Cemil YILMAZ, Türkan ÇORUH, Nihan YAPICI, Özlem YILMAZ, Hüseyin MAÇİKA, Zuhal AYKAÇ

Koroner arter bypass greft cerrahisinde torasik epidural ile preemptif analjezinin solunum fonksiyon testleri, ağrı skoru ve hemodinami üzerine etkileri

Amaç: Elektif koroner arter bypass greft (KABG) cerrahisi geçirecek hastalarda opioid esaslı (fentanil) genel anestezi ile kombine olarak uygulanan torasik epidural analjezinin operasyon sırası ve sonrası erken dönemde ağrı kontrolü, ekstübasyon zamanı, hemodinamik parametreler, solunum fonksiyon testleri ve pulmoner komplikasy onlar üzerine olan etkisini karşılaştırmaktır. Yöntem: Çalışmamızda ASA II-III, elektif KABG cerrahisi geçirecek 34 hasta randomize olarak iki grupta ele alındı. Her iki grupta da anestezi indüksiyonu yüksek doz fentanil (25 $mu$g $kg^{-1}$) ile yapıldı. Kontrol grubunda (n-17, grup K) postoperatif ağrı kontrolü aralıklı intravenöz fentanil ile sağlandı. Epidural grubunda (n=17, grup E) ameliyattan 16-24 saat önce yerleştirilen kateterden, cerrahi insizyon yapılmadan 45 dakika önce 6 mL volümde %0.25 bupivakain, 5 $mu$g $kg^{-1}$ morfin uygulandı ve 6 saatlik aralarla 6 mL volümde %0.12 bupivakain, 2.5 $mu$g $kg^{-1}$ morfin tekrarlandı. Her iki grup ağrı skorları, hemodinamik parametreler, ekstübasyon zamanı, solunum fonksiyon testleri ve pulmoner komplikasyonlar açısından karşılaştırıldı. Bulgular: Epidural grupta ağrı skorları ve ekstübasyon zamanı kontrol grubuna göre anlamlı biçimde düşük bulundu. Kalp hızı, ortalama ve sistolik arter basıncı kontrol grubunda epidural gruba göre sternotomi öncesi ve sonrası yüksek olarak bulundu. Gruplar arası solunum fonksiyon testleri ve pulmoner komplikasy onlar arasında anlamlı fark izlenmedi. Sonuç: Bulgularımız KABG cerrahisinde preemptif torasik epidural analjezinin operasyon sırası ve sonrası dönemde daha düşük ağrı skoru, kısa ekstübasyon süresi, daha stabil hemodinamik değerler sağladığını göstermektedir.

Anahtar Kelimeler:

Koroner arter köprüleme, Analjezi, epidural, Solunum fonksiyon testleri, Ağrı ölçümü

The effects of preemptive analgesia with thoracic epidural on respiratory function tests, pain scores and hemodynamics in coronary artery bypass graft surgery

Objective: The objective of this study was to compare the effects of opioid (fentanyl) based general anaesthesia, combined with thoracic epidural analgesia on perioperative pain control, extubation time, hemodynamics and pulmonary parameters in patients undergoing elective coronary artery bypass graft (CABG) surgery. Method: Thirty four ASA II-III patients undergoing elective CABG surgery were prospectively randomized into two groups. The control group patients (n=17, group C) received intermittent TV bolus fentanyl for postoperative pain control, whereas the epidural analgesia group patients (n=17, group E) received 6 mL 0.25% bupivacaine + 5 $mu$g $kg^{-1}$ morphine 45 minutes before the surgical incision via an epidural catheter at T3_6 level inserted 16-24 hours before the operation. In group E postoperative pain control was achieved with intermittent boluses of epidural bupivacaine (6 mL 0.12%) + morphine (5 $mu$g $kg^{-1}$) every 6 hours. Results: Pain scores and extubation time were significantly higher in group C compared to group E. Heart rate, mean and systolic arterial blood pressure values were significantly higher in group C than in group E before and after sternotomy. There were no significant differences between the groups for postoperative pulmonary function test values and pulmonary complications. Conclusion: Our data demonstrate that preemptive thoracic epidural analgesia provides better perioperative pain control, shorter extubation time and a more stable hemodynamic status in patients undergoing elective CABG surgery.

Keywords:

Coronary Artery Bypass, Analgesia, Epidural, Respiratory Function Tests, Pain Measurement,

