Canlı karaciğer nakil vericilerinde torakal epidural anestezinin intraoperatif karaciğer kan akımı üzerine etkisi
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Tarih
2014
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Yayıncı
İnönü Üniversitesi
Erişim Hakkı
info:eu-repo/semantics/openAccess
Özet
ÖZET: Giriş ve Amaç: Kadavradan organ bağışının azlığı ve artan hasta popülasyonuna bağlı olarak organ ihtiyacının artması nedeniyle ülkemizde canlı vericili karaciğer naklinde artış olmuştur. Karaciğer nakli hastalarında, greft fonksiyonu; hemodinamik parametreler ve organ kan akımı gibi birçok faktörden etkilenmektedir. Donörler, herhangi bir sağlık problemi olmayan gönüllülerdir. Bu nedenle, anestezi yönetiminde donörlerin güvenliği en önemli konudur. Hepatektomi gibi majör abdominal cerrahi geçiren hastalar çoklu organ yetmezliği dahil postoperatif komplikasyonlar açısından risk altındadır. Epidural anestezi ve analjezinin intraoperatif kan kaybında, tromboembolik olayların insidansında azalma, iyileşmiş postoperatif solunum, kardiyovasküler ve intestinal fonksiyon ve modifiye immün fonksiyon gibi perioperatif riskleri azaltmada etkin olduğu gösterilmiştir. Ayrıca epidural anestezinin sempatik blokaj ile splenik alanda organ perfüzyonunu artırdığı düşünülmektedir. İndosiyanin yeşili (İSY) klirens testi başlangıçta kan akımının ölçümü için tasarlanmış ve daha sonra fonksiyonel hepatosit kitlesini ölçerek karaciğer fonksiyonunun değerlendirilmesinde kullanılmıştır. Şimdilerde klinikte en yaygın olarak kullanılan sayısal karaciğer fonksiyon testidir. İSY klirens testi KC nakli yapılan alıcılarda ve onların donörlerinde KC fonksiyonlarının değerlendirilmesinde ve izlenmesinde endikedir. Bu çalışmadaki amacımız, canlı karaciğer nakil vericilerinde torakal epidural anestezinin genel anesteziye kıyasla karaciğer kan akımı üzerine etkilerinin indosiyanin yeşili ve karaciğer fonksiyon testleri ile karşılaştırılmasıdır. Materyal ve Metod: Bu çalışma, Etik kurul izni ve hasta onamı alındıktan sonra karaciğer nakli vericisi olan sağ hepatektomi yapılacak 40 olguda gerçekleştirildi. Olguların cinsiyeti, yaşı, boy, sigara kullanımı, vücut ağırlığı, vücut kitle indeksi, ASA sınıflandırması kaydedildi. Olgular kapalı zarf yöntemi ile kontrol grubu (Grup 1) ve epidural blok uygulanan grup (Grup 2) olarak iki eşit gruba ayrıldı. Operasyon odasına alınan olgulara elektrokardiyografi, periferik oksijen saturasyonu, BİS, noninvaziv kan basıncı monitorizasyonu yapıldı. Olguların bazal hemodinamik değerleri kaydedildi. Epidural blok uygulanacak gruptaki (Grup 2) olgulara T6-8 seviyesinden epidural katater takıldı. Tüm olgulara lidokain, fentanil ve tiyopental ile standart anestezi indüksiyonu yapıldı. Kas gevşemesi vekuronyum ile sağlanan olgular entübe edildi. Olguların