Cardiogenic Shock - Diagnosis and Treatment

Chapter 7 / Operative Strategies for Cardiogenic Shock 81
muscle relaxant to be delivered is made in advance. After a patient is preoxygenated for
3–5 min with pure oxygen, the anesthetic agent and the muscle relaxant are delivered in
rapid sequence while cricoid pressure is applied. In the classic rapid-sequence induc-
tion, thiopental and succinylcholine are used. In some modifications of this technique,
other anesthetic agents like propofol, etomidate, or ketamine in conjunction with suc-
cinylcholine or a high dose of nondepolarizing muscle relaxants are delivered (19,20).
The drawback is that an overdose of medication before intubation can lead to cardiovas-
cular collapse, whereas an underdose can cause tachycardia, a temporary rise in blood
pressure, worsening of ischemia, and then cardiovascular collapse.
Awake intubation with topical anesthesia or upper airway block in experienced
hands can be used as an alternative approach in a patient with full stomach. However,
this is a stressful procedure that can worsen the ischemia. In addition, a patient with
cardiogenic shock who is not fully alert may become combative, which can make the
airway management more difficult.
Another method to consider is the titration approach, which entails delivering the
anesthetic medication in small doses until the desired effect is achieved. Yet this
approach cannot always ensure cardiovascular stability and may expose the patient to
the risk of aspiration (18).
With whatever approach and whatever combination of anesthetic agents the anesthe-
siologist chooses, there will always be the risk that the patient will experience cardio-
vascular collapse during intubation. To be prepared for this complication, drugs for
inotropic support should be ready for use in advance, an experienced cardiac surgeon
should be present during induction of anesthesia, and the team should be ready for
emergency sternotomy and connection to CPB.
Anesthetic Medication Choices
OPIOIDS
Morphine as a sole anesthetic agent for cardiac surgery was first introduced in the late
1960s and was popular in the 1970s. The need for prolonged mechanical ventilation after
the surgery, cases of inadequate anesthesia (even with extremely high doses of 8–11
mg/kg), and the tendency for histamine release and hypotension led to the development
of a new generation of opioids like fentanyl, sufentanil, remifentanil, and alfentanil (21).
All of these agents were successfully tested as the sole anesthetic for cardiac surgery
(22,23). Using an opioid as the sole anesthetic agent is advantageous because of the
remarkable hemodynamic stability that occurs during the induction and maintenance of
anesthesia. However, there have been occasional reports of awareness during surgery and
the need for prolonged mechanical ventilation, as compared with anesthesia based on
opioids in conjunction with nonopioid agents and volatile anesthetics (22–26).
NONOPIOID AGENTS
Many different nonopioids and inhalational agents were successfully investigated
and are now used as supplements for opioids for induction and maintenance during
CABG. It is beyond the scope of this chapter to describe all of them. The most com-
mon nonopioid agents, volatile anesthetics, and their cardiovascular effects are summa-
rized in Table 1.
There are no prospective or retrospective reports in the literature that compare dif-
ferent anesthetic medications for intubating patients in cardiogenic shock and there are
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