Nevriye SALMAN, Ahmet Barış DURUKAN, Hasan Alper GÜRBÜZ, Halil İbrahim UÇAR, Cem YORGANCIOĞLU

Koroner arter bypass cerrahisinde postoperatif serebrovasküler olay ve deliryum için risk faktörlerinin belirlenmesi

Amaç: Bu çalışmada KABG yapılmış hastaların SVO ve deliryum insidanslarının ve bu komplikasyonlarla ilişkili risk faktörlerinin belirlenmesi amaçlanmıştır. Yöntem: KABG yapılmış hastalardan postoperatif SVO ve deliryum tanısı alanlar belirlendi. Bunların yaş, cinsiyet, kilo, miyokard infarktüsü (MI), SVO, periferik vasküler hastalık (PVH), hipertansiyon (HT), diabetes mellitus (DM), böbrek yetmezliği (BY), kronik obstrüktif akciğer hastalığı (KOAH), kardiyak cerrahi, karotid arter endarterektomi (KAE), atriyal fibrilasyon (AF), sigara, hiperlipidemi öyküsü ve ejeksiyon fraksiyonu (EF) araştırıldı. Ayrıca greft sayısı, kros-klemp süresi, kardiyopulmoner bypass süresi, entübe kalınan süre, hastanede kalma süresi, pompalı/pompasız cerrahi yapılan hastaların verileri incelendi. Bulgular: 310 hasta çalışmaya dahil edildi. Preoperatif SVO, PVH, DM, KAE öyküsü, AF ve düşük EFnin postoperatif SVO görülme riskini arttırdığı; greft sayısı, kros-klemp ve kardiyopulmoner bypass süresinin etkilemediği saptandı. Ayrıca SVO geçiren hastalarda entübe kalma ve hastanede yatma sürelerinin daha uzun olduğu görüldü. Postoperatif deliryum riskini arttıran faktörler ise ileri yaş ve KAE öyküsü idi. Sonuç: Serebrovasküler olay (SVO) ve deliryum koroner arter bypass gretleme (KABG) cerrahisi sonrası görülebilen önemli komplikasyonlardandır. Bu komplikasyonları etkileyen klinik ve perioperatif faktörlerin belirlenmesi ve giderilmeye çalışılması bu hastalarda kardiyak cerrahi sonrası görülen mortalite ve morbiditenin azaltılmasına yardımcı olabilir.

Risk factors for postoperative cerebrovascular accident and delirium following coronary artery bypass grafting

Objective: The aim of this study is to investigate the incidence of postoperative cerebrovascular accident and delirium among patients who were subjected to coronary artery bypass grafting, and to determine the risk factors associated with these complications. Method: Among patients with coronary artery bypass grafting, those with a diagnosis of postoperative cerebrovascular accident and delirium were determined. Their age, sex, body weight, history of myocardial infarction, cerebrovascular accident, peripheral vascular disease, hypertension, diabetes mellitus, renal failure, chronic obstructive pulmonary disease, cardiac surgery, carotid endarterectomy, atrial fibrillation, smoking, hyperlipidemia, and ejection fraction were analyzed. Also, data on number of grafts, cross-clamp time, cardiopulmonary bypass time, duration of intubation, duration of hospitalization, and on-pump or off-pump coronary artery surgery were investigated. Results: 310 patients were included in the study. Preoperative history of cerebrovascular accident, peripheral vascular disease, diabetes mellitus, carotid endarterectomy, atrial fibrillation and low ejection fraction increased the risk of postoperative cerebrovascular accident whereas number of grafts, cross-clamp time, and cardiopulmonary bypass time were not associated with such a risk. Also, among patients with postoperative cerebrovascular accident, the duration of intubation and the duration of hospitalization were longer. Older age and history of carotid endarterectomy were found to be associated with increased postoperative delirium risk. Conclusion: Cerebrovascular accident and delirium are among the significant complications which may be observed following coronary artery bypass grafting surgery. The determination and management of clinical and perioperative factors associated with these complications may help decrease mortality and morbidity after surgery in these patients.

