Cardiovascular effects of low-dose epinephrine infusions in relation to the extent of preoperative β-adrenoceptor blockade

Abstract

The relationship between the extent of preoperative β-adrenoceptor blockade and the hemodynamic properties of epinephrine was investigated in patients scheduled for elective myocardial revascularization during the immediate preoperative period under steady-state hemodynamic and anesthetic conditions. Twenty patients had been treated with β-adrenoceptor blocking drugs for at least 3 weeks before the study; 11 unblocked patients served as control group. The extent of clinical β-adrenoceptor blockade was quantified using the isoproterenol sensitivity test. The dose of isoproterenol required to increase heart rate by 25 beats per min was defined as the chronotropic dose 25 (CD25), representing the degree of β-adrenoceptor blockade. Geometric mean CD25 per 70 kg was 3.0 μg in the control group and 21.8 μg in the patients receiving β-adrenoceptor blocking drugs. The authors found a significant inverse relationship between CD25 values and changes in cardiac index in response to three epinephrine infusion rates (0.01, 0.02, and 0.04 μg·kg-1·min-1), the correlation coefficients being -0.71, -0.81, and -0.86, respectively. Compared to unblocked patients, almost no change, or even a decrease, of the cardiac index was observed at greater degrees of clinical β-adrenoceptor blockade, particularly in patients receiving nonselective blockers. Moreover, there was a significant linear correlation (r = 0.76-0.86) between CD25 values and the effects of epinephrine on systemic vascular resistance index (SVRI); i.e., SVRI significantly decreased in control patients but markedly increased in patients with high degrees of preoperative β-adrenoceptor blockade. This unmasked vasoconstrictive response to low doses of epinephrine was observed despite the fact that the majority of our patients had received cardioselective adrenergic blocking drugs. We also found a significant positive relationship between CD25 values and the effect of epinephrine on mean arterial pressure, whereas correlations between the degree of β-blockade and heart rate responses to epinephrine were inverse. The authors conclude that these results could have important clinical implications for the use of epinephrine during the prebypass period in patients who are receiving chronic β-blocker therapy and require inotropic support.