The Effects of Local Anaesthetics on QT Parameters during Thoracic Epidural Anaesthesia Combined with General Anaesthesia: Ropivacaine versus Bupivacaine

Abstract

Background: Many studies focusing on the effects of local anaesthetics on QT intervals have been performed, but the articles evaluating the relationship between thoracic epidural anaesthesia combined with general anaesthesia and QT parameters are very limited. Aims: We aimed to compare the effects of bupivacaine and ropivacaine on QT interval, corrected QT, dispersion of QT, and corrected dispersion of QT in patients undergoing lung resection under thoracic epidural anaesthesia combined with general anaesthesia. Study Design: Prospective clinical study. Methods: Thirty ASA physical status 1–3 patients requiring thoracic epidural anaesthesia combined with general anaesthesia for thoracic surgery. Patients were randomly assigned to two groups, which were allocated to receive either bupivacaine (Group B) or ropivacaine (Group R) during thoracic epidural anaesthesia. Following haemodynamic monitoring, a thoracic epidural catheter was inserted. Local anaesthetic at an average dose of 1.5 mL/segment was given through an epidural catheter. The same general anaesthesia protocol was administered in both groups. Records and measurements were performed on 10 phases that were between the thoracic epidural catheter insertion to the 5th min of endobronchial intubation. In all phases, systolic arterial pressure, diastolic arterial pressure, mean arterial pressure, heart rate, peripheral O2 saturation, and electrocardiogram monitoring were performed in patients. All QT parameters were recorded by 12-lead electrocardiogram and analysed manually by a cardiologist. Results: QT intervals were similar between two groups. In Group R, corrected QT values at the 20th min of local anaesthetic injection and the 5th min of endobronchial intubation were shorter than those in Group B (p<0.05). The basal dispersion of QT and dispersion of QT values at the 1st min of propofol injection were shorter than those in Group R (p<0.05). The corrected dispersion of QT value at the 1st min of propofol injection was shorter in Group R (p<0.05). In Group R, the decrease in mean arterial pressure at the 1st min of fentanyl injection was significant compared with Group B (p<0.05). There was no significant difference between the groups with respect to heart rate and complications. Conclusion: The corrected QT, dispersion of QT, and corrected dispersion of QT intervals were slightly longer in the patients receiving bupivacaine compared with those receiving ropivacaine in various phases of the present study. Turkish Başlık:Torakal Epidural Anestezi ile Genel Anestezi Kombinasyonu Sırasında Lokal Anesteziklerin QT Parametreleri Üzerine Olan Etkileri: Ropivakain-Bupivakain Karşılaştırması Anahtar Kelimeler:Bupivakain, ropivakain, QT parametreleri, torakal epidural anestezi, lokal anestezikler Arkaplan: Lokal anestezik lerin QT intervalleri üzerine olan etkileri üzerine birçok çalışma yapılmakla birlikte genel anestezi ile torakal epidural anestezi kombinasyonu ve QT parametreleri arasındaki ilişkiyi değerlendiren çalışmalar oldukça sınırlıdır. Amaç: Bu çalışmada torakal epidural ve genel anestezi kombinasyonu ile akciğer rezeksiyonu yapılan hastalarda bupivakain ve ropivakainin QT intervali, düzeltilmiş QT, QT dispersiyonu ve düzeltilmiş QT dispersiyonuüzerine etkilerinin karşılaştırılmasını amaçladık. Çalışma Tasarımı: Prospektif klinik çalışma Yöntemler: Göğüs cerrahisi için torakal epidural ve genel anestezi kombinasyonu gerektiren 30 ASA 1-3 hasta randomize olarak torakal epidural anestezi sırasında bupivakain (Grup B) ya da ropivakain (Grup R) alan iki gruba ayrıldı. Hemodinamik monitorizasyonu takiben torakal epidural kateter yerleştirildi. Yaklaşık 1.5 mL/segment lokal anestezik torakal epidural kateterden verildi. Aynı genel anestezi protokolü iki grup için de uygulandı. Kayıt ve ölçümler torakal epidural kateter yerleştirilmesinden endobronşiyal entübasyonun 5. dk'sına kadar 10 fazda yapıldı. Bütün fazlarda hastaların sistolik arter basıncı, diyastolik arter basıncı, ortalama arter basıncı, kalp atım hızı, periferik O2 saturasyonu ve elektrokardiografi monitorizasyonu yapıldı. Kardiyolog tarafından bütün QT parametreleri 12 derivasyonlu EKG kayıtlarından manuel olarak analiz edildi. Bulgular: QT intervalleri iki grup arasında benzerdi. Lokal anestezik verilmesinden 20 dk sonra ve endobronşiyal entübasyonun 5. dk'sında düzeltilmiş QT değerleri Grup R'de Grup B'ye göre kısa bulundu (p<0.05). Bazal QT dispersiyonu ve propofol enjeksiyonunun 1. dk'sındaki QT dispersiyonu değerleri Grup R' ye göre kısa bulundu (p<0.05). Propofol enjeksiyonunun 1. dk'sındaki düzeltilmiş QT dispersiyonu değerleri Grup R' de kısa bulundu (p<0.05). Fentanil enjeksiyonunun 1. dk'sındaki ortalama arter basıncı değerindeki düşme Grup R'de Grup B'ye göre anlamlı idi. İki grup arasında kalp atım hızı ve komplikasyonlar açısından anlamlı bir fark bulunmadı. Sonuç: Bu çalışmada ölçüm yapılan fazların değişik aşamalarında düzeltilmiş QT, QT dispersiyonu ve düzeltilmiş QT dispersiyonu intervalleri bupivakain alan hastalarda ropivakain uygulananlara göre hafifçe daha uzun bulundu.

