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Year : 2008  |  Volume : 52  |  Issue : 6  |  Page : 805 Table of Contents     

Comparison of Haemodynamic and Cardiovascular Effects of VIMA with Sevoflurane Versus TIVA with Propofol in Patients Undergoing Coronary Artery Bypass Surgery

1 Associate professor, Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh - 160012, India
2 Ex-Professor & Head, Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh - 160012, India
3 Professor & Head, Department of Cardiovascular & Thoracic Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh - 160012, India

Date of Acceptance09-Nov-2008
Date of Web Publication19-Mar-2010

Correspondence Address:
Neerja Bharti
Department of Anaesthesia and Intensive Care, PGIMER, Chandigarh-160012
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Source of Support: None, Conflict of Interest: None

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Sevoflurane provides protection against myocardial ischaemia during bypass surgery. This prospective, random­ized study was conducted to compare the haemodynamic and cardiovascular effects of sevoflurane induction& maintenance of anaesthesia(VIMA) with a standard total intravenous technique using propofol(TIVA) during coro­nary artery bypass graft (CABG) surgery.
Thirty adult patients undergoing elective CABG surgery were randomly allocated to receive either sevoflurane (S group) or propofol (P group) for induction and maintenance of anaesthesia. In both groups, analgesia was supple­mented with fentanyl and muscle relaxation with vecuronium. Patients' heart rate, systemic and pulmonary pressures, cardiac index and mixed venous oxygen saturation were measured at following time intervals: pre-induction, post­induction, post-intubation, skin incision, post sternotomy, chest closure, and 1 hr after surgery, at spontaneous respira­tion and post extubation. The type and duration of inotropic support, duration of postoperative ventilation and ICU stay, perioperative complications and outcome were assessed.
Patients' characteristics and demographic data were similar for both groups. Induction of anaesthesia was rapid and smooth in all patients. Compared to sevoflurane group more patients in the propofol group required nitroglycerine(NTG) to control blood pressure during prebypass period. Patients receiving sevoflurane had higher cardiac index (P<0.05) and required less inotropic support during post-operative period as compared to propofol treated patients. Duration of postoperative ventilation and ICU stay was similar in both groups. The incidence of postoperative complications and outcome were comparable between groups.
In conclusion, sevoflurane provided better perioperative haemodynamic control and cardiovascular profile than propofol during elective CABG surgery.

Keywords: Cardiac anaesthesia, Sevoflurane, Propofol, CABG surgery, VIMA, TIVA

How to cite this article:
Bharti N, Chari P, Thingnam SK, Arora S. Comparison of Haemodynamic and Cardiovascular Effects of VIMA with Sevoflurane Versus TIVA with Propofol in Patients Undergoing Coronary Artery Bypass Surgery. Indian J Anaesth 2008;52:805

How to cite this URL:
Bharti N, Chari P, Thingnam SK, Arora S. Comparison of Haemodynamic and Cardiovascular Effects of VIMA with Sevoflurane Versus TIVA with Propofol in Patients Undergoing Coronary Artery Bypass Surgery. Indian J Anaesth [serial online] 2008 [cited 2021 Apr 17];52:805. Available from: https://www.ijaweb.org/text.asp?2008/52/6/805/60692

   Introduction Top

The perioperative period imposes physiological burdens on the heart by surgery and anaesthesia for patients with coronary artery disease (CAD), leading to serious complications, like, acute myocardial infarc­tion (AMI) and death [1] . Not only the adequacy of sur­gical revascularisation but also the choice of anaesthetic regimen influences postoperative myocardial function and outcome in coronary bypass surgery patients [2] . Al­though intravenous induction of anaesthesia is gener­ally favored because of its speed and smoothness, cur­rent cardiac anaesthesia practice devotes considerable attention to preserve myocardial function and avoid­ance of myocardial ischaemia. Volatile anaesthetics have been shown to exert protection against myocardial is­chaemia and reperfusion injury during coronary artery bypass graft(CABG) surgery [2],[3] . Therefore, volatile induction and maintenance of anaesthesia (VIMA) is gaining popularity in cardiac anaesthesia especially with the introduction of low-solubility and non- irritating volatile agents.