anestezi idamesi % 50/50 oksijen-hava karışımı içinde Grup 1 hastalarda izofluran, remifentanil infüzyonu ve sisatrakuryum infüzyonu ile, Grup 2 hastalarda izofluran, epidural infüzyon ve sisatrakuryum infüzyonu ile sağlandı. İnvaziv arteryel kan basıncı monitorizasyonu, vücut ısısı monitörizasyonu yapıldı. Isıtıcı battaniyeler kullanılarak olguların cerrahi sırasında normotermik kalmaları sağlandı. Tüm hastalara internal juguler vene santral venöz katater yerleştirildi ve santral venöz basınç takibi yapılıp kayıt edildi. Operasyon boyunca olguların OAB, KAH, SpO2 ve BİS değerleri kaydedildi. Pringle manevrası uygulandıysa süresi, remmant karaciğer, toplam kanama miktarı, idrar miktarı, toplam anestezi süresi, toplam cerrahi süresi, operasyon evrelerinin süresi kaydedildi. Operasyon sırasında verilen toplam sıvı miktarı ile bu sıvıların cinsi (kristaloid, kolloid, kan ve kan ürünleri) kaydedildi. Transseksiyondan sonra çıkan greft ağırlıkları kaydedildi. Operasyon sonunda kas gevşetici etkisi antagonize edilen olgular ekstübe edildi. Postoperatif derlenme ünitesinde yarım saat gözlenen olgular daha sonra cerrahi yoğun bakım ünitesine gönderildi. İndosiyanin yeşili klirens testi değerleri, PDR ve R15 açısından genel anestezi öncesi (Z0), genel anestezi indüksiyonundan sonra (Z1), transseksiyondan sonra (Z2), postoperatif 24. ve 72. saatlerde ölçülüp kaydedildi. Eş zamanlı olarak hemoglobin (Hb), hematokrit (Htc), trombosit, PT, INR, total bilüribin, direk bilüribin, albumin, AST, ALT değerleri çalışıldı ve kaydedildi. Bulgular: Operasyon süreleri, remnant KC yüzdesi, greft ağırlığı ve kanama miktarları açısından gruplar arasında istatistiksel olarak anlamlı bir farklılık görülmedi (p> 0,05). Volatil anestezik dozunda istatiksel olarak gruplar arası anlamlı farklılıklar bulundu (p<0,05). PDR ve R15 açısından gruplar karşılaştırıldığında; gruplar arasında istatistiksel olarak anlamlı farlılık görülmedi (p > 0.05). Grup içi karşılaştırılmalarda hem PDR hem de R15 değerlerinde her iki grup içinde Z1, Z2, Z3 ve Z4 zamanlarındaki değerler Z0'a göre istatistiksel olarak anlamlı bulundu (p< 0.05). ALT, değerlerinde ölçüm zamanlarında grup içi anlamlı değişimler görüldü (p < 0.05) ancak gruplar arası anlamlı bir farklılık yoktu (p > 0.05). PT ve INR değerlerinde grup içi değişimlerde anlamlı farklılıklar bulundu (p < 0.05). SAB, DAB ve OAB açısından gruplar arasında diseksiyon evresinde istatistiksel olarak anlamlı farklılık bulundu (p < 0.05). Sonuç: Elektif karaciğer donör olgularında uygulanan torakal epidural anestezinin global KC fonksiyonunun değerlendirilmesinde kullanılan İSY klirens testi ve KC ile ilgili rutin testleri etkilemediği kanısındayız. Anahtar kelimeler: Canlı vericili KC nakli, indosiyanin yeşili, torakal epidural anestezi, KC fonksiyon testleri.
