart Disease. Pediatric Anesthesia, 18, 715-721. http://dx.doi.org/10.1111/j.1460-9592.2008.02637.x
[5]	Malik, M., Malik, V., Chauhan, S., Dhawan, N. and Kiran, U. (2011) Ketamine-Etomidate for Children Undergoing Cardiac Catheterization. Asian Cardiovascular and Thoracic Annals, 19, 143-148. http://dx.doi.org/10.1177/0218492311402132
[6]	Rivenes, S.M., Lewin, M.B., Stayer, S.A., Bent, S.T., Schoenig, H.M., McKenzie, E.D., Fraser, C.D. and Andropoulos, D.B. (2001) Cardiovascular Effects of Sevoflurane, Isoflurane, Halothane, and Fentanyl-Midazolam in Children with Congenital Heart Disease: An Echocardiographic Study of Myocardial Contractility and Hemodynamics. Anesthesiology, 94, 223-229. http://dx.doi.org/10.1097/00000542-200102000-00010
[7]	Ebert, T.J., Muzi, M., Berens, R., Goff, D. and Kampine, J.P. (1992) Sympathetic Responses to Induction of Anesthesia in Humans with Propofol or Etomidate. Anesthesiology, 76, 725-733. http://dx.doi.org/10.1097/00000542-199205000-00010
[8]	Reves, J.G., Glass, P.S.A., Lubarsky, D.A., McEvoy, M.D. and Martinez-Ruiz, R. (2009) Intravenous Anesthetics. In: Miller, R.D., Ed., Miller’s Anesthesia, 7th Edition, Elsevier Churchill Livingstone, Philadelphia.
[9]	Sarkar, M., Laussen, P.C., Zurakowski, D., Shukla, A., Kussman, B. and Odegard, K.C. (2005) Hemodynamic Responses to Etomidate on Induction of Anesthesia in Pediatric Patients. Anesthesia Analgesia, 10, 645-650. http://dx.doi.org/10.1213/01.ane.0000166764.99863.b4
[10]	Dhawan, N., Chauhan, S., Kothari, S.S., Kiran, U., Das, S. and Makhija, N. (2010) Hemodynamic Responses to Etomidate in Pediatric Patients with Congenital Cardiac Shunt Lesions. Journal of Cardiothoracic and Vascular Anesthesia, 24, 802-807. http://dx.doi.org/10.1053/j.jvca.2010.02.005
[11]	Tibby, S.M., Hatherill, M., Marsh, M.J., Morrison, G., Anderson, D. and Murdoch, I.A. (1997) Clinical Validation of Cardiac Output Measurements Using Femoral Artery Thermodilution with Direct Fick Technique in Ventilated Children and Infants. Intensive Care Medicine, 23, 987-991. http://dx.doi.org/10.1007/s001340050443
[12]	Noori, S., Drabu, B., Soleymani, S. and Seri, I. (2012) Continuous Non-Invasive Cardiac Output Measurements in the Neonate by Electrical Velocimetry: A Comparison with Echocardiography. Archives of Disease in Childhood-Fetal and Neonatal Edition, 97, F340-F343. http://dx.doi.org/10.1136/fetalneonatal-2011-301090
[13]	Norozi, K., Beck, C., Osthaus, W.A., Wille, I., Wessel, A. and Bertram, H. (2008) Electrical Velocimetry for Measuring Cardiac Output in Children with Congenital Heart Disease. British Journal of Anaesthesia, 100, 88-94. http://dx.doi.org/10.1093/bja/aem320
[14]	Zoremba, N., Bickenbach, J., Krauss, B., Rossaint, R., Kuhlen, R. and Schalte, G. (2007) Comparison of Electrical Velocimetry and Thermodilution Techniques for the Measurement of Cardiac Output. Acta Anaesthesiologica Scandinavica, 51, 1314-1319. http://dx.doi.org/10.1111/j.1399-6576.2007.01445.x
[15]	Schmidt, C., Theilmeier, G., Van Aken, H., Korsmeier, P., Wirtz, S.P., Berendes, E., Hoffmeier, A. and Meissner, A. (2005) Comparison of Electrical Velocimetry and Transoesophageal Doppler Echocardiography for Measuring Stroke Volume and Cardiac Output. British Journal of Anaesthesia, 95, 603-610. http://dx.doi.org/10.1093/bja/aei224
[16]	Schubert, S., Schmitz, T., Weiss, M., Nagdyman, N., Huebler, M., Alexi-Meskishvili, V., Berger, F. and Stiller, B. (2008) Continuous, Non-Invasive Techniques to Determine Cardiac Output in Children after Cardiac Surgery: Evaluation of Transesophageal Doppler and Electric Velocimetry. Journal of Clinical Monitoring and Computing, 22, 299- 307. http://dx.doi.org/10.1007/s10877-008-9133-0
[17]	Grollmuss, O., Demontoux, S., Capderou, A., Serraf, A. and Belli, E. (2012) Electrical Velocimetry as a Tool for Measuring Cardiac Output in Small Infants after Heart Surgery. Intensive Care Medicine, 38, 1032-1039. http://dx.doi.org/10.1007/s00134-012-2530-3
[18]	Noonan, P.M., Viswanathan, S., Chambers, A. and Stumper, O. (2014) Non-Invasive Cardiac Output Monitoring during Catheter Interventions in Patients with Cavopulmonary Circulations. Cardiology in the Young, 24, 417-421. http://dx.doi.org/10.1017/S1047951113000486
[19]	Tomaske, M., Knirsch, W., Kretschmar, O., Woitzek, K., Balmer, C., Schmitz, A., Bauersfeld, U. and Weiss, M. (2008) Cardiac Output Measurement in Children: Comparison of Aesculon? Cardiac Output Monitor and Thermodilution. British Journal of Anaesthesia, 100, 517-520. http://dx.doi.org/10.1093/bja/aen024