Sevoflurane is a non-pungent, non-irritating vola­tile agent with low blood gas partition coefficient. These properties enable sevoflurane to provide rapid and smooth induction like intravenous agents with minimal induction complications [4], [5] . When used in high concen­trations for rapid inhalational induction of anaesthesia in adults, it is well accepted by majority of patients [4] . Several studies have shown that sevoflurane exerts cardio protective effects against myocardial ischaemia and reperfusion injury during CABG surgery [6][7][8][9][10][11] . How­ever, only few studies have compared the efficacy of sevoflurane induction and maintenance of anaesthesia with total intravenous anaesthesia (using either high doses of opioids [12] , midazolam [13] or etomidate [14],[15] in cardiac surgery. Two of them [13],[14] have reported higher incidence (>50%) of bradycardia during induction of anaesthesia with sevoflurane in cardiac patients.

The aim of this study was to compare the haemodynamic effects and cardiovascular profile of volatile induction and maintenance of anaesthesia with sevoflurane versus total intravenous anaesthesia (TIVA) with propofol in patients undergoing CABG surgery.

   Methods Top

After obtaining ethical committee approval, 30 adult patients of ASA grade I-III, scheduled for elective CABG surgery were included in the study. Patients were exam­ined for their cardiac and respiratory functions and as­sociated medical illnesses. All the necessary investiga­tions including complete haemogram, blood sugar, se­rum electrolytes, renal function test, pulmonary function test, x-ray chest, liver function test, coagulation profile, ECG, echocardiography and angiography were per­formed before surgery. Patients with severely impaired left ventricular function (EF <30%, LVEDP >18), renal or liver impairment, recent myocardial infarction (<6 weeks), associated valvular lesion or heart block, gross obesity (BMI >30%) and anticipated difficult intubation were excluded. Patients undergoing repeat coronary surgery, concurrent valve repair, or aneurysmal resec­tion were also excluded. An informed consent was taken after explaining the procedure to the patients. All pa­tients received a standard pre-medication consisting of 5 mg diazepam orally at night and 2 hour before surgery. Patient's usual cardiac medications were continued until the morning of surgery. Morphine sulphate 0.15 mg.kg -1 and promethazine 0.5 mg.kg -1 were administered intra­muscularly one hour before surgery.

In the operating room, all patients received 5 ml.kg -1 normal saline before induction. Standard basic anaesthesia monitors including ECG of lead II and V 5 with continuous ST-segment analysis, pulse oximeter& non invasive blood pressure were connected to the pa­tient. A 20-G radial artery cannula, a double lumen central venous catheter and thermo-dilution pulmonary artery catheter were placed under local anaesthesia and supple­mental intravenous (IV) sedation with 0.02 mg.kg -1 midazolam. Fentanyl (2 µg.kg -1 ) was injected five min before induction. Patients were randomly divided into two groups using a sealed envelope technique. In VIMA group (Group S), anaesthesia was induced using the vital capacity rapid inhalational induction (VCRII) tech­nique with 5% sevoflurane in oxygen via a closed ana­esthesia circuit. In this technique the patients were in­structed to breathe out to residual volume. The face­mask connecting to a close circuit delivering 100% oxygen with sevoflurane was then applied, and the pa­tients were instructed to breathe in deeply and to hold their breath for as long as it was comfortable. They were then asked to take deep breaths until loss of con­sciousness i.e. absence of response to verbal command and the absence of eyelash reflex. In TIVA group (Group P), anaesthesia was induced with propofol 1.0­1.5 mg.kg -1 IV while the patients were breathing 100% oxygen. In both groups following loss of conscious­ness, the patient's lungs were manually ventilated and a bolus of vecuronium bromide 0.1 mg.kg -1 was given IV to facilitate orotracheal intubation. After intubation con­trolled ventilation was established with 100% oxygen via closed circuit at 10-12 breaths/ min and a tidal vol­ume of 8-10 ml.kg -1 aiming at normocapnia.

Anaesthesia was maintained with sevoflurane 0.5­2 MAC (Group S) or propofol infusion 40-150 µg.kg­1 .hr -1 (Group P) and was adjusted to maintain the bispectral index (BIS) between 40 and 60. Both groups received a continuous infusion of fentanyl at a rate of 0.5 µg.kg -1 .hr -1 until closure of the chest. In ad­dition a bolus of fentanyl (0.5 µg.kg -1 IV) was adminis­tered before skin incision and sternotomy. Neuromus­cular block was maintained with intermittent boluses of vecuronium 0.02 mg.kg -1 . If anaesthetic adjustments failed in maintaining haemodynamic values within 20% of baseline, the following drugs were administered: phe­nylephrine and dopamine for hypotension, nitroglycer­ine (NTG) and/or sodium nitroprusside (SNP) for hy­pertension, atropine for bradycardia and esmolol for tachycardia. When cardiac index was below 2.5 l.min­1 .m -2 , dobutamine was initiated. Intravenous nitroglyc­erine was administered if myocardial ischaemia was de­tected by ST-segment analysis. During cardiopulmo­nary bypass, in the S group, 2% sevoflurane was ad­ministered by connecting the vaporizer to the fresh gas flow canalization proximal to the oxygenator.

