Brazilian Journal of Anesthesiology
https://bjan-sba.org/article/doi/10.1590/S0034-70942007000500002
Brazilian Journal of Anesthesiology
Scientific Article

Estudo prospectivo das repercussões de baixas doses de remifentanil na função sinoatrial e na condução e refratariedade cardíaca

Prospective study on the repercussions of low doses of remifentanil on sinoatrial function and in cardiac conduction and refractory period

Simone Soares Leite; Elizabeth Bessadas Penna Firme; Márcia Santana Bevilaqua; Leonel dos Santos Pereira; Jacob Atié

http://dx.doi.org/10.1590/S0034-70942007000500002 Braz J Anesthesiol, vol.57, n5, p.465-475, 2007
PDF Português
PDF English
Downloads: 0
Views: 1042

Resumo

JUSTIFICATIVA E OBJETIVOS: O remifentanil é um opióide com início e término de ação rápidos, cujo uso em procedimentos de curta duração vem se propagando nos últimos anos. Entre os efeitos colaterais descritos, há relatos de bradicardia e assistolia. O objetivo deste estudo foi avaliar os efeitos desse fármaco na condução e refratariedade cardíaca, em humanos. MÉTODO: Estudo prospectivo de 16 pacientes, entre 18 e 65 anos, de ambos os sexos, ASA I a III, submetidos a estudo eletrofisiológico intracardíaco eletivo. Foram excluídos os pacientes com doença do nódulo sinoatrial e os portadores de bloqueios cardíacos graves. No laboratório de eletrofisiologia, os pacientes foram inicialmente sedados com midazolam (0,03 mg.kg-1), após 5 minutos (M0) avaliou-se o grau de sedação de intensidade de dor, pressões arteriais sistólica e diastólica, freqüências cardíaca e respiratória e saturação de oxigênio. O eletrofisiologista avaliou as variáveis de condução cardíaca (duração do QRS, intervalos AA, AH, HV e PA), o tempo de recuperação do nódulo sinoatrial e as variáveis de refratariedade cardíaca (período refratário do átrio direito, período refratário do ventrículo direito e período refratário do nódulo atrioventricular). Após as medidas iniciais o remifentanil foi introduzido (bolus de 0,5 µg.kg-1 + infusão de 0,05 µg.kg-1.min-1) e após 20 minutos as mesmas variáveis foram reavaliadas (M1). RESULTADOS: Observou-se diminuição das pressões sistólica e diastólica (p = 0,0001) entre M0 e M1, sem diferença estatística significativa da freqüência respiratória ou da saturação de oxigênio. Houve aumento do intervalo átrio-His (p = 0,006) e do tempo de recuperação do nódulo sinoatrial (p = 0,0004), do período refratário do átrio direito (p = 0,001) e do período refratário do nódulo atrioventricular (p = 0,0001), porém não houve diminuição da freqüência cardíaca basal entre M0 e M1. CONCLUSÕES: O remifentanil alterou as variáveis eletrofisiológicas cardíacas, o que em doses maiores que as estudadas poderiam causar bradicardia sinusal, assistolia e distúrbios de condução.

Palavras-chave

ANALGÉSICOS, Opióide, CIRURGIA, Cardíaca, COMPLICAÇÕES, FISIOLOGIA, Cardiovascular

