Murat DEMİREL, Füsun GÜZELMERİÇ, Rezan YALTIRIK, Fahriye GÜLER, Halide OĞUŞ, Haluk KARACA, Tuncer KOÇAK

Kardiyopulmoner bypass uygulanan koroner arter hastalarında desfluran anestezisinin karaciğer fonksiyonlarına etkisi

Bu çalışmada kardiyopulmoner bypass (KPB) ile koroner bypass operasyonu geçiren hastalarda desfluran + opioid anestezisi ile yüksek doz opioid anestezisinin karaciğer fonksiyonlarına etkilerini karşılaştırmak amaçlanmıştır. Çalışma hastane etik kurulu ve hastaların onayı alınarak koroner revaskülarizasyon operasyonu uygulanacak 16'şar olguluk iki grupta yapıldı. Anestezi indüksiyonu her iki grupta da tiyopental + fentanil + pankuronyum ile sağlandı. İdamede I. grup (Grup F) hastaya 3 ug $kg^-1$ $sa^-1$ fentanil infüzyonu ve diyazepam, H. gruba (Grup D) ise %6-7 desfluran ve l fiğ $kg^-1$ $sa^-1$ fentanil infüzyonu uygulandı. Operasyon öncesi ve intraoperatif dönemde hemodinamik parametreler izlendi ve kaydedildi. Tüm hastalardan; preoperatif, anestezi indüksiyonundan bir saat sonra, postoperatif 2. ve 48. saat olmak üzere 4 dönemde kan alınarak serumda alfa glutatyon-S-transferase (alfa GST) düzeyi ölçüldü. Karaciğer enzim düzeyleri ise preoperatif ve postoperatif 48. saat olmak üzere 2 dönemde ölçüldü. Hemodinamik parametreler açısından grup içi ve gruplar arası anlamlı bir fark olmadı. Serum alfa GST düzeyi postoperatif 2. saatte her iki grupta anlamlı olarak yükseldi ancak bu yükselme normal sınırlar içinde oldu ve postoperatif 48.saatte başlangıç değerine döndü. Sonuç olarak alfa GST'nin her iki grupta da benzer şekilde yükselmesi; bu yükselmenin metabolitlere karşı oluşmuş immün bir yanıttan ziyade hepatosellüler bütünlüğü değiştiren minör bir oksijenasyon bozukluğu olduğunu düşündürmektedir.

Anahtar Kelimeler:

Glutatyon transferaz, Kardiyopulmoner bypass, Karaciğer fonksiyon testleri, Anestezikler, inhalasyon

The effect of desflurane on hepatic function in patients undergoing cardiopulmonary bypass

The aim ofthis study was to compare effects of desflurane + opioid anesthesia with high döşe opioid anesthesia on hepatic function in patients undergoing cardiopulmonary bypass. After obtaining hospital ethic committee approval and informed consent, the patients scheduledfor coronary revascularization were randomly divided in two groups. Induction of anesthesia was performed with thiopentone + fentanyl + pancuronium in both groups. For maintenance of anesthesia, fentanyl infusion and diazepam were used in thefirst group (Group F) while 6-7 % desflurane + l ug $kg^-1$ $hr^-1$ fentanyl infusion were used in the second group (Group D). Preoperative and intraoperative hemodynamic parameters were monitored and recorded . Serum alpha Gluthation S Transferase (alpha GST)levels of ali patients were measured according to following order; preoperatively, l hour after induction of anesthesia, postoperative 2nd and 48th hours. Liver enzyme levels were measured preoperatively and at postoperative 48th hour. Serum alpha GST levels signiflcantly increased in both groups at postoperative 2nd hour without showing differences between the groups. A return to baseline values in aGST levels was seen 48h after the operation. As a result, similar increase in the levels of alpha GST in both groups is thought to be due to a minor oxygenation impairment that can change hepatocellular integrity rather than reaction against the metabolites of desflurane.

