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TRANSFUSIONS DURING CARDIOPULMONARY BYPASS: TRIGGERED BY VENOUS
OXYGEN SATURATION
Zhanturganov M., Albazarov A., Mendykulov S., Altenov K., Isanov A., Tojiboyev R.
National Scientific Medical Research Center, Astana, Kazakhstan
During cardiopulmonary bypass (CPB), red blood cell transfusions may be required to correct dilutional anemia. The decision-making process for transfusions is usually based on the level of hemoglobinThis study investigates the hypothesis that oxygen-derived variables (mixed venous oxygen saturation, SvO (2) may be more reliable predictor of the efficacy of the transfusion. Thirty-four patients for 41 transfusion episodes during CPB were retrospectively analyzed. For each patient, oxygen-derived variable, including SvO (2) was measured before and after the transfusion. No changes in pump flow were allowed between the two measurements. The efficacy of transfusion was defined as an increase in SvO (2) of at least 5%. We identified 10 transfusion episodes leading to an efficacious SvO (2) increase.No association was found with hemoglobin values, unless for a trend for efficacy of transfusion in patients with very low (<6 g/dL) hemoglobin values. Cut-off values of 63% for SvO(2) was predictive for the efficacy of red blood cell transfusions.In conclusion, SvO(2) better than the hemoglobin value for guiding the decision-making process of red blood cell transfusions to correct hemodilutional anemia during CPB.
ROUTINE PLACEMENT OF NASOGASTRIC TUBES AFTER CARDIAC SURGERY AND POSTOPERATIVE NAUSEA AND VOMITING
Tojiboyev R., Konakbay B.
National Scientific Medical Research Center, Astana, Kazakhstan
Background: Incidence of postoperative nausea and vomiting (PONV) after cardiac surgery is 30-40%. The role of nasogastric tube (NGT) in reduction of PONV is still controversial.
Objectives: The purpose of this study is to assess the impact of NGT placement on PONV in patients undergoing cardiacsurgery.
Methods: After informed consent, 85 patients undergoing cardiac surgery with cardiopulmonary bypass were randomized to either receive NGT after induction of anesthesia (Group NGT) or to the controlgroup (no NGT). Patients with history of gastro/duodenal ulcer, gastric/esophageal surgery, and/or history of antiemetic treatment were excluded. Standard cardiac anesthesia and postoperative care were employed for all patients. Incidence of PONV was recorded hourly for first 4 hours after extubation and every 4hours afterwards for 24hours. Usage of antiemetics and pain medication were also recorded. Data were analyzed with t-test.
Results: The groups were similar with respect to demographic data, surgical characteristics, and opioid usage. There was no significant difference in the incidence of PONV and the antiemetic usage between the two groups.
Discussion: This study showed that placement of NGT did not impact on the incidence of PONV or requirements for antiemetics after cardiac surgery. The results of this study do not support the routine use of NGT to reduce PONV after cardiac surgery.
ИННОВАЦИИ В ЛЕЧЕНИИ БОЛЬНЫХ СО СТАБИЛЬНОЙ СТЕНОКАРДИЕЙ
Кусымжанова Ж.М.
Центральная клиническая больница УДП РК, Алматы, Казахстан
В Европе и России накоплен большой фактический материал, свидетельствующий о центральной роли уровня частоты сердечных сокращений (ЧСС) в патогенезе стабильной стенокардии. Высокая ЧСС - это непрямое повреждение сосудов и провакация развития атеросклероза, что одновременно и повышает потребность миокарда в кислороде, и дестабилизирует атеросклеротические бляшки, повышая вероятность разрыва их покрова. Это в конечном итоге приводит к развитию таких сердечно-сосудистых осложнений, как внезапная коронарная смерть и инфаркт миокарда. Помимо неблагоприятного влияния на уровень смертности высокая ЧСС является независимым фактором риска прогрессирования ИБС. В эпидемиологическом исследовании REALITY, проведенном в Казахстане, выявлено, что из 508 пациентов с ИБС, стабильной стенокардией - 87% больных на фоне проводимого лечения не имели оптимальный уровень ЧСС в покое, 88% больных на фоне проводимого лечения отмечались приступы стенокардии.
Кораксан (ивабрадин) - инновационный препарат, который селективно ингибирует If- каналы в клетках синусового узла и снижает ЧСС, не влияя на другие показатели сердечной деятельности.
Цель. Изучить эфффективность Кораксана у больных с верифицированным диагнозом стабильной стенокардии.
