Murat Ökten

Use of bone wax is related to increased postoperative sternal dehiscence

Aim To investigate the relation between use of bone wax and postoperative sternal dehiscence after cardiac surgery. Material and methods Five thousnad three hundred and eighteen consecutive patients who underwent cardiac surgery between 1999 and 2009 were evaluated prospectively. Perioperative use of bone wax, perioperative data and outcome parameters were recorded. Multivariate logistic regression analysis was performed to define independent risk factors for postoperative sternal dehiscence. Results Bone wax was used in a total of 1151 (21%) patients. Postoperative sternal dehiscence was detected in 88 (1.6%) patients. The postoperative sternal dehiscence rate was 1.4% in patients without bone wax and 2.5% in patients with bone wax (p = 0.001). The rate of bone wax use was 36.4% in patients with sternal dehiscence and 21.4% in patients without sternal dehiscence (p < 0.001). Independent risk factors for postoperative sternal dehiscence were defined as: age > 70 (OR = 1.9, 95% CI: 1.2-3.1, p = 0.005), chronic obstructive lung disease (OR = 2.4, 95% CI: 1.5-3.9, p < 0.001), use of bone wax (OR = 1.6, 95% CI: 1.03-2.5, p = 0.03), nonelective operation (OR = 2, 95% CI: 1.1-3.4, p = 0.009), and body mass index > 30 (OR = 2.2, 95% CI: 1.4-3.5, p < 0.001). Conclusions Our findings suggest that use of bone wax may be associated with increased postoperative sternal dehiscence after cardiac surgery. Thus liberal use of bone wax should be restricted.

Utility of cerebral oxymetry for assessing cerebral arteriolar carbon dioxide reactivity during cardiopulmonary bypass.

BACKGROUND Our study evaluated changes in cerebral arterial oxygen saturation (rSO2) during cardiopulmonary bypass (CPB) that were caused by changes in arterial carbon dioxide tension (PaCO2). METHODS A group of 126 patients undergoing routine, elective, first-time coronary artery bypass graft surgery (CABG) was entered into a prospective study using bilateral near-infrared spectroscopy (NIRS) before anesthetic induction (T1), after anesthetic induction (T2), and continuing at 5-minute intervals during moderate hypothermic (32°C) CPB. Pump flows were set at 2.5 L/min/m(2) and adjusted to maintain mean arterial pressure (MAP) within 10 mmHg of the MAP recorded at the initial fifth minute of CPB (T3). Thirty-two patients were excluded from data collection because MAP could not be stabilized within the target range of 60-90 mmHg. In the remaining 94 patients, after obtaining steady state flow, MAP, and oxygenation, a trial period of hypocarbia (mean PaCO2 of 30 mmHg) was induced by increasing oxygenator fresh gas flow rate (FGFR) to 2.5 L/min/m(2) (T4). A reciprocal period was then measured at reduced FGFR (0.75 L/min/m(2)) (T5). RESULTS After 20 minutes of a higher (2.75 L/min/m(2)) (FGFR), mean PaCO2 decreased from a baseline of 38 ± 4 mmHg to 30 ± 2 mmHg. This was associated with a parallel decrease (-10 ± 9%) in mixed cerebral oxygen saturation without alteration of mean arterial oxygen tension (PaO2), lactate, MAP, CPB flow, or other parameters implying increased cerebral oxygen extraction. CONCLUSION Parallel changes in PaCO2 and rSO2 occur during CPB when other variables remain constant, and are due to the effects of carbon dioxide on cerebral arterioles. Cerebral oxygen saturation measured by NIRS may be a useful indirect measure of PaCO2 when continuous blood gas analysis is not possible during open-heart surgery. Cerebral oximetry values may be useful measurements for setting an optimum gas flow rate through the oxygenator.

Comparative Effects of Blood and Crystalloid Cardioplegia on Cellular Injury and Oxidative Stress in Cardiovascular Surgery

