Sitoredüktif cerrahi ve hipertermik intraperitoneal kemoterapi geçiren hastaların kardiyovasküler durumlarının PRO-BNP, CK-MB ve Troponin-T ile değerlendirilmesi
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Tarih
2020
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Yayıncı
Ege Üniversitesi, Tıp Fakültesi
Erişim Hakkı
info:eu-repo/semantics/openAccess
Özet
AMAÇ: Sitoreduktif cerrahi (SRC) ve Hipertermik İntraperitoneal Kemoterapi (HİPEK) prosedürü peritoneal karsinomatozisli hastalarda sağkalıma olumlu etkileri sebebiyle giderek artan sıklıkta uygulanmaktadır. İşlem sırasındaki hemodinamik ve metabolik dengesizlikler anestezi yönetimini zorlaştırmaktadır. Çalışmamızda özellikli olarak myokardın bu prosedürde nasıl etkilendiğini incelemek istedik. Bu nedenle çalışmanın birincil amacı bu hastalarda myokard fonksiyonlarındaki bozulmanın varlığı ve nedenini CK-MB, Pro-BNP, Troponin-T ile saptamak; ikincil amacı myokard fonksiyonları ile peroperatif anestezi uygulamasının ilişkisini değerlendirmektir. Bu ilişki günümüzde SRC ve HİPEK ameliyatlarında optimal anestezi uygulamalarına yön verecektir. METOD: Çalışmamız, kesitsel, prospektif, kohort çalışma olarak planlandı. Klinik araştırmalar Etik Kurulu onayı alınarak Ocak 2018-Eylül 2019 arasında SRC-HİPEK operasyonu geçiren hastalar çalışmaya alındı. Standart inhalasyona dayalı genel anestezi ve invazif monitorizasyon izlemi dışında hastalardan, preoperatif ve postoperatif 6.saat Pro-BNP, CK-MB ve Troponin-T ve rutin hemogram, biyokimya ölçümleri yapıldı. İntraoperatif norepinefrin (NE) gereksinimi olup olmamasına göre hastalar iki gruba ayrıldı. İstatistiksel analiz için Kolmogorov-Smirnow, Shapiro Wilk, Mann-Whitney, Fisher-exact, Chi-square, Wilcoxon ve Spearman's correlation testleri kullanıldı. BULGULAR: Çalışma dönemi içinde ulaşılan 38 hastadan 8'i HİPEK prosedüründen vazgeçilmesi nedeniyle çalışma dışı bırakıldı, 30 hasta istatistiksel olarak değerlendirildi. Hastalar ortalama 54 (±10) yaşında, 165 (±10) cm, 72 (±12) kg, K/E: 12/18 idi. ASA I/II/III skoru dağılımı 8/21/1'dir. Çalışmamızda ortalama anestezi süresi 432 (±122) dk, operasyon süresi 394 (±125) dk, SRC süresi 264 (±111) dk, HİPEK süresi ise 64 (±32) dk'dır. NE gereken (n=14) grubun Anestezi süresi, ve SRC süreleri, eritsosit süspansiyonu gereksinimi, renal komplikasyon oranı NE gerekmeyen (n=16) gruba göre anlamlı farklı bulundu (p<0.05). Her iki grubun intraoperatif sıvı gereksinimi, hemodinamik seyri ve mortalite oranı benzer bulundu (p>0.05). Postoperatif NT-ProBNP, Troponin-T ve CK-MB mass düzeyleri preoperatif döneme göre anlamlı arttığı gözlendi. Enzimlerin postoperatif-preoperatif farkları karşılaştırıldığında NT-proBNP ve CK-MB mass ölçümünün iki grupta da anlamlı arttığı ancak Troponin-T ölçümünün sadece NE gerektiren grupta anlamlı yükseldiği saptandı. Aynı zamanda Troponin-T'nin postoperatif düzeyi ve postoperatif-preoperatif düzey farkı, SRC ve hastanede yatış süresi ile anlamlı ilişkili bulundu. Postoperatif CK-MB ve postoperatif-preoperatif CK-MB farkının ise Anestezi süresi ve Operasyon süresi ile anlamlı ilişkide olduğu saptandı. SONUÇ: Sitoredüktif cerrahi ve hipertermik intraperitoneal kemoterapi, intraoperatif hemodinamik dengesizlik nedeniyle vazokonstriktör gereksinimi olan kompleks cerrahi uygulamalardır. Enzimlerdeki değişikliklere bakıldığında, perioperatif dönemde hemodinamik dengesizlik miyokard hasarlanması ile ilişkili olabilir. Ancak bu bulgunun, daha geniş hasta serilerini içeren çalışmalar ile doğrulanmaya ihtiyacı vardır.
