Total intravenous anesthesia with remifentanil and propofol for implantation of cardioverter-defibrillators in patients with severely reduced left ventricular function

Objective: To determine the cardiocirculatory effects of total intravenous anesthesia (TIVA) using remifentanil and propofol in high-risk cardiac surgical patients. Design: Prospective study of 20 patients undergoing first-time implantation of a cardioverter-defibrillator (ICD). Setting: Major, community, university-affiliate hospital. Participants and Interventions: In 20 patients with severely reduced left ventricular function (left ventricular ejection fraction <30%) undergoing first-time implantation of an ICD, TIVA using remifentanil and propofol was performed. Measurements and Main Results: Extensive hemodynamic monitoring using a pulmonary artery catheter was performed: (T1) before induction of anesthesia, (T2) after intubation, (T3) after skin incision, (T4) after first defibrillation, and (T5) 10 minutes after extubation. Propofol, 3.0 @ 0.6 mg/kg/h (range, 1.9 to 4.4 mg/kg/h), and remifentanil, 0.30 +/- 0.05 mu g/kg/min (range, 0.21 to 0.40 mu g/kg/min), were used. Total costs added up to US $44.60 per patient. Patients could be extubated within 12.5 +/- 4.2 minutes after stopping anesthesia. There were significant decreases in heart rate (HR: from 77 +/- 12 to 57 +/- 10 beats/min [T3]), mean arterial blood pressure (MAP; from 98 +/- 14 to 70 +/- 12 mmHg [T2]) and systemic vascular resistance (from 1,551 +/- 309 to 1,233 +/- 274 dyne . s . cm(-5) [T2]). Cardiac index (CI) slightly decreased only at T3 (from 2.46+/-0.42 to 1.92+/-0.29 L/min/m(2): p = 0.04). The decrease in MAP could easily be treated by volume infusion in most patients (17 patients). Sixty-five percent of the patients needed dobutamine to increase CI to greater than 2.0 L/min/m(2) (mean dose, 2.2 +/- 1.8 mu g/kg/min). Dobutamine could be stopped before extubation in all patients. No patient needed sustained inotropic or ventilatory support and intensive care therapy could be avoided. Conclusion: TIVA using remifentanil and propofol in patients with severely reduced left ventricular function is safe, well-controllable, and allows early extubation after implantation of an ICD. Because patients without complications did not need a postoperative intensive care stay, costs may be considerably reduced. Copyright (C) 1999 by W.B. Saunders Company.