Münire BABAYİĞİT, Güngör Enver ÖZGENCİL, Serdar ÇATAV, Çiğdem Evren DENKER, Mustafa Alparslan BABAYİĞİT

Açık kalp cerrahisinde kardiyopulmonerBypass sürecinde ventilasyonun postoperatif akciğer fonksiyonları üzerine etkisi

Amaç: Bu çalışmada, kardiyopulmoner bypass süresince devamlı ventilasyon uygulamasının hemodinami, kompliyans ve ekstübasyon zamanı üzerine etkisi araştırılmıştır. Yöntem: Kardiyopulmoner bypass kullanılarak koroner arter bypass greftleme ve/veya kalp kapak cerrahisi uygulanacak 50–75 yaş arasında 60 hasta basit randomizasyon ile iki gruba ayrıldı. Kardiyopulmoner bypass süresince Grup I’de (kontrol grubu) akciğerler atmosfere açık bırakılırken Grup II’de (çalışma grubu) 5 cmH2O inspiratuar basınç, 5 soluk/dk frekans ve 5 cmH2O PEEP ile ventilasyona devam edildi. Entübasyon sonrası, kardiyopulmoner bypass öncesi ve sonrasında, postoperatif 2 ve 6. saatlerdeki hemodinamik veriler, arteryel kan gazları ölçümleri kaydedildi. Entübasyon sonrası ve postoperatif 2. saat akciğer kompliyansı ölçüldü. Ekstübasyon süreleri kaydedildi. Bulgular: Hemodinamik verilerde iki grup arasında anlamlı bir fark bulunmadı. Çalışmanın tüm aşamalarında PaO2 değerlerinin Grup II’de Grup I’e göre daha yüksek olduğu ancak aradaki farkların istatistiksel olarak anlamsız olduğu tespit edildi. Grup I ile Grup II’nin entübasyon sonrası kompliyans ölçümleri arasında anlamlı bir fark bulunmazken, postoperatif 2. saat akciğer kompliyans ölçümleri Grup I’e göre Grup II’de anlamlı düzeyde yüksek bulundu (p= 0,013). Ekstübasyon süresi Grup II’de Grup I’e göre anlamlı derecede kısa bulundu (p=0,006). Sonuç: Bu çalışmada kardiyopulmoner bypass süresince devamlı ventilasyon uygulamasının hemodinamiyi bozmadığı, akciğer koruyucu etki ile kompliyansta iyileşme sağladığı ve mekanik ventilasyon süresini kısalttığı sonucuna varılmıştır.

Effect of ventilation during cardiopulmonary bypass in open heart surgery on postoperative pulmonary functions

Objective: The aim of this study was to determine the effects of continuous ventilation on hemodynamic parameters, pulmonary compliance, and extubation time during cardiopulmonary bypass (CPB). Method: Using cardiopulmonary bypass, sixty patients between 50-75 years old, applied for coronary artery bypass grefting and/or heart valve surgery, were divided into two groups by simple randomization. In group I, patients were not ventilated during cardiopulmonary bypass, and in group II ventilation was continued with 5 cmH2O inspiratory pressure, 5 breaths/minute frequency and 5 cmH2O PEEP. Hemodynamic parameters and arterial blood samples were followed up and recorded after intubation, before and after cardiopulmonary bypass, at postoperative 2nd and 6th hours. Lung compliance was measured after intubation and at the 2nd postoperative hour. Extubation times were recorded. Results: There was no significant difference in hemodynamic data between the two groups. In Group II PaO2 values were higher than in Group I in all phases of the study. But the differences between them were found to be statistically insignificant. While there was no statistically difference in postintubation lung compliance values between Group I and Group II; Group II had higher values than Group I according to postoperative 2nd hour lung compliance measurements, which was statistically significant (p<0.013). Extubation times were extremely lower in Group II than Group I, which was also statistically significant (p=0.006). Conclusion: The continuous ventilation during cardiopulmonary bypass appears to have a lung protective effect by shortening mechanical ventilation time without hemodynamic side effects.