Standard median sternotomy and pericardiotomy were performed. After administration of 300 U.kg -1 he­parin, the aortic cannula was secured in place. Car­diopulmonary bypass (CPB) was performed with a membrane oxygenator and moderate hypothermia (28­30 0 C). Activated coagulation time was kept above 450 seconds throughout the CPB. After removal of aortic cannula heparin activity was neutralized with protamine at a ratio of 1 mg protamine/100 U heparin. After completion of surgery, the patients were transferred to the intensive care unit (ICU). Postoperative analgesia was managed with fentanyl 0.5-1.0 µg.kg -1 IV as re­quired. Haemodynamic and respiratory variables were monitored continuously. Patients were weaned from mechanical ventilation when they were haemodynamically stable, completely rewarmed and responding to verbal stimuli.

   Data collection Top

The time from initiation of induction to loss of con­sciousness was recorded. Any behavioural or airway incidents like excitation, movement, cough, laryngospasm, etc were noted. Haemodynamic measurements includ­ing heart rate (HR), mean arterial pressure (MAP), cen­tral venous pressures (CVP), pulmonary artery pressure (PAP), pulmonary capillary wedge pressures (PCWP) and cardiac index (CI) were recorded at pre-induction, post-induction, post-intubation, 5 min post-intubation, at skin incision, at sternotomy, at beginning of chest clo­sure, 1 hr after arrival in ICU, on spontaneous breathing (before extubation) and 1 hr after extubation. At the same time, arterial and mixed venous blood gas analysis was also done. ECG and ST-segment changes, oxygen satu­ration, end-tidal carbon di-oxide concentration, inspired and expired concentration of volatile agent and nasopha­ryngeal temperature were monitored continuously. The type and duration of inotropic support needed, time to extubation, length of stay in ICU and major adverse events like myocardial ischaemia, ventricular failure and death were recorded.

   Statistical analysis Top

Sample size was calculated on the basis of 50% reduction in the incidence of bradycardia based on the previous study for a power of 0.8 and cc = 0.05. Data were analyzed using student's t-test and chi-square test. One way analysis of variance with post hoc analysis was used for continuous variables such as heart rate, systemic and pulmonary pressures. P value of <0.05 was considered as significant.

   Results Top

The groups were demographically similar with no differences in terms of age, weight, height, body sur­face area, sex ratio, ASA physical status and New York Heart Association (NYHA) grading [Table 1]. Distribution of patients was comparable with regard to the number of vessels involved, left ventricular ejection frac­tion, associated medical illness and preoperative car­diac medications [Table 2].

All the patients were rapidly unresponsive to stimu­lation within one minute of beginning the induction (Gp P: 38±9 s vs Gp S: 46±11 s, P=NS) and remained free of excitation, movement or airway related incident. Mean baseline blood pressure was numerically higher in P group than in S group although not statistically significant. The remaining baseline values were similar [Table 3]. After induction, there was a significant decrease in heart rate, mean arterial pressure and cardiac index compared to base line values in both groups. During the same pe­riod there was an increase in mixed venous oxygen satu­ration (SvO 2 ). Thereafter, these variables remained stable following tracheal intubation, skin incision, ster­notomy and prior to onset of CPB.

Following CPB, heart rate increased significantly (P<0.001, compared to base line) in both groups. There was a reduction in MAP values during post bypass pe­riod in propofol group but not in sevoflurane group. MPAP and CVP were kept stable throughout in both groups. The values of HR, MAP, CVP and MPAP pressure were comparable between the groups through­out the data collection [Table 3]. The post bypass val­ues of cardiac index were significantly (P< 0.05) higher in sevoflurane group than propofol group. However, the SvO 2 remained lower than the preoperative values secondary to an increase in oxygen consumption and extraction.

