Erişkin Kalp Cerrahisinde Kardiyopulmoner Baypas Sırasındaki Beyin Perfüzyonu ile Mortalite Skorlarının Etkileşimi

Year 2019, Volume: 22 Issue: 2, 79 - 84, 15.08.2019

Onur Şen Okan Yıldız

Abstract

Giriş: Bu çalışmada
erişkin kalp cerrahisi ameliyatları sırasındaki beyin perfüzyonu ile mortalite
skorlarının etkileşimlerinin araştırılması amaçlandı.

 

Hastalar ve Yöntem:
Nisan 2018-Ağustos 2018 tarihleri arasında kliniğimizde kardiyopulmoner baypas
(KPB) ile ameliyat edilecek erişkin hastalar çalışmaya dahil edildi (n= 91).
Beyin perfüzyonunu belirlemek için “Near Infrared Spectroscopy (NIRS)” yöntemi
kullanıldı. Ölçümler dört zaman aralığında yapıldı. T0: KPB öncesi, T1: soğuma
periyodu, T2: ısınma periyodu, T3: KPB sonrası. Mortalite skorları olarak
EuroSCORE II ve “Acute Physiology and Chronic Health Evaluation (APACHE)” II
skoru değerleri her bir hasta için kaydedildi.

 

Bulgular: Ameliyat
verileri, koroner arter baypas cerrahisi (n= 41, %45), kapak ameliyatları (n=
47, %51), koroner arter baypas cerrahisi ve kapak ameliyatlarının birlikte
uygulandığı hastalar (n= 3, %4) olarak saptandı. Ortalama Euroscore II 1.1
(0.7-36.6) ve ortalama APACHE II skoru 6 (0-23) bulundu. Ölüm gelişen dört
hastada EuroSCORE II C indeksi 0.702 (Confidence interval 0.411-0.993, p=
0.048) ve APACHE II score C indeksi 0.871 (Confidence interval 0.660-1, p=
0.010) belirlendi. Ameliyat sırasında T3 dönemindeki NIRS ölçüm değerleri düşük
bulunan ve T0-T3 periyodundaki NIRS değeri değişiklikleri anlamlı olan
hastalarda APACHE II skoru ölçümlerinde anlamlı değişiklik saptandı.

 

Sonuç: NIRS
ölçümlerindeki değişiklikler, mortalite ve morbidite skorlama yöntemleri
ölçümleriyle paralellik gösterir. Bu nedenle ameliyat öncesi ve sonrası
dönemdeki hasta yönetimi açısından NIRS ölçümü iyi bir belirteçtir.

Keywords

Erişkin kalp cerrahisi, kardiyopulmoner baypas, serebral NIRS

Relation Between Cerebral Perfusion Changes and Mortality Scores During Cardiopulmonary Bypass at Adult Cardiac Surgery

Abstract

Introduction: This
study aims to investigate the correlation between cerebral perfusion changes
and mortality rate in individuals undergoing adult cardiac surgery.

 

Patients and Methods:
Between April 2018-August 2018, 91 adult individuals who underwent open heart
surgery with cardiopulmonary bypass (CPB) were prospectively evaluated.
Cerebral perfusion was monitored via near-infrared spectroscopy (NIRS). The
NIRS values were recorded at four intervals: T0, just before CPB; T1, cooling
period (time taken to reach targeted hypothermia); T2, warming period (time
taken to reach normal body temperature); and T3, following minutes of
termination of CPB. Euro Score II and Acute Physiology and Chronic Health
Evaluation (APACHE) II scores were recorded for each individual.

 

Results: The
operations performed include coronary artery bypass surgery (n= 41, 45%),
valvular surgery (n= 47, 51%), and coronary artery bypass combined with
valvular surgery (n= 3, 4%). Median Euro Score II was calculated to be 1.1
(range 0.7-36.6), and median APACHE II score was calculated to be 6 (range
0-23). Mortality occurred in four individuals for whom the Euro Score II C
index was 0.702 (confidence interval, 0.411- 0.993; p= 0.048) and APACHE-II
score C index was 0.871 (confidence interval, 0.660-1; p= 0.010). During the
operative period, cerebral NIRS values decreased during T3 period, and
significant changes occurred at T0-T3 period, consequently leading to an
increase in the APACHE-II scores and the prediction of mortality.

 

Conclusion: The
changes at NIRS values were related with higher mortality, morbidity, and
predicting scores. It is now suggested that these changes can eventually be a
good guide and predictor for the management of patients during preoperative and
postoperative periods.

