Açık kalp cerrahisi uygulanan hastalarda pulsatil ve nonpulsatil akımların karşılaştırılması
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Abstract
Fakülte etik kurul ve hastaların yazılı onamı alındıktan sonra Kasım 2008-Ağustos 2009 tarihleri arasında kalp operasyonu uygulanan 120 hasta pulsatil ve nonpulsatil perfüzyon grubu olmak üzere 60'şar kişilik 2 gruba ayrıldı. Preoperatif; off-pump cerrahi, reoperasyon, acil cerrahiler, renal yetmezlikli hastalar, postoperatif; ilk 24 saat içinde kaybedilen hastalar çalışma dışı bırakıldılar.Rutin kalp ilaçlarına operasyon gününe kadar devam edildi. Operasyon odasında iskemi analizi için DII ve V5 derivasyonların EKG kayıtları, noninvaziv arteriyel kan basıncı ve puls oksimetre ile monitorizasyona başlandı. Anestezi indüksiyonunda 10 µg/kg fentanyl, 0.3 mg/kg etomidat ve 0.1 mg/kg pankuronyum, idamede 5-10 µg/kg/h fentanyl ve 0.5-1% isoflurane kullanıldı. Hasta endotrakeal entübasyondan sonra mekanik ventilatöre bağlandı. 20-G radial artere kanül yerleştirildi. 7-Fr sağ internal juguler vene intraduser takıldı. Standart KPB protokolleri uygulandı. Hafif hipotermi (32 ºC), 2.4 L/dk/m2 pompa akımı ile ortalama kan basıncı 50 mmHg'da devam ettirildi. Hem pulsatil hem de nonpulsatil akım için Stöckert S3 roller pompa kullanıldı. Pulsatil grupta AKK'dan sonra pulsatil akım moduna çevrildi. Pulsatil akım modları: Nabız hızı 60 atım/dk, nabız genişliği %60 ve bazal akım %30 olacak şekilde ayarlandı. Preoperatif hasta özellikleri (yaş, BSA, EF, cinsiyet, perfüzyon, AKK, operasyon ve cerrahi süreler, yandaş hastalıklar, medikasyonlar, renal risk skorları ve EuoroSCORE), intraoperatif (hemodinamik değişkenler, diürez, transfüzyon, vazoaktif ve inotropik ilaç kullanımı, AKG analizleri), postoperatif (hastanede, yoğun bakımda ve mekanik ventilasyonda kalış süreleri), nefrolojik (dializ, hemodiafiltrasyon, renal yetmezlik), kardiyak ( IABP, inotropik ve vazokonstrüktif ilaç kullanımı), laboratuvar verileri (tam kan sayımı, SGOT, SGPT, üre, kreatinin, kreatinin klirens), mortalite oranları değerlendirildi.Preoperatif hasta özellikleri benzerdi. Ancak EuoroSCORE pulsatil grupta istatistiksel olarak daha yüksek bulundu. İntraoperatif ortalama ve diastolik kan basınçları pulsatil grupta daha düşüktü ve bu istatistiksel olarak anlamlı idi. Pulsatil grupta hem pompa süresince ve operasyon sonunda diürez anlamlı olarak daha düşüktü. Postoperatif laboratuvar verileri, mortalite oranları, hastanede, yoğun bakım ve ventilatörde kalış süreleri arasında fark bulunmadı.Sonuç olarak pulsatil gruptaki hastalar EuroSCORE'ye göre yüksek risk grubunda yer alan hastalardı. Yani yüksek mortalite oranlarına sahiptiler. Ancak postoperatif hasta mortalite ve morbiditeleri arasında fark bulunmadı. Pulsatil akım yüksek riskli hastalarda faydalı gibi gözükmektedir. Comparision of Pulsatile and Nonpulsatile Flows in Patients Undergoing Open Heart SurgeryAfter ethical committee approval and informed concent, 120 consecutive patients scheduled for open heart surgery were enrolled in this study from November 2008 to August 2009. The patients were assigned either to the pulsatile perfusion group (group P, n=60) or the nonpulsatile perfusion group (group NP, n=60). Patients were excluded from the study if they underwent off-pump procedures, if they had preoperative chronic renal dysfunction, reoperation, emergency surgery and if patients were died within the first operative 24 hours.Preoperative medication was maintained until surgery. Monitoring included electrocardiography with ST-segment analysis of lead II and V5, blood pressure and pulse oximetry. Anesthesia was induced with 5-10 µg/kg fentanyl, 0.3 mg/kg etomidate, and 0.1 mg/kg pancuronium and maintained with 5-10 µg/kg/h fentanyl, and 0.5-1% isoflurane. After endotracheal intubation a single-lumen central venous catheter 7?Fr introducer was inserted a routine into the right internal jugular vein and 20-G radial arterial cannula was inserted.All patients underwent a standart CPB protocol. Cardiac surgery with bypass was performed with mild hypothermia (32 ºC), during which mean arterial pressure was maintained at 50 mmHg by a flow rate of 2.4 L/min/m2. Roller pump (Stöckert S3), hollow fiber membrane oxygenator were used in both groups. In the nonpulsatile group the pump was used in continue flow throughout the perfusion. In the pulsatile group bypass was started in the nonpulsatile mode and switched to pulsatile flow when aorta was crossclamped. During the pulsatile mode the pump was set to deliver pulse rate of 60/min, pulse width 60% and baseflow 30%.Study parameters included preoperative patient characteristics (age, gender, BSA, EF, comorbid disease, medications; renal risk assesment scores, EuoroSCORE; AKK, perfusion, anesthesia and operation time), intraoperative (analyses of arterial blood gases hemodynamic variables, the need for vazodilatator, intropic therapy and transfusion and urine output); and postoperative laboratory data (alanine aminotransferase, ALT, aspartate aminotransferase, AST) creatinine, creatinine clearence, leukocytes, hematocrit, platelets). Postoperative clinical variables were also recorded and analysed: the requirement for vazoconstrictor or inotropic drugs the need for hemotransfusions, nephrological (requriment of hemodialysis or hemodiafiltration), cardiovascular (IABP) and respiratory complications (duration of mechanical lung ventilation status) and mortality rates were evaluated daily by clinical examination and laboratory tests.There was no statistically significant differnces seen in either preoperative or operative parameters between two groups but during perfusion in pulsatil group mean and diastolic arterial pressures were higher than the nonpulsatil group and EuoroSCORE (lower in nonpulsatile group than pulsatil group) were significant differences. There were no differences between the groups in terms of total amount of packed cell volume transfused during and after the operation. Arterial blood pH, base excess, and arterial lactate concentration remained steady during the intraoperative period, and there were no differences between the two groups. Although urinary output was significantly lower during CPB in the pulsatile group during surgery, blood creatinine and creatinine clearance and urine output did not differ among the groups postoperatively. Hepatic function, assessed by hepatic enzymes concentration determination was equally preserved in both groups during first and second postoperative days.We concluded that pulsatile flow resulted in improved outcomes expecially in high risk groups.
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