Keywords

• Bupivacaine, ropivacaine, QT parameters, thoracic epidural anaesthesia, local anaesthetics

The Effects of Local Anaesthetics on QT Parameters during Thoracic Epidural Anaesthesia Combined with General Anaesthesia: Ropivacaine versus Bupivacaine

Öz

Kaynakça

1. Campos JH. Fast track in thoracic anesthesia and surgery. Curr Opin Anaesthesiol 2009;22:1-3. [CrossRef]
2. Xu Y, Tan Z, Wang S, Shao H, Zhu X. Effect of thoracic epidural anesthesia with different concentrations of ropivacaine on arterial oxygenation during one-lung ventilation. Anesthesiology 2010;112:1146-54. [CrossRef]
3. Freise H, Van Aken HK. Risks and benefits of thoracic epidural anaesthesia. Br J Anaesth 2011;107:859-68. [CrossRef]
4. Senturk M. Acute and chronic pain after thoracotomies. Curr Opin Anaesthesiol 2005;18:1- 4. [CrossRef]
5. Moller R, Covino BG. Cardiac electrophysiologic properties of bupivacaine and lidocaine compared with those of ropivacaine, a new amide local anesthetic. Anesthesiology 1990;72:322-9. [CrossRef]
6. Pitkanen M, Feldman HS, Arthur GR, Covine BG. Chronotropic and inotropic effects of ropivacaine, bupivacaine, and lidocaine in the spontaneously beating and electrically paced isolated, perfused rabbit heart. Reg Anesth 1992;17:183-92.
7. Lefrant JY, de La Coussaye JE, Ripart J, Muller L, Lalourcey L, Peray PA, et al. The comparative electrophysiologic and hemodynamic effects of a large dose of ropivacaine and bupivacaine in anesthetized and ventilated piglets Anesth Analg 2001;93:1598-605. [CrossRef]
8. Mazoit JX, Cao LS, Samii K. Binding of bupivacaine to human serum proteins, isolated and isolated alpha1-acid glycoprotein:differences between the two enantiomers are partly due to cooperativity. J Pharmacol Exp Ther 1996;256:109-15