Purpose: The purpose of this study was to evaluate the effect of different cardioplegic solutions on endothelial integrity and oxidative stress in cardiovascular surgery. Methods: In this randomized prospective study, after ethics approval and informed consent, 60 surgical patients were included. Patients undergoing coronary bypass surgery were randomized into two groups as warm blood cardioplegia (n = 30) and cold crystalloid cardioplegia (n = 30) following the cross-clamping. Measurements were performed at three time points: before induction of anesthesia (T1), at admission to intensive care unit (ICU) (T2) and at the 24th postoperative hour (T3). Besides biochemical routine hemodynamic monitoring, patients were assessed for the sialic acid (SA), ischemic-modified albumin (IMA), advanced oxide protein products (AOPPs), total thiol (SH), and free hemoglobin (fHb) level. Results: Neither crystalloid nor blood cardioplegia led to significant changes in the AOPPs, T-SH, and SA level (p >0.05). Crystalloid cardioplegia, however, increased IMA level compared to both baseline (p <0.01) and blood cardioplegia group (p <0.05). fHb levels were transiently increased in both groups at the second-time point (p <0.001). fHb level was lower in the crystalloid group compared to that in the other group (p <0.05) at T2. Conclusion: Cardioplegia type creates similar effects on glycocalyx integrity. However, myocardial protection could be provided with warm blood cardioplegia.

Koroner Arter Baypas Cerrahisinde Fentanil ve Midazolamin Hedef Kontrollü İnfüzyon (HKİ) Şeklinde Kullaniminin Anestezi Düzeyi ve İlaç Tüketimi Üzerine Etkileri

Amac: Hedef kontrollu infuzyon (HKI) sistemleri, ilaclarin farmakokinetik ozelliklerine gore gelistirilen bilgisayar yazilimlarini iceren cihazlar kullanilarak hastalarin yas, cinsiyet, boy ve agirlik gibi parametrelerinin dikkate alinarak hedef ilac plazma konsantrasyonunun belirlendigi infuzyon seklidir. Calismamizda fentanil ve midazolamin geleneksel intravenoz (IV) infuzyon teknigi ve HKI teknigi ile uygulanmasini, hemodinami, anestezi derinligi ve ilac tuketimi acisindan karsilastirmayi amacladik.Gerec ve Yontem: Etik kurul onayi ve hasta onamlari alinan elektif koroner arter baypas cerrahisi (KABG) gecirecek 80 hasta prospektif olarak calismaya alindi. Hastalarin kalp hizi, pulse oksimetre (SpO2), elektrokardiyografi (EKG), invaziv arteryel monitorizasyonu, Bispektral indeks (BIS) ve serebrel rejiyonel oksijen saturasyonu (rSO2) monitorizasyonlari yapildi. Anestezi induksiyonu sonrasi hastalar sirayla randomize edilerek 2 gruba ayrildi. Grup 1: HKI teknigi ile fentanil ve midazolam infuzyonu uygulanan 40 hasta, Grup 2: geleneksel IV infuzyon teknigi ile fentanil ve midazolam infuzyonu uygulanan 40 hasta tarafindan olusturuldu. Hastalarin BIS degerleri ve hemodinamik parametrelerine gore fentanil ve midazolamin infuzyon hizlarinda ya da hedef plazma konsantrasyonunda gerekli ayarlamalar yapildi.Bulgular: Hastalarin demografik, hemodinamik ve sonuc parametrelerinde gruplar arasi anlamli fark gozlenmemistir (Tablo 1). Ancak, ameliyat boyunca tuketilen fentanil ve midazolam miktarlari Grup 1’de, Grup 2’ye gore istatistiksel olarak anlamli olarak daha dusuk bulunmustur. Ayrica BIS degerleri de daha az ilac tuketimi olmasina ragmen Grup 1’de istatistiksel olarak anlamli olcude daha dusuk bulunmustur.Sonuc: Hemodilusyon, hipotermi ve nonpulsatil akimin kullanildigi baypas cerrahisi uygulamalarinda kan ilac konsantrasyonu bircok faktore bagli olarak degisebilmektedir. Acik kalp cerrahisi kullanilan anestezik ilaclarin kan konsantrasyonlarinin, cerrahinin her safhasinda istenen araliklarda tutulmasi; anestezi yeterliligi acisindan onem tasimaktadir. HKI uygulamasinin anestezi derinligi, farkindalik ve sonuc parametreleri acisindan anlamli olacagi dusuncesindeyiz

A right coronary artery saccular aneurysm leading to an embolic myocardial infarction during diagnostic cardiac catheterization: A case report

Coronary artery aneurysms are localized dilatations greater than 1.5 times the diameter of the adjacent segments. These rarely seen abnormalities may lead to serious life-threatening complications such as myocardial infarction, coronary perforation and death. Here, we present a case of periprocedural thromboembolic inferior myocardial infarction arising from a proximal right coronary artery saccular aneurysm during a diagnostic coronary angiography in a stable 70-year-old patient.