SUMMARY Backround and aim: Depending on the needs of the growing population and shortage of cadaveric organ donation, the rate of live donor liver transplantation has been increased in our country. In liver transplant patients, graft functionis affected by many factors such as hemodynamic parameters and organ blood flow. Donors are volunteers without any health problems. Therefore, the anesthetic management of donor safety is an important issue. Patients undergoing major abdominal surgery such as hepatectomy are at risk for. postoperative complications including multiple organ failure. Epidural anesthesia and analgesia has been shown to be effective in reducing perioperative risk such as intraoperative blood loss, reduction in the incidence of thromboembolic events, improved postoperative pulmonary, cardiovascular and intestinal function and modified immune function. İn addition to epidural anesthesia by sympathetic blockade is thought to increase organ perfusion in splenic area. Indocyanine green (ICG) clearance test originally intended for the measurement of blood flow. For the time being, it has been most widely used to evaluate the liver function. ICG clearance test is indicated in liver transplant recipients and their donors for the assessment and monitoring hepatic function. Our aim in this study, thoracic epidural anesthesia compared to general anesthesia effects on liver blood flow by liver function tests and indocyanine green is compared with in the living donor liver transplantation. Materials and Methods: After Ethics Committee approval and patient consent right hepatectomy was performed in 40 patients. Patients' sex, age, height, smoking, body weight, body mass index, ASA classification were recorded. Cases, the control group (Group 1) and the epidural block group (Group 2) with closed envelope method were divided into two equal groups. In the operating room electrocardiography, oxygen saturation, noninvasive blood pressure monitoring was performed and basal hemodynamic values were recorded. BIS was used to assess depth of anesthesia. Epidural blocks to be implemented group (Group 2) patients, the epidural catheter is inserted T6-8 level. In all patients, anesthesia was standardized with lidocaine, fentanyl and thiopental. Patients were intubated after muscle relaxation provided with vecuronium. Anesthesia maintenence of Cases, in 50/50% oxygen-air mixture in Group 1 patients isoflurane, remifentanil infusion and cisatracurium infusion, Group 2 patients isoflurane, epidural infusion and cisatracurium infusion was provided. . Nondominant radial artery invasive arterial blood pressure monitoring was provided. Internal jugular venous catheter was inserted to central venous pressure monitoring in all patients. Patients MAP, HR, SpO2 and BIS values were recorded. If applied Pringle maneuver time, remmant liver total amount of bleeding, the amount of urine, total anesthesia time, the total operation time, times ofoperation phases, total amount of liquid during operation and type of fluid (crystalloid, colloid, blood and blood products) were recorded. After transection, the graft weight were also recorded. After antagonizes the effects of muscle relaxants end of the operation, patients was extubated. After observed in the postoperative care unit along half an hour, patients was sent to the surgical intensive care unit. Indocyanine green clearance test values before general anesthesia (T0), after induction of general anesthesia (T1), after transection (T2), postoperative 24 and 72 hours were recorded. Simultaneously, hemoglobin (Hb), hematocrit (Hct), platelet count, PT, INR, total bilirubin, direct bilirubin, albumin, AST, ALT values were analyzed. Results: İn terms of operation time, the percentage of KC remnant, the graft weight and amount of bleeding statistically significant difference was not observed between groups (p> 0.05). At a dose of volatile anesthetics statistically significant differences were found between groups (p <0.05). PDR and R15 compared to the groups; statistically significant difference was not observed between groups (p> 0.05). İntra-group comparison both PDR and R15 values in both groups Z1, Z2, Z3 and Z4 the values in the time according to Z0 was statistically significant (p <0.05). Significant changes in the ALT levels was observed at measurement time points within groups (p <0.05) but no significant difference between groups (p> 0.05). PT and INR values were significant differences in the changes in the within the group (p <0.05). SAP, DAP, and MAP between the groups were found statistically significant differences in the stages of dissection (p <0.05). Conclusion: It was concluded that used thoracic epidural anesthesia has no effecton global liver function and liver-related liabilities tests in patients undergoing elective liver donor surgery. Key words: Liver donor liver transplantation, indocyanine green, thoracic epidural anesthesia, liver function tests.
