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İntratekal Morfin Uygulamasının Koroner Arter Bypass Greft Operasyonlarında Stres Yanıt ve Ağrı Kontrolü Üzerine Etkisi

Year 2012, Volume: 4 Issue: 1, 18 - 23, 01.04.2012

Abstract

Koroner arter bypass greft operasyonlarında intratekal morfin uygulamasının cerrahi travmaya stres, hemodinamik yanıt ve postoperatif ağrı üzerine etkileri değerlendirildi. Prospektif, randomize bu çalışmaya etik komite izni ve hastaların bilgilendirilmiş onayı alındıktan sonra, ASA II-III grubu, elektif koroner arter cerrahisi planlanan, 35-70 yaş arası 40 hasta dahil edildi. Operasyon odasında L2-3 aralığından intratekal yolla Grup ITM'ye 20 mcg kg-1 morfin verildi. Grup K'ya hiçbir şey uygulanmadı. Tüm hastalara standart genel anestezi, cerrahi ve kardiyopulmoner bypass teknikleri uygulandı. Operasyon süresince kullanılan toplam fentanil miktarı kaydedildi. Ortalama arter basıncı, kalp hızı, SpO2 değerleri ile plazma kortizol düzeyleri; anestezi indüksiyon öncesi, sternotomi sonrası, KPB ilk 5. dakika, AKK sırasında, KPB ısınma sonu, hastanın YBÜ transferinden sonra, postoperatif 8. saat, postoperatif 1. gün olmak üzere kaydedildi. Hastalara postoperatif dönemde hasta kontrollü anestezi HKA cihazı takıldı. Ekstübasyon sonrası 0-6, 6-12, 12- 24, 24-48. saatlerde kümülatif morfin miktarları kaydedildi. Hastaların ağrı düzeyi; ekstübasyondan hemen sonra ve ekstübasyon sonrası 6, 12, 24, 36, 48. saatlerde Vizüel anolog skala VAS ile değerlendirildi. İstatistiksel değerlendirmede; t- Student testi; Ki-kare testi kullanıldı. Demografik, intraoperatif ve hemodinamik veriler, postoperatif ekstübasyon süreleri, postoperatif komplikasyonlar açısından iki grup benzer bulundu. Operasyon süresince kullanılan fentanil miktarı Grup ITM'de Grup K'ya göre daha düşük bulundu. Postoperatif kümülatif morfin tüketimi ITM Grubunda K Grubuna göre anlamlı olarak düşük bulundu. YBÜ&'39;e transferden sonra, postoperatif 8. saat ve postoperatif 1.gün alınan kan örneklerindeki serum kortizol düzeyleri Grup ITM'39;de K Grubuna göre anlamlı olarak düşük saptandı. Öksürme halindeki VAS değerleri Grup ITM'de Grup K&'39;a göre ekstübasyon sonrası, ekstübasyondan sonra 6, 12, 24 ve 36. saatlerde anlamlı olarak düşük bulundu. p