9. Takmaz SA, Uysal HY, Inan N, Kaptan Z, Basar H. Effects of right and left stellate ganglion block on blood pressure and QT-QTc intervals in patients with primary Raynaud’s phenomenon. Turk J Med Sci 2012;42:89-94.
10. Scott DB, Lee A, Fagan D, Bowler GMR, Bloomfield P, Lundh R. Acute toxicity of ropivacaine compared with that of bupivacaine. Anesth Analg 1989;69:563-9. [CrossRef]
11. Schwartz PJ, Wolf S. QT interval prolongation as predictor of sudden death in patients with myocardial infarction. Circulation 1978;57:1074-7. [CrossRef]
12. Bazett HC. An analysis of the time-relation of electrocardiograms. Heart 1929;7:353-67.
13. Reiz S, Häggmark S, Johansson G, Narh S. Cardiotoxicity of ropivacaine - a new amide local anaesthetic agent. Acta Anaesthesiol Scand 1989;33:93-8. [CrossRef]
14. Magnano AR, Holleran S, Ramakrishnan R, Reiffel JA, Bloomfield DM. Autonomic nervous system influences on QT interval in normal subjects. J Am Coll Cardiol 2002;39:1820-6. [CrossRef]
15. Hotvedt R, Platou ES, Refsum H. Electrophysiological effects of thoracic epidural analgesia in the dog heart in situ. Cardiovasc Res 1983;17:259-66. [CrossRef]
16. Hotvedt R, Platou ES, Refsum H. Effects of thoracic epidural analgesia on cardiovascular function and plasma concentration of free fatty acids and catecholamines in the dog. Acta Anaesthesiol Scand 1984;28:132-7. [CrossRef]
17. Irie T, Kaneko Y, Nakajima T, Saito A. QT interval prolongation and torsade de pointes induced by propofol and hypoalbuminemia. Int Heart J 2010;51:365-6. [CrossRef]
18. McConachie I, Keaveny JP, Healy TE, Vohra S, Million L. Effect of anaesthesia on the QT interval. Br J Anaesth 1989;63:558-60. [CrossRef]
19. Kim DH, Kweon TD, Nam SB, Han DW, Cho WY, Lee JS, et al. Effects of target concentration infusion of propofol and tracheal intubation on QTc interval. Anaesthesia 2008;63:1061-4. [CrossRef]
20. Wilton NC, Hantler CB. Congenital long QT syndrome:changes in QT interval during anesthesia with thiopental, vecuronium, fentanyl and isoflurane. Anesth Analg 1987;66:357-60. [CrossRef]
21. Michaloudis DG, Kanakoudis FS, Xatzikraniotis A, Bischiniotis TS. The effects of midazolam followed by administration of either vecuronium or atracurium on the QT interval in humans. Eur J Anaesthesiol 1995;12:577-83.
22. Scheinin B, Lindgren L, Randell T, Scheinin H, Scheinin M. Dexmedetomidine attenuates sympathoadrenal responses to tracheal intubation and reduces the need for thiopentone and peroperative fentanyl. Br J Anaesth 1992;68:126-31. [CrossRef]
23. Aypar E, Karagoz AH, Ozer S, Celiker A, Ocal T. The effects of sevoflurane and desflurane anesthesia on QTc interval and cardiac rhythm in children. Paediatr Anaesth 2007;17:563-7. [CrossRef]
24. Kazanci D, Unver S, Karadeniz U, Iyican D, Koruk S, Yilmaz MB, et al. A comparison of the effects of desflurane, sevoflurane and propofol on QT, QTc, and P dispersion on ECG. Ann Card Anaesth 2009;12:107-12. [CrossRef]
25. Diercks DB, Shumaik GM, Harrigan RA, Brady WJ, Chan TC. Electrocardiographic manifestations: electrolyte abnormalities. J Emerg Med 2004;27:153-60. [CrossRef]