SUMMARY Backround and aim: Depending on the needs of the growing population and shortage of cadaveric organ donation, the rate of live donor liver transplantation has been increased in our country. In liver transplant patients, graft functionis affected by many factors such as hemodynamic parameters and organ blood flow. Donors are volunteers without any health problems. Therefore, the anesthetic management of donor safety is an important issue. Patients undergoing major abdominal surgery such as hepatectomy are at risk for. postoperative complications including multiple organ failure. Epidural anesthesia and analgesia has been shown to be effective in reducing perioperative risk such as intraoperative blood loss, reduction in the incidence of thromboembolic events, improved postoperative pulmonary, cardiovascular and intestinal function and modified immune function. İn addition to epidural anesthesia by sympathetic blockade is thought to increase organ perfusion in splenic area. Indocyanine green (ICG) clearance test originally intended for the measurement of blood flow. For the time being, it has been most widely used to evaluate the liver function. ICG clearance test is indicated in liver transplant recipients and their donors for the assessment and monitoring hepatic function. Our aim in this study, thoracic epidural anesthesia compared to general anesthesia effects on liver blood flow by liver function tests and indocyanine green is compared with in the living donor liver transplantation. Materials and Methods: After Ethics Committee approval and patient consent right hepatectomy was performed in 40 patients. Patients' sex, age, height, smoking, body weight, body mass index, ASA classification were recorded. Cases, the control group (Group 1) and the epidural block group (Group 2) with closed envelope method were divided into two equal groups. In the operating room electrocardiography, oxygen saturation, noninvasive blood pressure monitoring was performed and basal hemodynamic values were recorded. BIS was used to assess depth of anesthesia. Epidural blocks to be implemented group (Group 2) patients, the epidural catheter is inserted T6-8 level. In all patients, anesthesia was standardized with lidocaine, fentanyl and thiopental. Patients were intubated after muscle relaxation provided with vecuronium. Anesthesia maintenence of Cases, in 50/50% oxygen-air mixture in Group 1 patients isoflurane, remifentanil infusion and cisatracurium infusion, Group 2 patients isoflurane, epidural infusion and cisatracurium infusion was provided. . Nondominant radial artery invasive arterial blood pressure monitoring was provided. Internal jugular venous catheter was inserted to central venous pressure monitoring in all patients. Patients MAP, HR, SpO2 and BIS values were recorded. If applied Pringle maneuver time, remmant liver total amount of bleeding, the amount of urine, total anesthesia time, the total operation time, times ofoperation phases, total amount of liquid during operation and type of fluid (crystalloid, colloid, blood and blood products) were recorded. After transection, the graft weight were also recorded. After antagonizes the effects of muscle relaxants end of the operation, patients was extubated. After observed in the postoperative care unit along half an hour, patients was sent to the surgical intensive care unit. Indocyanine green clearance test values before general anesthesia (T0), after induction of general anesthesia (T1), after transection (T2), postoperative 24 and 72 hours were recorded. Simultaneously, hemoglobin (Hb), hematocrit (Hct), platelet count, PT, INR, total bilirubin, direct bilirubin, albumin, AST, ALT values were analyzed. Results: İn terms of operation time, the percentage of KC remnant, the graft weight and amount of bleeding statistically significant difference was not observed between groups (p> 0.05). At a dose of volatile anesthetics statistically significant differences were found between groups (p <0.05). PDR and R15 compared to the groups; statistically significant difference was not observed between groups (p> 0.05). İntra-group comparison both PDR and R15 values in both groups Z1, Z2, Z3 and Z4 the values in the time according to Z0 was statistically significant (p <0.05). Significant changes in the ALT levels was observed at measurement time points within groups (p <0.05) but no significant difference between groups (p> 0.05). PT and INR values were significant differences in the changes in the within the group (p <0.05). SAP, DAP, and MAP between the groups were found statistically significant differences in the stages of dissection (p <0.05). Conclusion: It was concluded that used thoracic epidural anesthesia has no effecton global liver function and liver-related liabilities tests in patients undergoing elective liver donor surgery. Key words: Liver donor liver transplantation, indocyanine green, thoracic epidural anesthesia, liver function tests.
Açıklama
Anahtar Kelimeler
Anestezi ve Reanimasyon, Anesthesiology and Reanimation
Kaynak
WoS Q Değeri
Scopus Q Değeri
Cilt
Sayı
Künye
Şayan, H. (2014). Canlı karaciğer nakil vericilerinde torakal epidural anestezinin intraoperatif karaciğer kan akımı üzerine etkisi. Yayımlanmış uzmanlık tezi, İnönü Üniversitesi, Malatya.
