The effects of intravenous aminoacid infusion on myocardial functions and postoperative analgesia during abdominal aortic surgery

Yıl 2013, Cilt: 40 Sayı: 1, 21 - 30, 01.03.2013

Mustafa Turhan Ayşe Baysal Mevlüt Doğukan Hüseyin Toman Ahmet Çelışkan Tuncer Koçak

https://doi.org/10.5798/diclemedj.0921.2013.01.0218

Öz

Objective: Effects of intravenous aminoacid infusion on myocardial functions and postoperative analgesia in ab­dominal aortic surgery were investigated. Materials and methods: Forty patients were randomly divided into groups of general anaesthesia with or with­out aminoacid infusion (Group 1 and 2, n=10), combined general+epidural with or without amino acid infusion (Group 3 and 4, n=10). Cardiac risk was evaluated using 2007 AHA/ ACC and modified Goldman classifications. Intravenous aminoacid solution of 80 g/L was infused at 2.5 ml/kg/h for a total of 8 hours. General anaesthesia included intravenous remifentanil, rocuronium, sevoflurane. The lumbar epidural include; 10 mL of 0.25% bupivacaine; bolus dose, an infu­sion of 0.25% bupivacaine; 4 ml/h for 24 hours. Heart rate, arterial blood pressures were collected intraoperative ev­ery 10 minute, 1, 24 hour postoperatively. Plasma creatine kinase MB fraction, troponin levels, pain assessment with numeric analog scale were collected preoperatively, 1, 24 hour postoperatively. Postoperative 24 hour analgesic us­age, complications were recorded. Results: Patients with mild and severe cardiac risk were higher in 2007 AHA/ACC classification (26/40, 65%) than modified Goldman risk classification (5/40, 12.5%) (p=0.04). In comparison between groups, myocardial enzyme levels and complications showed no difference (p>0.05). The use of analgesics were lower in group 3 and 4 in comparison to group 1 and 2 (p=0.002). Conclusion: During abdominal aortic surgery, intravenous infusion of amino acid did not show significant changes on intraoperative and postoperative hemodynamic parameters and myocardial enzymes. The patients received combined general plus epidural anaesthesia showed more successful postoperative analgesia.

Anahtar Kelimeler

Amino acid, abdominal aorta, vascular surgery, epidural anesthesia, general anesthesia, keratin kinase, troponin, postoperative analgesia

Abdominal aort cerrahisinde intravenöz aminoasit infüzyonunun miyokardiyal fonksiyonlar ve postoperatif analjezi üzerine etkileri

Öz

Amaç: Abdominal aort cerrahisinde intravenöz aminoasit infüzyonunun miyokard ve postoperatif analjezi üzerine et­kileri incelendi. Gereç ve yöntem: Ardışık 40 hasta genel anestezide ami­noasit infüzyonu uygulanan ve uygulanmayan (Grup 1 ve 2, n=10), kombine genel/epidural anestezide aminoasit in­füzyonu uygulanan ve uygulanmayan (Grup 3 ve 4, n=10) olarak rastgele ayrıldı. 2007 AHA/ACC ve Modifiye Gold­man ile kardiyak risk değerlendirildi. Genel anestezide int­ravenöz remifentanil, rokuronyum ve sevofluran uygulandı. Kombine genel/epidural anestezide, indüksiyon öncesi lom­ber epidural kateterden 10 mL %0,25 bupivakain sonrası infüzyon %0,25 bupivakain 4 mL/saat, 24 saat uygulandı. İntravenöz aminoasit 80 g/L solüsyonundan 2,5 ml/kg/saat, toplam 8 saat uygulandı. İntraoperatif 10 dakikada bir, pos­toperatif 1. ve 24. saatlerde kan basıncı ve kalp atım hızı değerleri kaydedildi. Plazma kreatin kinaz MB fraksiyonu, troponin değerleri, numerik analog skala ile ağrı değerlen­dirmesi preoperatif, postoperatif 1. ve 24. saatte ölçüldü. Postoperatif 24 saatlik analjezik tüketimi ve yan etkiler kay­dedildi. Bulgular: 2007 AHA/ACC sınıflamasında orta ve yüksek kardiyak riskli hasta sayısı (26/40, %65), modifiye Goldman ile olan hasta sayısından (5/40, %12,5) yüksekti (p=0,04). Gruplar karşılaştırıldığında, miyokardiyal enzimlerin değer­leri ve komplikasyonlar açısından fark bulunmadı (p>0,05). Postoperatif analjeziklerin Grup 3 ve 4\'deki kullanımları Grup 1 ve 2\'den düşük bulundu (p=0,002). Sonuç: Abdominal aort cerrahisinde, intravenöz aminoasit infüzyonunun intraoperatif ve postoperatif hemodinamik parametreler yanısıra miyokardiyal enzim değerlerinde belirgin farklılıklar saptanmadı. Kombine genel + epidural uygulanan hastalarda postoperatif analjezi daha başarılı bulundu.