References

  • Liem TH, Booij LH, Gielen MJ, Hasenbos MA, van Eg- mond J. Coronary artery bypass grafting using two different anesthetic techniques: Part 3: Adrenergic responses. J Cardiothorac Vasc Anesth 1992;6:162- 167.
  • Reves JG, Karp RB, Buttner EE, Tosone S, Smith LR, Samuelson PN, et al. Neuronal and adrenomedullary catecholamine release in response to cardiopulmo- nary bypass in man. Circulation 1982;66:49-55.
  • Liem TH, Hasenbos MA, Booij LH, Gielen MJ. Coro- nary artery bypass grafting using two different anest- hetic techniques: Part 2: Postoperative outcome. J Cardiothorac Vasc Anesth 1992;6:156-161.
  • Mangano DT, Siliciano D, Hollenberg M, Leung JM, Browner WS, Goehner P, et al. Postoperative myocar- dial ischemia. Therapeutic trials using intensive anal- gesia following surgery. The Study of Perioperative Ischemia (SPI) Research Group. Anesthesiology 1992;76:342-353.
  • Anand KJ, Hickey PR. Halothane-morphine compared with high-dose sufentanil for anesthesia and postope- rative analgesia in neonatal cardiac surgery. N Engl J Med 1992;326:1-9.
  • Kayhan Z. Klinik Anestezi II. Baskı. Logos Yayıncılık, İstanbul 1997;354-360.
  • Gill GN. Endocrine and reproductive Diseases. İn: Wyngaarden B, Smith LH, Bennett JC, eds. Cecil Text- book of Medicine. 19,h ed. Philadelphia-W.B. Saun- ders, 1992: 1194-1397.
  • Jones SEF, Beasley JM, Macfarlane WR, et al. Intrathe- cal morphine for postoperative pain relief in children. Br J Anesth 1984;56:137-140.
  • Rawal N, Arner S, Gustafsson ,Allvin R. Present state of extradural and intrathecal opioid analgesia in Swe- den.Br J Anaest 1987;59:791.
  • Cousins MJ, Mather LE. Epidural and intrathecal ad- ministration of opioids .Anesthesiology 1984;61:276- 310
  • Maestroni GJM , Conti A. Anti-stress role of the im- muno- opioid netvvork: Evidence for a physiological mechanism involving T cell-derived, immunoreactive b-endorphin and metenkephalin binding to thymic opioid receptors. Int J Neurosci 1991; 61: 289-298.
  • Hall R,Natasha A.Does intrathecal morphine alter the stress response following CABG surgery.Can J Anesth 2000;47:5-463
  • Etches RC, Sandler AN, Daley MD. Respiratoyr depres- sion and spinal opioids. Can J Anaesth 1989;36:165- 185
  • Nordberg G, Hedner T, Mellstrand T, Dahlstrom B. Pharmacokinetic aspects of intrathecal morphine analgesia. Anesthesiology 1984;60:448-454
  • Roediger L, Joris J, Senard M. The use of pre-operati- ve intrathecal morphine for analgesia following CABG. Anesthesia 2006;61:838
  • Mark A, Chaney MD. İntrathecal and Epidural Anest- hesia and Analgesia for cardiac surgery.Anesth Analg 2006;102:45-64
  • Chaney MA, Furry PA, Fluder EM, Slogoff S. Intrathe- cal morphine for coronary artery bypass grafting and early extubation.Anesth Analg 1997;84:241-248
  • Boulanger A, Perreault S, Choiniere M, et al.Intrathe- cal morphine after cardiac surgery. Ann Pharm Fr 2002;36:1337-1343.
  • Alhashemi JA, Sharpe MD, Harris CL, et al. Effect of subarachnoid morphine administration on extubation time after CABG surgery. J Cardiothorac Vasc Anesth 2000;14.639-644
  • Chaney MA. Side effects of intrathecal and epidural opioids.Can J Anaesth 1995;42:891-903
  • Owens EL, Kasten GW, Hessel EA. Spinal subarachnoid hematoma after lumbar puncture and heparinizati- on:a case report,review of the literature, and discussi- on of anesthetic implications. Anesth Analg 1986;65:1201-1207.
  • Fitzpatrick GJ., Moriarty DC. İntrathecal morphine in the management of pain following cardiac surgery:a comparison with morphine i.v. Br J Anesth 1988; 60: 639-644
  • Vanstrum GS, Bjornson KM, Ilko R. Postoperative ef-
  • fects of intrathecal moorphine in coronary artery bypass surgery. Anesth Analg 1988;67:261-267

The Effect of Intrathecal Morphıne Application Upon Stress Response and Pain Control in The Operations of Coronary Arterial Bypass Graft

Year 2012, Volume: 4 Issue: 1, 18 - 23, 01.04.2012

Abstract

Aim: The effects of intrathecal morphine application upon surgical insult stress, hemodynamic response and postoperative pain in the operations of coronary arterial bypass graft have been evaluated. Material and Method: After getting permission of ethics committee and informed consent of patients,a prospective randomized study was planned. A total of 40 patients age range: 35-70 years of whom elective coronary artery surgery ASA II-III groups , have been planned were included into the study. In the operating room, 20 mcg kg-1 morphine has been given to Group ITM within the range of L2-3 by the way of intrathecal. Group “K” received no treatment. Standard general anesthesia, surgical and cardiopulmonary bypass techniques have been applied to all patients. Total amount of fentanyl, used during the operation, has been recorded. The average of blood pressure, heart rate, SpO2 values and the levels of blood plasma cortisol; before induction, after sternotomy, at the initial 5 minutes of CPB during AKK, at the end of CPB warm up, after transfering the patient to Intensive Care Unit ICU at postoperative 8th hour and postoperative 1st day have been recorded. Patient controlled anesthesia device has been mounted to patients during the postoperative period. After extubation, cumulative morphine portions have been recorded at 0-6, 6-12, 12-24, 24-48. hours. Soon after extubation and at 6, 12, 24, 36, 48. hours after etubation; pain levels of patients have been evaluated with Visual Analogue Scale VAS . At statistical evaluation; t-Student test; chi square test has been used. Results: Demographic, intraoperative and hemodynamic parameters, postoperative extubation terms have been found similar in the way of postoperative complications in two groups. Fentanyl dosage, used during the operation, has been found lower in group ITM compared to group K. In group ITM, consumption of postoperative cumulative morphine has been found significuntly low compared to group K. Following the transfer to ICU, serum cortisol levels, in the blood samples drawn at postoperative 8th hour and postoperative 1st day, have been detected superior in ITM group to at group K. Shortly after extubation and at 6, 12, 24, 36 hours after extubation, VAS values during coughing have been detected significantly lower in group ITM compared to group K. p