Abstract

BACKGROUND AND OBJECTIVES: Remifentanil is an opiod with fast onset of action and short acting, and its use in short-duration procedures has increased in the last few years. Bradycardia and asystole are among the side effects reported. The objective of this study was to evaluate the effects of this drug in cardiac conduction and refractory period in human beings. METHODS: A prospective study with 16 patients, ages 18 to 65, both genders, ASA I to III, undergoing elective intracardiac electrophysiological study, was undertaken. Patients with disorders of the sinoatrial node and those with severe cardiac blocks were excluded. In the laboratory of electrophysiology, patients were sedated with midazolam (0.03 mg.kg-1) after 5 minutes the degree of sedation and degree of pain, systolic and diastolic blood pressure, heart rate and respiratory rate, and oxygen saturation were evaluated. The electrophysiologist evaluated cardiac conduction (duration of the QRS complex, and AA, AH, HV, and PA intervals), duration of sinoatrial node recovery, and cardiac refractory period (refractory period of the right atrium, right ventricle, and atrioventricular node). After the initial measurements, remifentanil was administered (bolus of 0.5 µg.kg-1 + infusion of 0.05 µg.kg-1.min-1) and, after 20 minutes, the same parameters were evaluated. RESULTS: There was a reduction in systolic and diastolic blood pressure (p = 0.0001) between M0 and M1, and significant differences in respiratory rate and oxygen saturation, which were not statistically significant. The atrium-His interval (p = 0.006), recovery time of the sinoatrial node (p = 0.0004), refractory period of the right atrium (p = 0.001), and refractory period of the sinoatrial node (p = 0.0001) were all increased; however, there were no differences in heart rate between M0 and M1. CONCLUSIONS: Remifentanil changes cardiac electrophysiological parameters and, in doses higher than the ones used in this study, can cause sinus bradycardia, asystole, and conduction defects.

Keywords

ANALGESICS, Opioid, COMPLICATIONS, Heart Arrest, Arrhythmia, PHYSIOLOGY, Cardiovascular system, SURGERY, Cardiac

References

Glass PS, Gan TJ, Howell S. A review of the pharmacokinetics and pharmacodynamics of remifentanil. Anesth Analg. 1999;89:S7-14.

Nora FS, Fortis EAF. Remifentanil: Por que precisamos de outro opióide?. Rev Bras Anestesiol. 2001;51(146-159).

Shafer SL. New intravenous anesthetic: Remifentanil. ASA Refresher Course. 1996;24:243-255.

Egan TD. Pharmacokinetics and pharmacodynamics of remifentanil: an update in the year 2000. Curr Opin Anaesthesiol. 2000;13:449-455.

Videira RLR, Cruz JRS. Remifentanil na prática clínica. Rev Bras Anestesiol. 2004;54:114-128.

Thompson JP, Rowboteram DJ. Remifentanil: an opióide for the 21st century. Br J Anaesth. 1996;76:341-343.

Scott LJ, Perry CM. Spotlight on remifentanil for general anaesthesia. CNS Drugs. 2005;19(12):1069-74.

Bürkle H, Dunbar S, Van Aken H. Remifentanil: A novel, short-acting, mu-opioid. Anesth Analg. 1996;83:646-651.

Servin FS. Remifentanil: an update. Curr Opin Anaesthesiol. 2003;16:367-372.

Elliot P, O'Hare R, Bill KM. Severe cardiovascular depression with remifentanil. Anesth Analg. 2000;91:58-61.

Thompson JP, May AP, Russell J. Effect of remifentanil on the haemodynamic response to orotracheal intubation. Br J Anaesth. 1998;80:467-469.

Reid JE, Mirakhur RK. Bradycardia after administration of remifentanil. Br J Anesth. 2000;84:422-423.

DeSouza G, Lewis MC, TerRiet MF. Severe bradycardia after remifentanil. Anesthesiology. 1997;87:1019-1020.

Glass PSA. Pharmacology of remifentanil. Eur J Anaesthesiol. 1995;12(10):73-74.

Wang J, Winship S, Russell G. Induction of anaesthesia with sevoflurane and low-dose remifentanil: asystole following laryngoscopy. Br J Anestth. 1998;81:994-995.

Altermatt FR, Muñoz HR. Asystole with propofol and remifentanil. Br J Anesth. 2000;84:696-697.

Starr NJ, Sethna DH, Estafanous FG. Bradycardia and asystole following the rapid administration of sufentanil with vecuronium. Anesthesiology. 1986;64:521-523.

Maryniak JK, Bishop VA. Sinus arrest after alfentanil. Br J Anaesth. 1987;59:390-391.