Материалы и методы. Препарат был назначен 12 пациентам со стабильной стенокардией 3 функционального класса в дозе 5 мг 2 раза в день, через 1 месяц дозировка у 10 больных увеличилась до 7,5 мг 2 раза в день. Средний возраст больных 72,1 лет, у 78% выявлялась ЧСС свыше 80 уд/ мин. Все пациенты принимали базовую терапию статинами, ИаПф и/или АКК, антиагрегантами, 84% - нитраты. Продолжительность лечения составила 3 месяца. Эффективность терапии оценивалась по количеству приступов стенокардии и по потребности в нитратах короткого действия.
Результаты. На фоне приема Кораксана у всех больных выявлено достоверное урежение ЧСС на 20 уд/мин, значительно уменьшилась частота приступов стенокардии, что в свою очередь, привело к снижению потребности в нитроглицерине и изокете-спрей. Посредством нагрузочного теста 6-минутной ходьбы отмечено достоверное улучшение толерантности к физической нагрузке у всех пациентов. У одного больного зарегистрирована брадикардия до 48 уд/мин, других нежелательных явлений на фоне приема Кораксана не выявлено.
Заключение. Кораксан (ивабрадин) является препаратом выбора при лечении пациентов со стабильной стенокардией, сопровождающейся нарушением ритма.
KETAMINE-PROPOFOL COMBINATION FOR INDUCTION IN CARDIAC SURGERY PATIENTS
Tojiboyev R, Konakbay B, Vershinin M.
National Scientific Medical Research Center, Astana, Kazakhstan
Anesthetic management of patients with severe heart disease aims at prevention of myocardial damage by optimizing the myocardial oxygen demand/supply ratio. Induction of anesthesia using high doses of narcotics alone or with benzodiazepines was favored by many practitioners before the introduction of the concept of 'fast-track' anesthesia. However it is associated with bradycardia, rigidity and delayed intubation. Other commonly used hypnotic agents include Pentothal, Etomidate, Versed, Ketamine and Propofol. The cardiovascular effects of ketamine are secondary to maintaining the sympathetic tone and include increased cardiac output, heart rate, mean arterial pressure and central venous pressure. Propofol has centrally mediated hypotensive effects as well as peripheral vasodilator properties that result in a decrease in the systemic vascular resistance and blood pressure by 15-30%.The heart rate either decreases or remains unchanged, while the cardiac output and oxygen consumption decrease after a full induction dose. We use a combination of Ketamine and Propofol for the induction of anesthesia for our patients undergoing cardiopulmonary bypass for myocardial revascularization or valve repair/replacement procedures with poor left ventricular function. The combination consists of about 40-50% of the full induction dose of each agent; thereby minimizing the untoward hemodynamic effects associated with the use of either agent alone.We examined the hemodynamic parameters during and immediately following induction of anesthesia in patients undergoing cardiac surgery. Arterial pressure monitoring was placed under local anesthesia before induction in all patients. Patients were divided into 2 groups that were matched for the underlying pathology, comorbidities and age. Group I was induced with a combination of Fentanyl (5-7mcg/kg) and Relanium (5-10 mg) and group II was induced with a combination of Ketamine (0.5 -1 mg/ kg) and Propofol (0.5- 1 mg/kg).
Results: Group I patients had a greater drop in heart rates (30-50%) when compared to patients in group II, where the heart rate did not change or slightly increased (5-10 %). This bradycardia was accompanied by a concomitant drop in the arterial blood pressure in patients with stenotic valve lesions, necessitating immediate pharmacological intervention.
Conclusion: The use of Ketamine in combination with Propofol for the induction of anesthesia in unstable cardiac surgery patients result in stable hemodynamic parameters. This combination is particularly beneficial for patients with severe stenotic valve lesions and with left main stem coronary artery disease, since it has minimal effects on the heart rate and blood pressure.The Ketamine-Propofol combination is a useful alternative for induction of anesthesia for cardiac surgery patients.
CLINICAL AND EPIDEMIOLOGICAL METHODS OF DIAGNOSIS AND PROPHYLAXIS CARDIOVASCULAR DISEASES INDUCED BY ENDOTHELIAL DYSFUNCTION AT OFFSPRING OF
PEOPLE WHO HAD BEEN EXPOSED RADIATION
Pivina L.M.
State Medical University, Semey, Kazakhstan
Long monitoring of Semipalatinsk region people who were exposed to ionizing radiation in consequence of 40 year nuclear testing certifies about increasing of prevalence of circulatory system diseases. Conducting of the research in cohort, which exposed to direct radiation, showed that for all types of death from cardiovascular diseases (CVD) relative risk in exposed cohort composed 2,29 [2,13;2,47].