There were no significant inter-group differences with regard to the duration of surgery, cardiopulmo­nary bypass and aortic cross clamp times and number of vessels grafted [Table 4]. The incidence of hypoten­sion (Gp P: 39% vs Gp S: 26%, P=NS) and brady­cardia (Gp P: 13% vs Gp S: 19%, P=NS) was com­parable between the groups. No patient presented ta­chycardia or ischemic changes during induction and tra­cheal intubation. Hypertension was observed more frequently in P group than in the S group (Gp P: 69% vs Gp S: 26%, P<0.05) during sternotomy. The use of vasoactive drugs was similar during induction. How­ever, during prebypass period, more patients in Propofol group than Sevoflurane group required phar­macological intervention (NTG) to control blood pres­sure [Table 4]. The duration of postoperative ventila­tion and ICU stay was comparable between the groups. The incidence of atrial fibrillation and need for pacing after bypass did not differ between the groups. The intra-aortic balloon pump was never needed. The du­ration of post-CPB inotropic support was significantly (P<0.05) longer in Propofol group than Sevoflurane group. The requirement of vasopressor therapy was also higher in Propofol group during postoperative pe­riod [Table 4].

The postoperative complications were compa­rable among both groups [Table 5]. Two patients in Sevoflurane group and one in Propofol group presented excessive postoperative bleeding and needed re-ex­ploration surgery. No cerebrovascular insult occurred in any group of patients, and none of the patient re­quired postoperative haemofiltration or dialysis. One patient in propofol group developed congestive car­diac failure and expired.

   Discussion Top

The results of present study indicate that volatile induction and maintenance of anaesthesia with Sevoflurane provided better haemodynamic control than total intravenous technique with propofol during perioperative period in patients undergoing CABG sur­gery. With vital capacity rapid inhalational technique the induction of anaesthesia was rapid, smooth and well tolerated by all the patients in Sevoflurane group. No episode of coughing, laryngospasm or excitation was observed. A vital capacity breath technique is reported to be both faster& safer than commonly used tidal breath technique [5] . VCRII technique requires lower concentration of volatile agent with less haemodynamic effects as compared to the conventional technique [16] . Djaiani et al [15] demonstrated that vital capacity inhala­tional induction with 8% sevoflurane produces rapid onset of anaesthesia and a good haemodynamic profile like etomidate. Vidal et al [17] found that the time to in­duction of sevoflurane anaesthesia was significantly shorter with vital capacity technique as compared to tidal volume breathing technique in patients undergoing CABG surgery.

In present study, there was a comparable reduc­tion in HR, MAP, CVP, PAP and CI during induction period in both groups. Although, heart rate values were in the lower range (45-65 bpm), only 3/15 patients in Sevoflurane group and 2/15 patients in Propofol group required atropine. Few studies [13],[14] have reported higher incidence of bradycardia with sevoflurane induction in cardiac patients, which may be related to the high pre­operative doses of beta-blockers and combined use of remifentanil/sufentanil, midazolam and cis-atracurium in these studies. The mean value of post-intubation MAP was in clinically acceptable limits and the variance in pre-induction and post-intubation MAP was not sta­tistically significant between the groups. The incidents of hypotension were transient and non consequential. They were easily managed with adjustments of anaes­thetic agents and, if required, intravenous fluids and/or vasopressors. There was no hypertension or tachycar­dia during induction in either group. This may be re­lated to the combined effect of premedication and se­dation prior to invasive monitoring. During pre-CPB period significantly more patients in Propofol group re­quired NTG to control blood pressure than Sevoflurane group despite adequate level of anaesthesia. This is consistent with previous report which showed that in­traoperative control of blood pressure was better main­tained with sevoflurane than propofol during CABG surgery [8] . Gravel et al [13] also demonstrated higher inci­dence of pre CPB hypertension with propofol than sevoflurane in patients undergoing CABG surgery.

The patients who were anaesthetised with sevoflurane had preserved cardiovascular function af­ter weaning from CPB, and needed less inotropic sup­port than the patients anaesthetised with propofol. The post-CPB CI values were also significantly higher in Sevoflurane group than the Propofol group. Many fac­tors are known to determine the effectiveness of myo­cardium and left ventricular function after CABG sur­gery. Among these, patient characteristics (age, extent of coronary artery disease and degree of left ventricu­lar dysfunction etc) and surgery related events like num­ber and quality of grafts, type of cardioprotection, du­ration of aortic cross-clamp and CPB are the most commonly related with postoperative ventricular func­tion. Patient characteristics and surgical events were similar in both groups in our study. This suggests that the differences in cardiac function between both groups are not caused by patients characteristics and intraop­erative events but instead seems to be related to the choice of anaesthetic agent. However, opioids were shown to mimic the cardioprotective effect of ischaemic preconditioning [18] . The dosages of fentanyl were simi­lar in both groups in the present study, suggesting that the observed differences in cardiac function between groups might not be related to fentanyl.