PDF

___

1.Bucerius J, Gummert JF, Borger MA, et al. Stroke after cardiac surgery: a risk factor analysis of 16,184 consecutive adult patients. Ann Thorac Surg 2003; 75: 472-478.
2.John R, Choudhri AF, Weinberg AD, et al. Multicenter review of preoperative risk factors for stroke after coronary artery bypass grafting. Ann Thorac Surg 2000; 69: 30-36.
3.Orhan G, Sokullu O, Biçer Y ve ark. Koroner arter bypass cerrahisinde tek klemp tekni¤inin inme riski üzerine etkisi. Turkish J Thorac Cardiovasc Surg 2007; 15: 45-50.
4.Ülger A, Şahin S, Bahadır FE ve ark. Koroner arter bypass cerrahisi uygulanan hastalarda karotis arter lezyonları ve vertebrobaziler yetmezlik insidanslarının ameliyat sonrası serebrovasküler atak insidansı ile karşılaştırılması. Turkish J Thorac Cardiovasc Surg 2011; 19: 127-137.
5.Özatik MA, Göl MK, Fansa . Risk factors for stroke following coronary artery bypass operation. J Card Surg 2005; 20: 52-57.
6.Newman MF, Mathew JP, Grocott HP, et al. Central nervous system injury associated with cardiac surgery. Lancet 2006; 368: 694-703.
7.McKhann GM, Grega MA, Borowicz LM Jr, et al. Encephalopathy and stroke after coronary artery bypass grafting: incidence, consequences, and prediction. Arch Neurol 2002; 59: 1422-1428.
8.Rao V, Christakis GT, Weisel RD, et al. Risk factors for stroke fol- lowing coronary bypass surgery. J Card Surg 1995; 10: 468-474.
9.Roach GW, Kanchuger M, Mangano CM, et al. Adverse cerebral outcomes after coronary bypass surgery. N Engl J Med 1996; 335: 1857-1863.
10. Stamou SC, Hill PC, Dangas G, et al. Stroke after coronary artery bypass incidence, predictors, and clinical outcome. Stroke 2001; 32: 1508-1513.
11. Diegeler A, Hirsch R, Schneider F, et al. Neuromonitoring and neurocognitive outcome in off-pump versus conventional coronary bypass operations. Ann Thorac Surg 2000; 69: 1162-1166.
12. Edmunds LH Jr, Clark RE, Cohn LE, Grunkemeier GL, Miller DC, Weisel RD. Guidelines for reporting morbidity and mortality after cardiac valvular operations. J Thorac Cardiovasc Surg 1996; 112: 708-711.
13. Miyazaki S, Yoshitani K, Miura N, et al. Risk factors of stroke and delirium after off-pump coronary artery bypass surgery. Interact CardioVasc Thorac Surg 2011; 12: 379-383.
14. Mackinnon AD, Aaslid R, Markus HS. Ambulatory transcranial Doppler cerebral embolic signal detection in symptomatic and asymptomatic carotid stenosis. Stroke 2005; 36: 1726-1730.
15. Naylor RA, Mehta Z, Rothwell PM, et al. A systematic review of outcomes following staged and synchronous carotid endarterectomy and coronary artery bypass. Eur J Endovasc Surg 2003; 25: 380-389.
16. Borger MA, Ivanov J, Weisel RD, Rao V, Peniston CM. Stroke during coronary bypass surgery: principal role of cerebral macroemboli. Eur J Cardiothorac Surg 2001; 19: 627-632.
17. Rorich MB, Furlan AJ. Risk at cardiac surgery in patients with pri- or stroke. Neurology 1990; 40: 835-837.
18. Shroyer AL, Grover ş, Hattler B, et al. On-pump versus off-pump coronary artery bypass surgery. N Engl J Med 2009; 361: 1827- 1837.
19. Sedrakyan A, Wu AW, Parashar A, Bass EB, Treasure T. Off-Pump surgery is associated with reduced occurrence of stroke and other morbidity as compared with traditional coronary artery bypass grafting. A Meta-Analysis of systematically reviewed trials. Stroke 2006; 37: 2759-2769.
20. Dabrowski W, Rzecki Z, Pilat J, Czajkowski M. Brain damage in cardiac surgery patients. Curr Opin Pharmacol 2012; 12: 189-194.
21. Karmarkar SW, Bottum KM, Tischkau SA. Considerations for the use of anesthetics in neurotoxicity studies. Comp Med 2010; 60: 256-262.