Certain anesthetic agents can have significant effects on the cardiovascular system, causing changes in heart rate, blood pressure, and cardiac output. For patients with cardiovascular disease or other conditions that make them sensitive to hemodynamic fluctuations, choosing anesthetics with the least hemodynamic effects is essential for reducing the risk of complications.
Hemodynamic effects refer to changes in the circulatory system, particularly those related to heart function and blood flow. Anesthetic agents can cause a variety of hemodynamic changes, including hypotension, bradycardia, or tachycardia 1–3. These effects can be dangerous for patients with compromised cardiovascular function, such as those with coronary artery disease, heart failure, or severe hypertension. For these patients, anesthetics that have the least hemodynamic effects are preferred to reduce the risk of perioperative cardiovascular events, including heart attack and stroke.
Several anesthetic agents are known for their minimal effects on the cardiovascular system, making them ideal for use in high-risk patients. These agents include certain intravenous and inhaled anesthetics as well as local anesthetics used for regional blocks.
Dexmedetomidine is a sedative and anesthetic agent that has gained popularity due to its ability to provide sedation and pain relief with minimal hemodynamic effects. It acts as an alpha-2 adrenergic agonist, leading to a reduction in sympathetic nervous system activity, which can help prevent significant fluctuations in heart rate and blood pressure. Unlike other sedatives, such as propofol, dexmedetomidine tends to cause only mild hypotension and bradycardia without suppressing respiratory function, making it an excellent choice for patients with cardiovascular risk factors 4.
Etomidate is an intravenous anesthetic agent commonly used for induction in patients with hemodynamic instability. It is known for its ability to induce anesthesia rapidly without causing significant changes in heart rate, blood pressure, or cardiac output. Unlike other induction agents like propofol or thiopental, which can cause hypotension, etomidate maintains cardiovascular stability, making it especially useful in patients with heart failure or shock 5.
Midazolam, a benzodiazepine, is another agent with minimal hemodynamic effects. It is often used for preoperative sedation and as an adjunct in anesthesia protocols. While midazolam can cause mild hypotension in some cases, it generally has a favorable cardiovascular profile compared to other sedatives and is often used in patients with cardiovascular concerns. It is commonly administered alongside other agents for balanced anesthesia 6.
Sevoflurane is a widely used inhaled anesthetic with a relatively low impact on the cardiovascular system compared to other volatile anesthetics. It causes less myocardial depression and minimal vasodilation, leading to more stable blood pressure and heart rate during anesthesia. Sevoflurane is particularly useful for maintaining anesthesia in patients who require careful management of their cardiovascular status 7.
Local anesthetics used for regional anesthesia, such as bupivacaine and ropivacaine, have minimal systemic hemodynamic effects when used in appropriate doses 8,9.
For patients with cardiovascular concerns or those at risk of hemodynamic instability, selecting anesthetics with the least effects on blood pressure, heart rate, and cardiac output is essential for ensuring a safe surgical experience.
References
1. Barker, S. J., Gamel, D. M. & Tremper, K. K. Cardiovascular effects of anesthesia and operation. Critical Care Clinics (1987). doi:10.1016/s0749-0704(18)30545-1
2. Ebert, T. J. Sympathetic and hemodynamic effects of moderate and deep sedation with propofol in humans. Anesthesiology (2005). doi:10.1097/00000542-200507000-00007
3. Hemodynamic management during anesthesia in adults – UpToDate. Available at: https://www.uptodate.com/contents/hemodynamic-management-during-anesthesia-in-adults.
4. Dexmedetomidine – StatPearls – NCBI Bookshelf. Available at: https://www.ncbi.nlm.nih.gov/books/NBK513303/.
5. Etomidate – StatPearls – NCBI Bookshelf. Available at: https://www.ncbi.nlm.nih.gov/books/NBK535364/.
6. Midazolam – StatPearls – NCBI Bookshelf. Available at: https://www.ncbi.nlm.nih.gov/books/NBK537321/.
7. Sevoflurane – StatPearls – NCBI Bookshelf. Available at: https://www.ncbi.nlm.nih.gov/books/NBK534781/.
8. Rutten, A. J. et al. Hemodynamic and central nervous system effects of intravenous bolus doses of lidocaine, bupivacaine, and ropivacaine in sheep. Anesth. Analg. (1989). doi:10.1213/00000539-198909000-00004
9. Hashemian, M. et al. Comparison of Ropivacaine versus Bupivacaine in Spinal-Induced Hypotension in Preeclampsia Patients: A Randomized Control Trial. Anesthesiol. Pain Med. 14, (2024). doi: 10.5812/aapm-142646