Sherman EP, Lebowitz PW, Street WC. Bradycardia following sufentanil-succinylcholine. Anesthesiology. 1987;66.

Rivard JC, Lebowitz PW. Bradycardia after alfentanil-succinylcholine. Anesth Analg. 1988;67:907.

Egan TD, Brock-Utne JG. Asystole after anesthesia induction with fentanyl, propofol, and succinylcholine sequence. Anesth Analg. 1991;73:818-820.

Kennedy BL, West TC. Effect of morphine on electrically induced release of autonomic mediators in the rabbit sinoatrial node. J Pharmacol Exp Ther. 1967;157:149-158.

Tomichek RC, Rosow C, Philbin DM. Diazepan-fentanyl interaction hemodynamic and hormonal effects in coronary artery surgery. Anesth Analg. 1983;62:881-884.

Blair JR, Pruett JK, Introna RPS. Cardiac electrophysiologic effects of fentanyl and sufentanil in canine cardiac Purkinje fibers. Anesthesiology. 1989;71:565-570.

Puerto BA, Wong KC, Puerto AX. Epinephrine-induced dysrhythmias: Comparison during anaesthesia with narcotics and with halogenated agents in dogs. Can Anaesth Soc J. 1979;26:263-268.

Weber G, Stark G, Stark U. Direct cardiac electrophysiologic effects of sufentanil and vecuronium in isolated guinea-pig hearts. Acta Anaesthesiol Scand. 1995;39:1071-1074.

Reitan N, Stengert KB, Wymore ML. Central vagal control of fentanyl-induced bradycardia during halothane anesthesia. Anesth Analg. 1978;57:31-36.

Saeki T, Nishimura M, Sato N. Electrophysiological demonstration and activation of mu-opioid receptors in rabbit sinoatrial node. J Cardiovasc Pharmacol. 1995;26:160-168.

Gómes-Arnau J, Márquez-Montes J, Avello F. Fentanyl and droperidol effects on refractoriness of acessory pathways in the Wolff-Parkinson-White syndrome. Anesthesiology. 1983;58:307-313.

Sharpe MD, Dobkowski WB, Murkin JM. Alfentanil-midazolam anaesthesia has no electrophysiological effects upon the normal conduction system or accessory pathways in patients with Wolff-Parkinson-White syndrome. Can J Anaesth. 1992;39:816-821.

Sharpe MD., Dobkowski WB, Murkin JM. The electrophysiologic effects of volatile anesthetics and sulfentanil on the normal atrioventricular conduction system and accessory pathways in Wolff-Parkinson-White syndrome. Anesthesiology. 1994;80:63-70.

Sebel PS, Hoke JF, Westmoreland C. Histamine concentrations and haemodynamic responses after remifentanil. Anesth Analg. 1995;80:990-993.

Unlugenc H, Itegin M, Ocal I. Remifentanil produces vasorelaxation in isolated rat thoracic aorta strips. Acta Anaesthesiol Scand. 2003;47:65-69.

Shinohara K, Aodo H, Uruh GK. Suppressive effects of remifentanil on aerodynamics in baro-denervated rabbits. Can J Anaesth. 2000;47:361-366.

Josephson ME. Clinical Cardiac Eletrophysiology: Techniques and Interpretation. 2002:6-166.

Atlee JL, Bosnjak ZJ. Mechanism for cardiac dysrhythimias during anesthesia. Anesthesiology. 1990;72:347-374.

Gold MI, Watkins W, David MD. Remifentanil versus remifentanil/midazolam for ambulatory surgery during monitored anesthesia care. Anesthesiology. 1997;87:51-57.

Avramov MN, Smith IMB, White PF. Interactions between midazolam and remifentanil during monitored anesthesia care. Anesthesiology. 1996;85:1283-1289.

5dd81fef0e8825627e13f287 rba Articles
Links & Downloads
2352-2291 (Electronic) 0104-0014 (Printed)
Braz J Anesthesiol ©2024 All rights reserved.

Braz J Anesthesiol

Share this page
Page Sections