Keywords:

Glutathione Transferase, Cardiopulmonary Bypass, Liver Function Tests, Anesthetics, Inhalation,

___

1. Eger El. The clinical use of desflurane. Yale J Biol Med 1993; 66(5): 491-500.
2. Tiainen P, Rosenberg PH. Hepatocellular integrity during after isoflurane and halathone anaesthesia in surgical patients. Br J Anaesth 1996;77:744-7.
3. D. C. Ray, G. J. Beckett, and L. G. Allan. Hepatocellular integrity after inhalation anaesthesia. Br J Anaesth 1997; 78: 772-3.
4. Tiainen P, Lindgren L, Rosenberg PH et al. Changes in hepatocelluler integrity during and after Desflurane an İsoflurane anaesthesia in patients undergoing breast surgery. Br J Anaesth 1998; 80: 87-9.
5. Tiaivainien T, Tianen P, Meretaja O. Comparison of the effects of sevoflurane and halothane on the quality of anaesthesia and serum aGST and fluoride in pediatric patients . Br J Anaesth 1994; 73: 590-5.
6. Eğer EL New inhaled anesthetics. Anesthesiology 1994 Apr; 80(4): 906-22.
7. Mets B. Reich N.T., Mellas N., Beek J., Park S. Desflurane pharmacokinetics during CPB. J Cardiothorac Vasc Anesth. 2001;15:179-82.
8. Beckett GJ, Hoyes JD. Glutathione S-Transferases: Biomedical applications. Adv Clin Chem. 1993;30: 281-9.
9. Thea PJ, Mulder G, Daniel A. Count and Wilbert HM et al. Variability of aGST in human liver and plasma. Clin Chem 1999;45:355-9.
10. Cahalan MK, Weiskopf RB, Eğer El et al. Hemodynamic effects of Desflurane /N2O Anaesthesia İnvolunters Anaesthesia 1998; 47:980-5.
11. Merin RG, Bernard JM, Doursout MF, Cohen M. Comparison of the effects of isoflurane and desflurane on cardiovascuiar dynamics and regional blood flow m the chronıcally ınstrumented dog. Anesthesiology 1991; 73: 157-64
12. Martin J, Jackie L, Plewak B et al. Hepatotoxicity after Desflurane anesthesia. Anesthesiology 1995;83:1125-9.
13. Koblin DD. Characteristics implications of desflurane metabolism and toxicity. Anesth Analg 1992;75:10-6.
14. Kenna JG, Jones RM. The organ toxicity of inhaled anesthetics. Anesth Analg 1995;81:51-66.
15. Desai JB, Mathie RT, Taylor KM. Hepattc blood flow during cardıopulmonary bypass in the dog :a comparison between pulsatile and non pulsatile perfusion. Life supp systems 1984; 2:303-5
16. Less MH, Herr RH, Hill JD et al. Distribution of systemic blood flow during CPB. Thorac Cardiovasc Surg 1971; 61: 570-86.
17. Rudy LW Jr, Heymann MA, Edmunds LH Jr.Distribution of systemic blood flow during CPB. J Appl Physiol 1973; 34: 194-200.
18. Sicsic JC, Duranteau J, Corbineau H et al. Gastric mucosal oxygen delivery decreases during CPB despite constant systemic oxygen delivery. Anesth Analg 1998;86:455-60.
19. Wang MJ, Chao A, Huang CH et al. Hyperbilirubinemia after cardiac operation. Incidence, risk factors, and clinical significance. J Cardiovasc Surg 1994 ; 108:429-36.
20. Hussey AJ, Aldridge LM. Plasma aGST concentration as a measure of hepatocellüler integrity following a single general anesthetic with halothane, enflurane or isoflurane. Br J Anaesth. 1988; 60:130-5.
21. Hussey AJ, Howie LG. Impaired hepatocellüler integrity during general anaesthesia, as assessed by measurement of aGST. Clin Chimica Acta 1986; 161:19-28.