References

  • Liem TH, Booij LH, Gielen MJ, Hasenbos MA, van Eg- mond J. Coronary artery bypass grafting using two different anesthetic techniques: Part 3: Adrenergic responses. J Cardiothorac Vasc Anesth 1992;6:162- 167.
  • Reves JG, Karp RB, Buttner EE, Tosone S, Smith LR, Samuelson PN, et al. Neuronal and adrenomedullary catecholamine release in response to cardiopulmo- nary bypass in man. Circulation 1982;66:49-55.
  • Liem TH, Hasenbos MA, Booij LH, Gielen MJ. Coro- nary artery bypass grafting using two different anest- hetic techniques: Part 2: Postoperative outcome. J Cardiothorac Vasc Anesth 1992;6:156-161.
  • Mangano DT, Siliciano D, Hollenberg M, Leung JM, Browner WS, Goehner P, et al. Postoperative myocar- dial ischemia. Therapeutic trials using intensive anal- gesia following surgery. The Study of Perioperative Ischemia (SPI) Research Group. Anesthesiology 1992;76:342-353.
  • Anand KJ, Hickey PR. Halothane-morphine compared with high-dose sufentanil for anesthesia and postope- rative analgesia in neonatal cardiac surgery. N Engl J Med 1992;326:1-9.
  • Kayhan Z. Klinik Anestezi II. Baskı. Logos Yayıncılık, İstanbul 1997;354-360.
  • Gill GN. Endocrine and reproductive Diseases. İn: Wyngaarden B, Smith LH, Bennett JC, eds. Cecil Text- book of Medicine. 19,h ed. Philadelphia-W.B. Saun- ders, 1992: 1194-1397.
  • Jones SEF, Beasley JM, Macfarlane WR, et al. Intrathe- cal morphine for postoperative pain relief in children. Br J Anesth 1984;56:137-140.
  • Rawal N, Arner S, Gustafsson ,Allvin R. Present state of extradural and intrathecal opioid analgesia in Swe- den.Br J Anaest 1987;59:791.
  • Cousins MJ, Mather LE. Epidural and intrathecal ad- ministration of opioids .Anesthesiology 1984;61:276- 310
  • Maestroni GJM , Conti A. Anti-stress role of the im- muno- opioid netvvork: Evidence for a physiological mechanism involving T cell-derived, immunoreactive b-endorphin and metenkephalin binding to thymic opioid receptors. Int J Neurosci 1991; 61: 289-298.
  • Hall R,Natasha A.Does intrathecal morphine alter the stress response following CABG surgery.Can J Anesth 2000;47:5-463
  • Etches RC, Sandler AN, Daley MD. Respiratoyr depres- sion and spinal opioids. Can J Anaesth 1989;36:165- 185
  • Nordberg G, Hedner T, Mellstrand T, Dahlstrom B. Pharmacokinetic aspects of intrathecal morphine analgesia. Anesthesiology 1984;60:448-454
  • Roediger L, Joris J, Senard M. The use of pre-operati- ve intrathecal morphine for analgesia following CABG. Anesthesia 2006;61:838
  • Mark A, Chaney MD. İntrathecal and Epidural Anest- hesia and Analgesia for cardiac surgery.Anesth Analg 2006;102:45-64
  • Chaney MA, Furry PA, Fluder EM, Slogoff S. Intrathe- cal morphine for coronary artery bypass grafting and early extubation.Anesth Analg 1997;84:241-248
  • Boulanger A, Perreault S, Choiniere M, et al.Intrathe- cal morphine after cardiac surgery. Ann Pharm Fr 2002;36:1337-1343.
  • Alhashemi JA, Sharpe MD, Harris CL, et al. Effect of subarachnoid morphine administration on extubation time after CABG surgery. J Cardiothorac Vasc Anesth 2000;14.639-644
  • Chaney MA. Side effects of intrathecal and epidural opioids.Can J Anaesth 1995;42:891-903
  • Owens EL, Kasten GW, Hessel EA. Spinal subarachnoid hematoma after lumbar puncture and heparinizati- on:a case report,review of the literature, and discussi- on of anesthetic implications. Anesth Analg 1986;65:1201-1207.
  • Fitzpatrick GJ., Moriarty DC. İntrathecal morphine in the management of pain following cardiac surgery:a comparison with morphine i.v. Br J Anesth 1988; 60: 639-644
  • Vanstrum GS, Bjornson KM, Ilko R. Postoperative ef-
  • fects of intrathecal moorphine in coronary artery bypass surgery. Anesth Analg 1988;67:261-267
There are 24 citations in total.

Details

Primary Language Turkish
Journal Section Research Article
Authors

Emre Gürcü This is me

Tülay Kayacan Örki This is me

Füsun Güzelmeriç This is me

Atakan Erkılınç This is me

Evşen Ovat This is me

Tuncer Koçak This is me

Publication Date April 1, 2012
Published in Issue Year 2012 Volume: 4 Issue: 1

Cite

Vancouver Gürcü E, Kayacan Örki T, Güzelmeriç F, Erkılınç A, Ovat E, Koçak T. İntratekal Morfin Uygulamasının Koroner Arter Bypass Greft Operasyonlarında Stres Yanıt ve Ağrı Kontrolü Üzerine Etkisi. Maltepe tıp derg. 2012;4(1):18-23.