Journal: Eur J Anaesthesiol 25(8):627-633, 2008. 23 References
Reprint: Dept of Anaesthesiology and Intensive Care Medicine, Trauma Hospital Linz, Garnisonstrasse 7, 4020 Linz, Austria (M Ponschab, MD)
Faculty Disclosure: Abstracted by S. Ouellette, who has nothing to disclose.
Patients with heart failure undergoing major surgery suffer substantial morbidity and morbidity. The risk for adverse outcome is further increased in emergency or urgent cases. The urgency of surgery limits the time available to optimize cardiac performance and volume status or correct electrolyte imbalances and this increases the risk of serious cardiac complications.
Hip surgery is one of the most common traumatic injuries in the elderly and urgent surgical repairs seem to be crucial. In up to 25% of these patients cardiovascular comorbidities are present on admission, predisposing them to develop cardiac complications perioperatively. The most important complication in patients following hip fracture repair is the occurrence of heart failure, causing a 30-day mortality rate of 65%. In an attempt to reduce mortality, attention has focused on optimizing cardiac function in the perioperative period. Although positive inotropic drugs are used, they have limitations. The new inodilator levosimendan does not use the physiologic pathway of increasing intracellular calcium like beta-adrenergic agonists and phosphodiesterase inhibitors. Levosimendan promotes inotropy by inducing calcium sensitization of myofilaments by binding to cardiac troponin C. The purpose of this study was to evaluate the impact of preoperative levosimendan in elderly patients with heart failure having urgent hip fracture repair.
Ten consecutive patients with symptomatic heart failure and left ventricular ejection fraction below 35% undergoing urgent hip fracture were studied. Levosimendan was administered with an infusion of 0.1 mcg/kg/min in a total dose of 12.5 mg starting a minimum of 2 hours prior to surgery. Hemodynamic parameters were obtained at baseline and at 4, 8, 12, 16, 20, 24, 28, 36, and 48 hour after start of levosimendan. B-type natriuretic peptide was measured on admission and after 48 hours.
Levosimendan significantly increased cardiac index by increasing stroke volume index. Systemic vascular resistance index significantly decreased within 24 hours. Hemodynamic changes exerted by levosimendan persisted up to 48 hours. B-type natriuretic peptide plasma concentrations decreased after 48 hours.
It was concluded that in patients with heart failure, preoperative start of levosimendan infusion improves intraoperative and postoperative hemodynamics. These findings suggest that levosimendan is a useful drug for preoperative optimization of cardiac function in high-risk patients undergoing major surgery. |
