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Effect of Phenylephrine and Ephedrine on Cerebral (Tissue) Oxygen Saturation During Carotid Endarterectomy (PEPPER): A Randomized Controlled Trial.

Abstract

BACKGROUND

Short-acting vasopressor agents like phenylephrine or ephedrine can be used during carotid endarterectomy (CEA) to achieve adequate blood pressure (BP) to prevent periprocedural stroke by preserving the cerebral perfusion. Previous studies in healthy subjects showed that these vasopressors also affected the frontal lobe cerebral tissue oxygenation (rSO2) with a decrease after administration of phenylephrine. This decrease is unwarranted in patients with jeopardized cerebral perfusion, like CEA patients. The study aimed to evaluate the impact of both phenylephrine and ephedrine on the rSO2 during CEA.

METHODS

In this double-blinded randomized controlled trial, 29 patients with symptomatic carotid artery stenosis underwent CEA under volatile general anesthesia in a tertiary referral medical center. Patients were preoperative allocated randomly (1:1) for receiving either phenylephrine (50 µg; n = 14) or ephedrine (5 mg; n = 15) in case intraoperative hypotension occurred, defined as a decreased mean arterial pressure (MAP) ≥ 20% compared to (awake) baseline. Intraoperative MAP was measured by an intra-arterial cannula placed in the radial artery. After administration, the MAP, cardiac output (CO), heart rate (HR), stroke volume, and rSO2 both ipsilateral and contralateral were measured. The timeframe for data analysis was 120 s before, until 600 s after administration.

RESULTS

Both phenylephrine (70 ± 9 to 101 ± 22 mmHg; p < 0.001; mean ± SD) and ephedrine (75 ± 11 mmHg to 122 ± 22 mmHg; p < 0.001) adequately restored MAP. After administration, HR did not change significantly over time, and CO increased 19% for both phenylephrine and ephedrine. rSO2 ipsilateral and contralateral did not change significantly after administration at 300 and 600 s for either phenylephrine or ephedrine (phenylephrine 73%, 73%, 73% and 73%, 73%, 74%; ephedrine 72%, 73%, 73% and 75%, 74%, 74%).

CONCLUSIONS

Within this randomized prospective study, MAP correction by either phenylephrine or ephedrine showed to be equally effective in maintaining rSO2 in patients who underwent CEA. Clinical Trial Registration ClincalTrials.gov, NCT01451294.

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  • Authors+Show Affiliations

    ,

    Department of Vascular Surgery G04.129, University Medical Center Utrecht, University of Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands. l.m.m.fassaert@umcutrecht.nl.

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    Department of Vascular Surgery G04.129, University Medical Center Utrecht, University of Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.

    ,

    Department of Vascular Surgery G04.129, University Medical Center Utrecht, University of Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.

    ,

    Department of Vascular Surgery G04.129, University Medical Center Utrecht, University of Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.

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    Department of Vascular Surgery G04.129, University Medical Center Utrecht, University of Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.

    ,

    Department of Anesthesiology, University Medical Center Utrecht, Utrecht, The Netherlands.

    Department of Medical Biology, Laboratory for Clinical Cardiovascular Physiology, Amsterdam University Medical Center, Amsterdam, The Netherlands. Department of Anesthesiology, Amsterdam University Medical Center, Amsterdam, The Netherlands.

    Source

    Neurocritical care : 2019 Jun 12 pg

    Pub Type(s)