Although, underlying mechanisms responsible for the difference in postoperative cardiac function can not be elucidated from present study, previous observa­tions indicated that sevoflurane exerts protective effects against myocardial ischaemia and reperfusion injury during coronary bypass surgery which improves the post-CPB contractility of myocardium [3],[7],[8],[10] . The re­duction of myocardial stunning by sevoflurane might also contribute to the cardio protective effects of sevoflurane on ischemic myocardium [7] . Sevoflurane was shown to reduce the ischaemia induced metabolic changes in myocardium associated with decreased systemic haemodynamic parameters. Sevoflurane precondition­ing significantly decreases the postoperative release of brain natriuretric peptide, a sensitive marker of myo­cardial contractile dysfunction in patients undergoing CABG surgery [10] . De Hert et al [11] demonstrated that sevoflurane but not propofol preserve cardiac function after CPB. They observed a higher cardiac output after coronary bypass surgery in patients who were an­aesthetized with sevoflurane as compared to propofol treated patients. Nader et al [6] found that sevoflurane decreases the inflammatory response and improves myocardial function after CPB, as assessed by RWMA and LVSWI. Sevoflurane-mediated reduction in car­diac troponin was associated with improved long-term outcomes in one study [9] .

In a large clinical trial, Parker et al [19] demonstrated significantly shorter time to tracheal extubation with sevoflurane anaesthesia as compared to target control propofol anaesthesia in patients undergoing CABG surgery. However, there was no difference in duration of ICU stay between the groups [19] . The duration of post operative ventilation and ICU stay was not statistically different among groups in present study.

Despite the differences in early postoperative car­diac function, the postoperative complications and out­come variables did not differ between the groups. The incidence of myocardial ischaemia was 13% in sevoflurane group which is comparable to other stud­ies [10],[20]. As the incidence of postoperative cardiac events was low in both groups, we would have required more patients to show a difference in the outcome.

In conclusion, vital capacity rapid inhalational in­duction with sevoflurane offers a smooth and safe tech­nique, and may be an alternative for induction of ana­esthesia in patients with known CAD. Sevoflurane supplemented with low-dose fentanyl has no deleteri­ous haemodynamic effects when used as main induc­tion and maintenance agent in patients undergoing CABG surgery. Compared with total intravenous tech­nique, the sevoflurane based volatile anaesthetic tech­nique offers better control of blood pressure during perioperative period and preserve cardiac function af­ter CPB. However, our results cannot be extended to the patients with severe left ventricular dysfunction or with valvular disease. Further studies are required to prove the efficacy of sevoflurane induction and mainte­nance of anaesthesia in patients with severely impaired left ventricular function (EF<30%).

