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CARDIOVASCULAR ANESTHESIA

Halothane, Isoflurane, and Fentanyl Increase the Minimally Effective Defibrillation Threshold of an Implantable Cardioverter Defibrillator: First Report in Humans

Avi A. Weinbroum, MD^*, Aharon Glick, MD, Yitzchak Copperman, MRCPI, Tamar Yashar, MD, Valery Rudick, MD, and Ron Flaishon, MD

*Post-Anesthesia Care Unit and Departments of Anesthesiology and Critical Care and Cardiology, Tel Aviv Sourasky Medical Center and the Sackler Faculty of Medicine, Tel Aviv University, Israel

Address correspondence and reprint requests to Avi A. Weinbroum, MD, Post-Anesthesia Care Unit, Tel Aviv Sourasky Medical Center, 6 Weizman St., Tel Aviv 64239, Israel. Address e-mail to draviw{at}tasmc.health.gov.il

Placing an implantable cardioverter defibrillator (ICD) involves the induction of ventricular fibrillation, whereupon the minimally effective defibrillation energy threshold (DFT) is determined. We evaluated the effects of 0.7% halothane, 1% isoflurane, or 1.5 µg/kg of IV fentanyl during N₂O/oxygen-based general anesthesia (GA) or those of subcutaneous 1.5% lidocaine plus IV 0.35 mg/kg of propofol on the DFT during ICD implantation in humans (n = 20 per group). Thirty minutes after the first set of DFT measurements under such conditions, the inhaled anesthetics were withdrawn, and all three GA groups received fentanyl 1 µg/kg IV (second set). A third set was taken 30 min later, before the GA patients awakened and when only N₂O/oxygen was delivered for GA. The lidocaine plus propofol patients were given the same IV propofol bolus 1 min before each fibrillation/defibrillation trial and at the same time points as the three GA groups. The first DFTs were 16.1 ± 2.2 J (halothane), 17.7 ± 2.7 J (isoflurane), 16.4 ± 2.9 J (fentanyl), and 12.9 ± 3.8 J (lidocaine plus propofol) (P = 0.01). The second set of DFTs were significantly lower than the first sets for the halothane (P = 0.01) and isoflurane (P = 0.02), but not the fentanyl or lidocaine plus propofol, regimens. The third DFTs were significantly (P < 0.01) lower than the first ones for the three GA groups, but not for the lidocaine plus propofol patients. Thus, halothane, isoflurane, and fentanyl increased DFT values during ICD implantation in humans, whereas lidocaine plus intermittent small-dose IV propofol minimized these thresholds.

IMPLICATIONS: Halothane, isoflurane, and IV fentanyl added to N₂O/oxygen-based general anesthesia similarly increase minimal defibrillation threshold energy requirements (DFT) during cardioverter defibrillator implantation in humans. Subcutaneous lidocaine plus intermittent small-dose IV propofol minimizes DFT compared with these general anesthetics while providing equal patient satisfaction.

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