Anahtar Kelimeler

Aminoasit, abdominal aorta, vasküler cerrahi, epidural anestezi, genel anestezi, kreatin kinaz, tro­ponin, postoperatif analjezi

Kaynakça

• Baron JF, Bertrand M, Barré E, et al. Combined epidural and general anesthesia versus general anesthesia for abdominal aortic surgery. Anesthesiology 1991;75:611-8.
• Christopherson R, Beattie C, Frank SM, et al. Perioperative morbidity in patients randomized to epidural or general an- esthesia for lower extremity vascular surgery. Perioperative ischemia randomized anesthesia trial study group. Anesthe- siology 1993;79:422-34.
• Garnett RL, MacIntyre A, Lindsay P, et al. Perioperative ischemia in aortic surgery: Combined epidural/general an- aesthesia and epidural analgesia vs. general anaesthesia and i.v. analgesia. Can J Anaesth 1996;43:769-77.
• Christopherson R, Glavan NJ, Norris EJ, et al. Control of blood pressure and heart rate in patients randomized to epi- dural and general anesthesia for lower extremity vascular surgery. Perioperative ischemia randomized anesthesia trial study group. J Clin Anesth 1996;8:578-84.
• Bode RHJ, Lewis KP, Zarich SW, et al. Cardiac outcome af- ter peripheral vascular surgery. Comparison of general and regional anesthesia. Anesthesiology 1996;84:3-13.
• Sitzman BT, Watson D, Schug SA. Combined general and epidural anesthesia for abdominal aortic aneurysm surgery. Techniques in Regional Anesthesia and Pain Management
• Boylan JF, Katz J, Kavanagh BP, et al. Epidural bupivacaine- morphine analgesia versus patient controlled analgesia fol- lowing abdominal aortic surgery: Analgesic, respiratory, and myocardial effects. Anesthesiology 1998;89:585-593.
• Ballantyne JC, Carr DB, deFerranti S, et al. The comparative effects of postoperative analgesic therapies on pulmonary outcome: Cummulative meta-analyses of randomized, con- trolled trials. Anesth Analg 1998;86:598-612.
• Detsky AS, Abrams HB, Forbath N, et al. Cardiac assessment for patients undergoing noncardiac surgery. A multifacto- rial clinical risk index. Arch Intern Med 1986;146:2131-4.
• Yeager MP, Glass DD, Neff RK, et al. Epidural anesthesia and analgesia in high-risk surgical patients. Anesthesiology 1987;66:729-736.
• Mackey JJ, Parker SD, Nass CM, et al. Effectiveness of remifentanil versus traditional fentanyl-based anesthetic in high-risk outpatient surgery. J Clin Anesth 2000;12:427-32.
• Tuman KJ, McCarthy RJ, March RJ, et al. Effects of epidur- al anesthesia and analgesia on coagulation and outcome af- ter major vascular surgery. Anesth Analg 1991;73:696-704.
• Yılmaz AA. Anesthesia for intraabdominal aortic sur- gery. Turkiye Klinikleri J Anest Reanim-Special Topics 2008;1:68-78.
• Gold MS, DeCrosta D, Rizzuto C, et al. The effect of lumbar epidural and general anesthesia on plasma catecholamines and hemodynamics during abdominal aortic aneurysm re- pair. Anesth Analg 1994;78:225-30.
• de Leon-Casasola OA, Lema MJ, Karabella D, et al. Post- operative myocardial ischemia: epidural versus intravenous patient-controlled analgesia. A pilot project. Reg Anesth 1995; 20:105-12.
• Limberi S, Markou N, Sakayianni K, et al. Coronary artery disease and upper abdominal surgery: impact of anesthesia on perioperative myocardial ischemia. Hepatogastroenter- ology 2003;50:1814-20.
• Umenai T, Nakajima Y, Sessler DI, et al. Perioperative amino acid infusion improves recovery and shortens the duration of hospitalization after off-pump coronary artery bypass grafting. Anesth Analg 2006;103:1386-93.
• Widman J, Hammarqvist F, Sellden E. Amino acid infusion induces thermogenesis and reduces blood loss during hip arthroplasty under spinal anesthesia. Anesth Analg 2002; 95:1757-62.
• Sellden E, Lindahl SG. Amino acid-induced thermogenesis reduces hypothermia during anesthesia and shortens hospi- tal stay. Anesth Analg 1999;89:1551-6.
• Inoue S, Shinjo T, Kawaguchi M, et al. Amino acid infu- sions started after development of intraoperative core hy- pothermia do not affect rewarming but reduce the incidence of postoperative shivering during major abdominal surgery: a randomized trial. J Anesth 2011;25:850-4.
• Nakajima Y, Takamata A, Matsukawa T, et al. Effect of amino acid infusion on central thermoregulatory control in humans. Anesthesiology 2004;100:634-9.
• Hogue CW Jr, Bowdle TA, O’Leary C, et al. A multicenter evaluation of total intravenous anesthesia with remifentanil and propofol for elective inpatient surgery. Anesth Analg 1996;83:279-85.
• Casati L, Fernández-Galinski S, Barrera E, et al. Isoflurane requirements during combined general/epidural anesthesia for major abdominal surgery. Anesth Analg. 2002;94:1331- 7.
• Her C, Kizelshteyn G, Walker V, et al. Combined epidural and general anesthesia for abdominal aortic surgery. J Car- diothorac Anesth 1990;4:552-7.
• Kataja J. Thoracolumbar epidural anaesthesia and isoflu- rane to prevent hypertension and tachycardia in patients undergoing abdominal aortic surgery. Eur J Anaesthesiol
• Mann C, Pouzeratte Y, Boccara G, et al. Comparison of intravenous or epidural patient-controlled analgesia in the elderly after major abdominal surgery. Anesthesiology 2000;92:433-41.
• Shapiro A, Zohar E, Hoppenstein D, et al. A compari- son of three techniques for acute postoperative pain con- trol following major abdominal surgery. J Clin Anesth 2003;15:345-50.
• Flisberg P, Rudin A, Linnér R, Lundberg CJ. Pain relief and safety after major surgery. A prospective study of epidural and intravenous analgesia in 2696 patients. Acta Anaesthe- siol Scand 2003;47:457-65.