    Journal Article

    Language

    eng

    PubMed ID

    31190322

    Citation

    Fassaert, Leonie M M., et al. "Effect of Phenylephrine and Ephedrine On Cerebral (Tissue) Oxygen Saturation During Carotid Endarterectomy (PEPPER): a Randomized Controlled Trial." Neurocritical Care, 2019.
    Fassaert LMM, de Borst GJ, Pennekamp CWA, et al. Effect of Phenylephrine and Ephedrine on Cerebral (Tissue) Oxygen Saturation During Carotid Endarterectomy (PEPPER): A Randomized Controlled Trial. Neurocrit Care. 2019.
    Fassaert, L. M. M., de Borst, G. J., Pennekamp, C. W. A., Specken-Welleweerd, J. C., Moll, F. L., van Klei, W. A., & Immink, R. V. (2019). Effect of Phenylephrine and Ephedrine on Cerebral (Tissue) Oxygen Saturation During Carotid Endarterectomy (PEPPER): A Randomized Controlled Trial. Neurocritical Care, doi:10.1007/s12028-019-00749-w.
    Fassaert LMM, et al. Effect of Phenylephrine and Ephedrine On Cerebral (Tissue) Oxygen Saturation During Carotid Endarterectomy (PEPPER): a Randomized Controlled Trial. Neurocrit Care. 2019 Jun 12; PubMed PMID: 31190322.
    * Article titles in AMA citation format should be in sentence-case
    TY - JOUR T1 - Effect of Phenylephrine and Ephedrine on Cerebral (Tissue) Oxygen Saturation During Carotid Endarterectomy (PEPPER): A Randomized Controlled Trial. AU - Fassaert,Leonie M M, AU - de Borst,Gert J, AU - Pennekamp,Claire W A, AU - Specken-Welleweerd,Jantine C, AU - Moll,Frans L, AU - van Klei,Wilton A, AU - Immink,Rogier V, Y1 - 2019/06/12/ PY - 2019/6/14/entrez PY - 2019/6/14/pubmed PY - 2019/6/14/medline KW - Carotid endarterectomy KW - Cerebral KW - Cerebral autoregulation KW - Oxygen KW - Vasopressors JF - Neurocritical care JO - Neurocrit Care N2 - BACKGROUND: Short-acting vasopressor agents like phenylephrine or ephedrine can be used during carotid endarterectomy (CEA) to achieve adequate blood pressure (BP) to prevent periprocedural stroke by preserving the cerebral perfusion. Previous studies in healthy subjects showed that these vasopressors also affected the frontal lobe cerebral tissue oxygenation (rSO2) with a decrease after administration of phenylephrine. This decrease is unwarranted in patients with jeopardized cerebral perfusion, like CEA patients. The study aimed to evaluate the impact of both phenylephrine and ephedrine on the rSO2 during CEA. METHODS: In this double-blinded randomized controlled trial, 29 patients with symptomatic carotid artery stenosis underwent CEA under volatile general anesthesia in a tertiary referral medical center. Patients were preoperative allocated randomly (1:1) for receiving either phenylephrine (50 µg; n = 14) or ephedrine (5 mg; n = 15) in case intraoperative hypotension occurred, defined as a decreased mean arterial pressure (MAP) ≥ 20% compared to (awake) baseline. Intraoperative MAP was measured by an intra-arterial cannula placed in the radial artery. After administration, the MAP, cardiac output (CO), heart rate (HR), stroke volume, and rSO2 both ipsilateral and contralateral were measured. The timeframe for data analysis was 120 s before, until 600 s after administration. RESULTS: Both phenylephrine (70 ± 9 to 101 ± 22 mmHg; p < 0.001; mean ± SD) and ephedrine (75 ± 11 mmHg to 122 ± 22 mmHg; p < 0.001) adequately restored MAP. After administration, HR did not change significantly over time, and CO increased 19% for both phenylephrine and ephedrine. rSO2 ipsilateral and contralateral did not change significantly after administration at 300 and 600 s for either phenylephrine or ephedrine (phenylephrine 73%, 73%, 73% and 73%, 73%, 74%; ephedrine 72%, 73%, 73% and 75%, 74%, 74%). CONCLUSIONS: Within this randomized prospective study, MAP correction by either phenylephrine or ephedrine showed to be equally effective in maintaining rSO2 in patients who underwent CEA. Clinical Trial Registration ClincalTrials.gov, NCT01451294. SN - 1556-0961 UR - https://www.unboundmedicine.com/medline/citation/31190322/Effect_of_Phenylephrine_and_Ephedrine_on_Cerebral_(Tissue)_Oxygen_Saturation_During_Carotid_Endarterectomy_(PEPPER):_A_Randomized_Controlled_Trial L2 - https://dx.doi.org/10.1007/s12028-019-00749-w DB - PRIME DP - Unbound Medicine ER -