Keywords

Adult cardiac surgery, cardiopulmonary bypass, cerebral NIRS

References

• 1. Hoffman GM, Ghanayem NS, Tweddell JS. Noninvasive assessment of cardiac out-put. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2005;12-21.
• 2. Ghosh A, Elwell C, Smith M. Review article: cerebral nearinfrared spectroscopy in adults: a work in progress. Anesth Analg 2012;115:1373-83.
• 3. Toet MC, Lemmers PM. Brain monitoring in neonates. Early Hum Dev 2009;85:77-84.
• 4. Goldman S, Sutter F, Ferdinand F, Trace C. Optimizing intraoperative cerebral oxygen delivery using noninvasive cerebral oximetry decreases the incidence of stroke for cardiac surgical patients. Heart Surg Forum 2004;7:E376-81.
• 5. Nashef SAM, Roques F, Michel P, Gauducheau E, Lemeshow S, Salamon R, et al. European System for Cardiac Operative Risk Evaluation (EuroSCORE). Eur J Cardio Thorac Surg 1999;16:9-13.
• 6. Knaus WA, Zimmerman JE, Wagner DP, Draper EA, Lawrence DE. APACHE- Acute physiology and chronic health evaluation: a physiologically based classification system. Crit Care Med 1981;9:591-7.
• 7. Vincent JL, Moreno R. Clinical review: Scoring system in the critically ill. Critical Care 2010;14:1-9.
• 8. Roques F, Michel P, Goldstone AR, Nashef SAM. The logistic EuroSCORE. Eur Heart J 2003;24:882-3.
• 9. Murkin JM, Arango M. Near-infrared spectroscopy as an index of brain and tissue oxygenation. Br J Anaesth 2009;103(Suppl 1):i3-13.
• 10. Mittnacht AJ. Near infrared spectroscopy in children at highrisk of low perfusion. Curr Opin Anaesthesiol 2010;23:342-7.
• 11. Fischer GW. Recent advances in application of cerebral oximetry in adult cardiovascular surgery. Semin Cardio Thorac Vasc Anesth 2008;12:60-9.
• 12. Haydin S, Onan B, Onan IS, Ozturk E, Iyigun M, Yeniterzi M, et al. Cerebral perfusion during cardiopulmonary bypass in children: correlations between near-infrared spectroscopy, temperature, lactate, pump flow, and blood pressure. Artif Organs 2013;37:87-91.
• 13. Erdoes G, Rummel C, Basciani RM, Verma R, Carrel T, Banz Y, et al. Limitations of current near-infrared spectroscopy configuration in detecting focal cerebral ischemia during cardiac surgery: an observational case-series study. Artif Organs 2018.
• 14. Steppan J, Hogue CW Jr. Cerebral and tissue oximetry. Best Pract Res Clin Anaesthesiol 2014;28:429-39.
• 15. Tanidir IC, Ozturk E, Ozyilmaz I, Saygi M, Kiplapinar N, Haydin S, et al. Near infrared spectroscopy monitoring in the pediatric cardiac catheterization laboratory. Artif Organs 2014;38:838-44.
• 16. Aly SA, Zurakowski D, Glass P, Skurow-Todd K, Jonas RA, Donofrio MT. Cerebral tissue oxygenation index and lactate at 24 hours postoperative predict survival and neurodevelopmental outcome after neonatal cardiac surgery. Congenit Heart Dis 2017;12:188-195.
• 17. Colak Z, Borojevic M, Bogovic A, Ivancan V, Biocina B, Majeric-Kogler V. Influence of intraoperative cerebral oximetry monitoring on neurocognitive function after coronary artery bypass surgery: a randomized, prospective study. Eur J Cardiothorac Surg 2015;47:447-54.
• 18. Deschamps A, Lambert J, Couture P, Rochon A, LebonJS, Ayoub C, et al. Reversal of decreases in cerebral saturation in high-risk cardiac surgery. J Cardiothorac Vasc Anesth 2013;27:1260-6.
• 19. Vretzakis G, Georgopoulou S, Stamoulis K, Tassoudis V, Mikroulis D, GiannoukasA, et al. Monitoring of brainoxygen saturation (INVOS) in a protocol to direct blood transfusions during cardiac surgery: a prospective randomized clinical trial. J Cardio Thorac Surg 2013;8:145.
• 20. Rogers CA, Stoica S, Ellis L, Stokes EA, Wordsworth S, Dabner L, et al. Randomized trial of nearinfrared spectroscopy for personalized optimization of cerebral tissue oxygenation during cardiac surgery. BJA: British Journal of Anaesthesia 2017.
• 21. Gibbon JH Jr. The development of the heart-lung apparatus. Am J Surg 1978;135:608-19.
• 22. Baufreton C, Intrator L, Jansen PG, te Velthuis H, Le Besnerais P, Vonk A, et al. Inflammatory response to cardiopulmonary bypass using roller or centrifugal pumps. Ann ThoracSurg 1999; 67:972-7.
• 23. Exarchopoulos T, Charitidou E, Dedeilias P, Charitos C, Routsi C. Scoring systems for outcome prediction in a cardiac surgical intensive care unit: a comparative study. Am J Crit Care 2015;24:327-34;quiz335.
• 24. Gaygusuz EA, Öncül S, Yılmaz M, Esen O, Balcı C. Contribution of APACHE II to predict the mortality of medical and surgical patients in intensive care units. J Kartal TR 2015;26:127-31.