PDF

___

1. de Lange S, Boscoe MJ, Stanley TH, Pace N. Comparision of sufentanil--O2 and fentanil--O2 for coronary artery surgery. Anesthesiology 1982; 56: 112-8.
2. Wynands JE, Townsend GE, Wong P, Whalley DG, Srikant CB, Patel YC. Blood pressure response and plasma fentanyl concentrations during high- and very high-dose fentanyl anaesthesia for coronary artery surgery. Anesth Analg 1983; 62: 661-5.
3. Edde RR. Hemodynamic changes prior to and after sternotomy in patients anesthetized with high-dose fentanyl. Anesthesiology 1981; 55: 444-6.
4. Caspi J, Klausner JM, Safadi T, Amar R, Rozin RR, Merin G. Delayed respiratory depression following fentanyl anesthesia for cardiac surgery. Crit Care Med 1988; 16: 238-40.
5. Klausner JM, Caspi J, Lelcuk S ve ark.. Delayed muscular rigidity and respiratory depression following fentanyl anesthesia. Arch Surg 1988; 123: 66-7.
6. Schmidt C, Hinder F, Van Akentl H ve ark. The effect of high thoracic epidural anesthesia on systolic and diastolic left ventricular function in patients with coronary artery disease. Anesth Analg 2005;100: 1561-9.
7. Hasenbos M, van Egmond J, Gielen M, Crul JF. Post-operative analgesia by epidural versus intramuscular nicomorphine after thoracotomy Part II. Acta Anaesthesiol Scand 1985; 29: 577-82.
8. Klassen GA, Bramwell RS, Bromage PR, Zborowska-Sluis DT. Effect of acute sympathectomy by epidural anesthesia on the canine coronary circulation. Anesthesiology 1980; 52: 8-15.
9. Nygard E, Kofoed KF, Freiberg J ve ark. Effects of high thoracic epidural analgesia on myocardial blood flow in patients with ischemic heart disease. Circulation 2005; 111: 2165-70.
10. Liem TH, Booij LH, Hasenbos MA, Gielen MJ. Coronary artery bypass grafting using two different anesthetic techniques: Part I: Hemodynamic results. J Cardiothorac Vasc Anesth 1992; 6: 148-55.
11. Joachimsson PO, Nystrom SO, Tyden H. Early extubation after coronary artery surgery in efficiently rewarmed patients: a postoperative comparison of opioid anaesthesia versus inhalational anesthesia and thoracic epidural analgesia. J Cardiothorac Anesth 1989; 3: 444-54.
12. Royse CF, Royse AG, Soeding PF, Blake D, Pang J. Prospective randomized trial of high thoracic epidural analgesia for coronary artery bypass surgery. Ann Thorac Surg 2003; 75:93-100.
13. Chakravarthy M, Thimmangowda P, Krishnamurthy J, Nadiminti S, Jawali V. Thoracic epidural anesthesia in cardiac surgical patients: A prospective Audit of 2,113 cases. J Cardiothorac Vasc Anesth 2005; 19: 44-8.
14. El-Baz N, Goldin M. Continuous epidural morphine infusion for pain relief after open heart surgery. Anaesthesiology 1983; 59: A 193.
15. Lund PC. Peridural anaesthesia. A review of 10.000 administrations. Acta Anaesthesia Scand 1962; 6: 143-59.
16. Dawkins CJ. An analysis of the complications of extradural and caudal block. Anaesthesia 1969; 24: 554-63.
17. Stenseth R, Bjella L, Berg EM, Christensen O, Levang OW, Gisvold SE. Effects of thoracic epidural analgesia on pulmonary function after coronary artery bypass surgery. Eur J Cardiothorac Surg 1996; 10: 859-65.
18. Kirno K, Lundin S, Milocco I ve ark. Thoracic epidural anaesthesia during CABG: Central and coronary hemodynamics, cardiac metabolism and cardiac sympathetic blockade estimated by radio labelled norepinephrine spillover. J Cardiothorac Vasc Anesth 1992; 6: 39.
19. Bromage PR. Epidural Analgesia. Philadelphia, PA, Saunders, 1978; 443, 650.
20. Hansdottir V, Philip J, Olsen MF, Eduard C, Houltz E, Ricksten SE. Thoracic epidural versus intravenous patient-controlled analgesia after cardiac surgery: a randomized controlled trial on length of hospital stay and patient-perceived quality of recovery. Anesthesiology 2006; 104: 142-51.
21. Ronald A, Aziz KAA, Day TG, Scott M. In patients undergoing cardiac surgery, thoracic epidural analgesia combined with general anaesthesia results in faster recovery and fewer complications but does not affect length of hospital stay. Interact Cardio Vasc Thorac Surg 2006; 5: 207-16.
22. Priestley MC, Cope L, Halliwell R ve ark. Thoracic epidural anesthesia for cardiac surgery: The effects on tracheal intubation time and length of hospital stay. Anesth Analg 2002; 94: 275-82.
23. Fawcett WJ, Edwards RE, Quinn AC, MacDonald IA, Hall GM. Thoracic epidural analgesia started after cardiopulmonary bypass. Adrenergic, cardiovascular and respiratory sequelae. Anaesthesia 1997; 52: 294-9.
24. Shenkman Z, Shir Y, Weiss YG, Bleiberg B, Gross D. The effects of cardiac surgery on early and late pulmonary functions. Acta Anaesthesiol Scand 1997; 41: 1193-9.
25. Pastor MC, Sanchez MJ, Casas MA, Mateu J, Bataller ML. Thoracic epidural analgesia in coronary artery bypass graft surgery: Seven years’ experience. J Cardiothorac Vasc Anesth 2003; 17:154-9.