   References Top

1.Kirklin JW, Naftel DC, Blackstone EH, Pohost GM. Sum­mary of a consensus concerning death and ischemic events after coronary artery bypass grafting. Circula­tion 1989; 79: 181-91.  Back to cited text no. 1      
2.Yu CH, Beattie WS. The effects of volatile anesthetics on cardiac ischemic complications and mortality in CABG: a meta-analysis. Can J Anesth 2006; 53: 906-18.  Back to cited text no. 2  [PUBMED]    
3.De Hert SG, Cromheecke S, ten Broecke PW, Els Mertens, De Blier IG, et al. Effects of propofol, desflurane and sevoflurane on recovery of myocardial function after coronary surgery in elderly high-risk patients. Anes­thesiology 2003; 99: 314-23.  Back to cited text no. 3      
4.Hall JE, Stewart IM, Harmer M. Single breath induction of sevoflurane anaesthesia with and without nitrous oxide: a feasibility study in adults and comparison with an intravenous bolus of propofol. Anaesthesia 1997; 52: 410-5.  Back to cited text no. 4      
5.Yurino M, Kimura H. A comparison of vital capacity breath and tidal breathing techniques for induction of anaesthesia with high sevoflurane concentrations in nitrous oxide and oxygen. Anaesthesia 1995; 50: 308-11.  Back to cited text no. 5  [PUBMED]    
6.Nader ND, Li CM, Khadra WZ, Reedy R, Panos AL. Anesthetic myocardial protection with sevoflurane. J Cardiothorac Vasc Anesth 2004; 18: 269-74.  Back to cited text no. 6  [PUBMED]  [FULLTEXT]  
7.Toller WG, Kersten JR, Pagel PS, Hettrick DA, Warltier DC. Sevoflurane reduces myocardial infarct size and decreases the time threshold for ischemic precondition­ing in dogs. Anesthesiology 1999; 91: 1437-46.  Back to cited text no. 7  [PUBMED]  [FULLTEXT]  
8.Samarkandi AH, Mansour AK. Induced precondition­ing of cardiac performance in coronary bypass surgery - sevoflurane vs propofol. Middle East J Anesthesiol 2004; 17: 833-44.  Back to cited text no. 8  [PUBMED]    
9.Gracia C, Julier K, Bestmann L, Zollinger A, Von Segesser LK et al. Preconditioning with sevoflurane decreases PECAM-1 expression and improves one-year cardio­vascular outcome in coronary artery bypass graft sur­gery. Br J Anaesth 2005; 94: 159-65.  Back to cited text no. 9      
10.Julier K, Da Silva R, Gracia C, Bestmann L, Frascarolo P et al. Preconditioning by sevoflurane decreases bio­chemical markers and renal dysfunction in coronary ar­tery bypass graft surgery: a double-blinded, placebo­controlled, multicenter study. Anesthesiology 2003; 98:1315-27.  Back to cited text no. 10      
11.De Heart S, ten Broecke PW, Els Mertens, Van Sommeren EW, De Blier IG. Sevoflurane but not propofol preserves myocardial function in coronary surgery patients. An­esthesiology 2002; 97: 42-9.  Back to cited text no. 11      
12.El Azab SR, Scheffer GJ, Rosseel PMJ, de Lange JJ. In­duction and maintenance of anaesthesia with sevoflurane in comparison to high dose opioid during coronary artery bypass surgery. Eur J Anaesthesiol 2000; 17: 336-8.  Back to cited text no. 12      
13.Gravel NR, Searle NR, Taillefer J, Carrier M, Roy M and Gagnon L. Comparison of the haemodynamic effects of sevoflurane anesthesia induction and maintenance vs TIVA in CABG surgery. Can J Anesth 1999; 46: 240-6.  Back to cited text no. 13      
14.Wang JYY, Winship SM, Thomas SD, Gin T, Russell GN. Induction of anaesthesia in patients with coronary ar­tery disease: a comparison between sevoflurane­remifentanil and fentanyl-etomidate. Anaesthesia Inten­sive Care 1999; 27: 363-8.  Back to cited text no. 14      
15.Djaiani GN, Hall J, Pugh S, Peaston RT. Vital capacity inhalation induction with sevoflurane: an alternative to standard intravenous induction for patients undergo­ing cardiac surgery. J Cardiothorac Vas Anesth 2001; 15: 169-74.  Back to cited text no. 15      
16.Yurino M, Kimura H. Efficient inspired concentration of sevoflurane for vital capacity rapid inhalational induc­tion (VCRII) technique. J Clin Anesth 1995; 7: 228-31.  Back to cited text no. 16  [PUBMED]  [FULLTEXT]  
17.Vidal MA, Calderon E, Martinez E, Pernia A, Torres LM. Comparison of 2 techniques of inhaled anesthetic in­duction with sevoflurane in coronary artery revascularization. Rev Esp Anesthesiol Reanim 2006; 53: 639-42.  Back to cited text no. 17      
18.Schultz JE, Hsu AK, and Gross GJ.Morphine mimics the cardioprotective effect of ischemic preconditioning via a glibenclamide-sensitive mechanism in the rat heart. Cir Res 1996: 78: 1100-4.  Back to cited text no. 18      
19.Parker FC, Story DA, Poustie S, Liu G, McNicol L. Time to tracheal extubation after coronary artery surgery with isoflurane, sevoflurane, or target-controlled propofol anesthesia: a prospective, randomized, controlled trial. J Cardiothorac Vasc Anesth 2004; 18: 613-9.  Back to cited text no. 19  [PUBMED]  [FULLTEXT]  
20.Searle NR, Martineau RJ, Conzen P, Al-Hasani A, Mark L, et al. Comparison of sevoflurane/fentanyl and isoflurane fentanyl during elective coronary artery by­pass surgery. Can J Anesth 1996; 43: 890-9.  Back to cited text no. 20  [PUBMED]    


  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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