PDF

___

1. Wall MH, Royster RL. Pulmonary dysfunction after cardiopulmonary bypass: should we ventilate the lungs on pump? Crit Care Med 2000;28(5):1658-60.
2. Tenling A, Hachenberg T, Tyden H, et al. Atelectasis and gas exchange after cardiac surgery. Anesthesiology 1998;89(2):371–8.
3. Magnusson L, Zemgulis V, Wicky S, et al. Effect of CPAP during cardiopulmonary bypass on postoperative lung function. An experimental study. Acta Anaesthesiol Scand 1998;42(10): 1133–8.
4. Berry CB, Butler PJ, Myles PS. Lung management during cardiopulmonary bypass: is continuous positive airway pressure beneficial? Br J Anaesth 1993;71(6):864–8.
5. Boldt J, King D, Scheld HH, Hempelmann G. Lung management during cardiopulmonary bypass: influence on extravascular lung water. J Cardiothorac Anesth 1990;4(1):73–9.
6. Groeneveld AB, Jansen EK, Verheij J.Mechanisms of pulmonary dysfunction after on-pump and off-pump cardiac surgery: a prospective cohort study. J Cardiothorac Surg 2007;2:11.
7. Ellis EL, Brown A, Osborn JJ, Gerbode F. Effect of altered ventilation patterns on compliance during cardiopulmonary bypass. Anesth Analg 1969;48(6):947–52 .
8. Loeckinger A, Kleinsasser A, Lindner KH, et al. Continuous positive airway pressure at 10 cm H2O during cardiopulmonary bypass improves postoperative gas exchange. Anesth Analg 2000; 91(3):522–7.
9. Türko¤lu T. Kardiyopulmoner bypassa girilmeden (Off-Pump) atan kalpte ve kardiyopulmoner bypass kullan›larak kardiyak arrest ile uygulanan koroner bypass cerrahisi sonras› atrial fibrilasyon gelifliminin karfl›laflt›r›lmas›. Uzmanl›k Tezi, Dr. Siyami Ersek Gö¤üs Kalp ve Damar Cerrahisi E¤itim ve Araflt›rma Hastanesi, 2004.
10. Imanipour M, Bassampoor SS, Nikbakht NA. Intraoperative variables associated with extubation time in patients undergoing coronary artery bypass graft surgery. Jpn J Nurs Sci 2008;5(1): 23–30.
11. Berry CB, Butler PJ, Myles PS. Lung management during cardiopulmonary bypass: is continious positive airways pressure beneficial? Br J Anaesth 1993;71(4):864–8.
12. Figueiredo LC, Araújo S, Abdala RC, et al. CPAP at 10 cm H2O during cardiopulmonary bypass does not improve postoperative gas exchange. Rev Bras Cir Cardiovasc 2008;23(2):209-15.
13. Gilbert TB, Barnas G, Sequeira A. Impact of pleurotomy, continuous positive airway pressure, and fluid balance during cardiopulmonary bypass on lung mechanics and oxygenation. J Cardiothorac Vasc Anesth 1996;10(7):844-9.
14. John LC, Ervine IM. A study assessing the potential benefit of continued ventilation during cardiopulmonary bypass. Interact CardioVasc Thorac Surg 2008;7(1):14-7.
15. Nq CS, Arifi AA, Wan S, et al. Ventilation during cardiopulmonary bypass: impact on cytokine response and cardiopulmonar function. Ann Thorac Surg 2008;85(1):154-62.
16. Zabeeda D, Gefen R, Medalion B, et al. The effect of highfrequency ventilation of the lungs on postbypass oxygenation: A comparison with other ventilation methods applied during cardiopulmonary bypass. J Cardiothorac Vasc Anesth 2003;17(1):40-4.
17. Görgü A. Aç›k kalp cerrahisinde kalp akci¤er pompas› süresince akci¤erleri havaland›rman›n postoperatif akci¤er fonksiyonlar› üzerine olan etkisi. Uzmanl›k Tezi, Gaziantep Üniversitesi T›p Fakültesi, 2007.
18. Lee JH, Murrell HK, Kim KH, Cmolik BL, van Heeckeren DW, Geha AS. Early extubation leads to decreased lenght of stay following coronary bypss surger. Chest 1995;108(Suppl 3);116.
19. Reyes A, Vega G, Blancas R, et al. Early vs conventional extubation after cardiac surgery with cardiopulmonary bypass. Chest 1997;112(1);193-201.
20. Higgins TL. Pro: early endotracheal extubation is preferable to late extubation in patients following coronary artery surgery. J Cardiothorac Vasc Anesth 1992;6(4):488-93.
21. Epstein SK, Ciubotaru RL, Wong JB. Effect of failed extubation on the outcome of mechanical ventilation. Chest 1997;112(1): 186–92.
22. Esteban A, Alia I, Tobin MJ, et al. Effect of spontaneous breathing trial duration on outcome of attempts to discontinue mechanical ventilation. Spanish Lung Failure Collaborative Group. Am J Respir Crit Care Med 1999;159(2):512–8.
23. Epstein SK. Predicting extubation failure: is it in (on) the cards. Chest 2001;120(4):1061-3.
24. Toraman F, Karabulut EH, Alhan C. Fast Track Recovery uygulanan hastalarda yo¤un bak›mda kal›fl süresine etki eden parametreler. TGKDCD 2000;8:2,605-9.
25. Nicholson DJ, Kowalski SE, Hamilton GA,et al. Postoperative pulmonary function in coronary artery bypass graft surgery patients undergoing early tracheal extubation: a comparison between short-term mechanical ventilation and early extubation. J Cardiothorac Vasc Anesth 2002;16(1):27-31.