What is the recommended coinduction anesthesia technique for a patient with left ventricular (LV) failure?

Coinduction Anesthesia Technique for Patients with Left Ventricular Failure

The optimal coinduction anesthesia technique for patients with left ventricular (LV) failure is etomidate (0.2 mg/kg) combined with fentanyl (10 μg/kg) to maintain hemodynamic stability while minimizing myocardial depression. 1

Pathophysiological Considerations in LV Failure

• Patients with LV failure have reduced cardiac compliance, making ventricular filling highly dependent on preload and atrial contraction 2
• Tachycardia should be avoided as it shortens diastolic filling time, resulting in inadequate LV filling and decreased cardiac output 2
• Systemic hypotension can reduce diastolic blood pressure and coronary blood flow, potentially causing myocardial ischemia 2
• Patients with LV failure are at increased risk for perioperative low cardiac output syndrome (LCOS), requiring careful selection of induction agents 2

Recommended Coinduction Technique

First-Line Approach

• Etomidate (0.2 mg/kg) combined with fentanyl (10 μg/kg) provides superior hemodynamic stability in patients with LV dysfunction 1, 3
• Administer fentanyl first, followed by etomidate over 60-90 seconds to minimize hemodynamic fluctuations 4
• Add a short-acting non-depolarizing neuromuscular blocking agent prior to intubation 2

Hemodynamic Benefits

• Etomidate preserves cardiovascular stability with minimal effects on contractility, preload, and afterload 3
• Fentanyl blunts sympathetic response to laryngoscopy and intubation 1
• This combination minimizes the decrease in cardiac index compared to other induction agents 4

Alternative Approaches

For Patients with Specific Contraindications to Etomidate

• Midazolam (0.15 mg/kg) with fentanyl (10 μg/kg) may be considered as it effectively prevents intubation stress response 4
• Propofol in reduced doses (1 mg/kg) combined with fentanyl can be used if carefully titrated, though it causes more significant decreases in systemic vascular resistance 5

Perioperative Management Considerations

• Maintain sinus rhythm and control ventricular rate to optimize LV filling 2
• Titrate intravascular volume carefully to ensure adequate forward cardiac output without excessive rise in left atrial pressure 2
• Use invasive hemodynamic monitoring (arterial line, central venous pressure) and consider intraoperative TEE to guide management 2
• For blood pressure management, phenylephrine or norepinephrine are preferred vasopressors in patients with LV failure 2
• Treat systemic hypertension with arterial dilators (short-acting calcium channel blockers) rather than preload-reducing agents like nitroglycerin 2

Potential Pitfalls and Caveats

• Avoid rapid hemodynamic changes during induction as patients with LV failure have limited compensatory mechanisms 2
• Standard doses of propofol (1.5-2 mg/kg) can cause significant decreases in cardiac index (30-40%) and should be avoided or significantly reduced 4
• Ketamine alone may increase myocardial oxygen demand through sympathetic stimulation and should be used cautiously 3
• Thiopentone causes more significant myocardial depression than etomidate and is not recommended as first-line in LV failure 4
• Consider pre-induction optimization with positive inotropes in patients with severe LV dysfunction and signs of LCOS 2

Post-Induction Maintenance

• Volatile anesthetic agents may be considered for maintenance of anesthesia, but should be carefully titrated 2
• For patients with severe LV dysfunction, consider levosimendan to reduce the risk of perioperative LCOS, especially in those undergoing CABG 2
• Maintain adequate preload while avoiding volume overload, which can precipitate acute pulmonary edema 2