Perioperative variability of binding of lidocaine, quinidine, and propranolol after cardiac operations

This study examined the effect of changes in plasma concentrations of total protein, albumin, α1-acid glycoprotein, and free fatty acids occurring after heart operations on the protein binding of chemically basic drugs. Plasma protein and free fatty acid concentrations were measured simultaneously with in vitro determinations of the protein binding of lidocaine, quinidine, and propranolol: immediately before operation, immediately on weaning from cardiopulmonary bypass, on arrival in the recovery room, and 12, 24, 72, and 120 hours postoperatively. Initial decreases in the concentrations of all proteins were followed by a rise in a,-acid glycoprotein to 254% of baseline at 72 to 120 hours. The free fractions of drug were initially increased to 168% of baseline for lidocaine, 206% for quinidine, and 200% for propranolol and fell progressively with time, reaching sustained troughs of 65% for lidocaine, 50% for quinidine, and 57% for propranolol at 72 to 120 hours. Regression analysis indicated a major influence of changing α1-acid glycoprotein concentrations on free fractions of all three drugs, with a smaller effect of albumin that reached statistical significance only for lidocaine. There were no significant perioperative changes in plasma concentrations of free fatty acids when the in vitro effects of heparin were controlled. In conclusion, sequential changes in plasma protein concentrations after cardiac operations predictably alter the protein binding of lidocaine, quinidine, and propranolol and should be considered when interpreting total plasma drug concentrations.