PURPOSE: Cytoreductive surgery (CRS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) procedure has been applied increasingly often to patients with peritoneal carcinamatosis due to its positive effects on survival. The hemodynamic and metabolic instability in this procedure complicates the application of anesthesia. Peroperative practises' effects on mortality and morbidity are not clear. In our study, we proposed to examine how specifically myocard is affected from this procedure. Therefore, the first purpose of this study is to determine the causes of the presence of myocardial function impairment using the CK MB, NT ProBNP, Troponin T levels; secondarily is to determine the relation between the myocardial functions and peroperative anesthesia practises. This relation will channel the optimal anesthesia practises on CRS an HIPEC surgeries. METHOD: Our study is planned as cross sectional, prospective and cohort. With the consent of the Clinical Research Ethics Committee, the patients who underwent a CRS HIPEC surgery between January 2018 September 2019 were included in the study. Except the standard inhalation anesthesia and invasive monitorization, the pro BNP, CK MB and troponin t and routine biochemical tests and hemogram levels at preoperative period and postoperative 6th hour were determined. Patients are separated into two different groups acccording to the demand for norepinephrine intraoperatively. Kolmogorov Smirnow, Shapiro Wilk, Mann Whitney, Fisher exact, Chi square, Wilcoxon ve Spearman’s correlation tests are used for statistical analysis. FINDINGS: Due to withdrawal from the HIPEC procedure 8 of the 38 patients were excluded from the study, 30 patients are evaluated statistically. Patients were 54 (±10) years old, 165 (±10) cm length, 72 (±12) kg body weight; female/male 12/18. ASA Scores distribution were 8/21/1(I/II/III). There was no significant difference in demographic properties between the groups. The mean time for anesthesia was 432 (±122) minutes, for operation 394 (±125) minutes, for SRC was 264 (±111) minutes, for HIPEC was 64 (±32) minutes. . The norepinephrine required group's (n=14) anesthesia times and SRC times, erytrocyte suspension requirement and renal complication rate were statistically significantly higher than the non NE required group (n=16)(p<0,05). Crystalloid and colloid volumes used, mortality rate and hemodynamic course were similar in groups (p>0,05). Blood pressure and heart rates significantly decreased in both groups in the process of time (p<0,05). Postoperative NT ProBNP, Troponin T and CK MB mass levels significantly increased according to preoperative period. When the preoperative postoperative enzyme levels compared, Nt proBNP and CK MB mass have been observed to increase significantly in both groups, but the Troponin T level increased significantly only in the NE required group. However, postoperative Troponin T level and the difference between postopreative preoperative levels had found to be significantly related to the time of CRS and hospitalization times. Postoperative CK MB level and the level difference between postoperative preoperative periods were significiantly related witg anesthesia and operation times. RESULT: The Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy are complex surgery practises that require vasoconstructor agents because of the hemodynamic instability. Considering enzyme levels changes, perioperative hemodynamic instability may refer to myocardial damage. However, this evidence needs to be justified by further studies that implemented with larger patients series.
PURPOSE: Cytoreductive surgery (CRS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) procedure has been applied increasingly often to patients with peritoneal carcinamatosis due to its positive effects on survival. The hemodynamic and metabolic instability in this procedure complicates the application of anesthesia. Peroperative practises' effects on mortality and morbidity are not clear. In our study, we proposed to examine how specifically myocard is affected from this procedure. Therefore, the first purpose of this study is to determine the causes of the presence of myocardial function impairment using the CK MB, NT ProBNP, Troponin T levels; secondarily is to determine the relation between the myocardial functions and peroperative anesthesia practises. This relation will channel the optimal anesthesia practises on CRS an HIPEC surgeries. METHOD: Our study is planned as cross sectional, prospective and cohort. With the consent of the Clinical Research Ethics Committee, the patients who underwent a CRS HIPEC surgery between January 2018 September 2019 were included in the study. Except the standard inhalation anesthesia and invasive monitorization, the pro BNP, CK MB and troponin t and routine biochemical tests and hemogram levels at preoperative period and postoperative 6th hour were determined. Patients are separated into two different groups acccording to the demand for norepinephrine intraoperatively. Kolmogorov Smirnow, Shapiro Wilk, Mann Whitney, Fisher exact, Chi square, Wilcoxon ve Spearman’s correlation tests are used for statistical analysis. FINDINGS: Due to withdrawal from the HIPEC procedure 8 of the 38 patients were excluded from the study, 30 patients are evaluated statistically. Patients were 54 (±10) years old, 165 (±10) cm length, 72 (±12) kg body weight; female/male 12/18. ASA Scores distribution were 8/21/1(I/II/III). There was no significant difference in demographic properties between the groups. The mean time for anesthesia was 432 (±122) minutes, for operation 394 (±125) minutes, for SRC was 264 (±111) minutes, for HIPEC was 64 (±32) minutes. . The norepinephrine required group's (n=14) anesthesia times and SRC times, erytrocyte suspension requirement and renal complication rate were statistically significantly higher than the non NE required group (n=16)(p<0,05). Crystalloid and colloid volumes used, mortality rate and hemodynamic course were similar in groups (p>0,05). Blood pressure and heart rates significantly decreased in both groups in the process of time (p<0,05). Postoperative NT ProBNP, Troponin T and CK MB mass levels significantly increased according to preoperative period. When the preoperative postoperative enzyme levels compared, Nt proBNP and CK MB mass have been observed to increase significantly in both groups, but the Troponin T level increased significantly only in the NE required group. However, postoperative Troponin T level and the difference between postopreative preoperative levels had found to be significantly related to the time of CRS and hospitalization times. Postoperative CK MB level and the level difference between postoperative preoperative periods were significiantly related witg anesthesia and operation times. RESULT: The Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy are complex surgery practises that require vasoconstructor agents because of the hemodynamic instability. Considering enzyme levels changes, perioperative hemodynamic instability may refer to myocardial damage. However, this evidence needs to be justified by further studies that implemented with larger patients series.
Açıklama
Anahtar Kelimeler
Sitoreduktif Cerrahi, Hipertermik İntraperitoneal Kemoterapi, Norepinefrin, Troponin, ProBNP, CK-MB, Cytoreductive Surgery, Hyperthermic Intraperitoneal Chemotherapy, Norephinephrine, Troponin
