Title page for ETD etd-10102003-100731


Document Type Doctoral Thesis
Author Smith, Francois Jacobus
URN etd-10102003-100731
Document Title Ondersoek na die invloed van die narkosetegniek (Ketamien plus Midasolam teenoor Sufentaniel) op breinskade tydens hartoperasies by die mens (Afrikaans)
Degree MD
Department Anaesthesiology
Supervisor
Advisor Name Title
Prof J M Hugo
Prof P R Bartel Committee Co-Chair
Prof W J H Vermaak Committee Co-Chair
Keywords
  • anaesthetic drugs
  • neuropsychological deterioration
  • anesthetic technique
  • cardiac surgery
  • brain ischaemia
Date 2003-04-15
Availability unrestricted
Abstract
Introduction

The neuropsychological deterioration after cardiac surgery involving cardiopulmonary bypass (CPB), is ascribed to brain ischaemia caused by, amongst others, hypotension, cerebral hyperthermia, cerebral embolism, interaction between pharmacological methods and hypothermia during ischaemia, and the directly neurotoxic of anaesthetic drugs.

Aim

To investigate the effect of the anaesthetic techniques midazolam plus ketamine (MK) or sufentanil (S) on the quantitative EEG (QEEG), reaction time (RT), serum neuron specific enolase (NSE), and serum S-100b protein after cardiac surgery involving CPB in humans.

Patients and methods

The sample consisted of a total of 42 patients scheduled for elective coronary artery bypass (CABG) or valve replacement (VR). All patients were not available for all the postoperative tests. Patients were allocated randomly to group MK or S.

Anaesthetic technique: S or MK. Isoflurane was administered when necessary.

CPB technique: 30C, membrane oxygenation, a 40 mm filter in the arterial cannula and a-stat-blood gas management, blood pressure of 50 to 70 mm Hg and a haematocrit > 22%. Patients were weaned from CPB when nasopharyngeal temperature reached a maximum of 37,5C.

QEEG and RT was performed 1 to 2 days preoperatively and 5 to 6 days postoperatively.

Serum-NSE and -S-100b protein were measured preoperatively, 2 minutes after going on CPB, after rewarming to 37C, just before the end of CPB and 2, 4, 10, 20, 30, and 48 hours after CPB.

Results

QEEG: The most noticable finding was an increase in slow wave activity (relative q and s). The QEEG outcome was better after CABG than after VR (p < 0,001), but not different between MK and S (p = 0,5000). Dq% was better with MK than S (p = 0,0120). Dq% (p = 0,0010), Da/q% (p = 0,0090) and DPS% (p = 0,0025) was better after CABG than VR.

Reaction time: There was a significant deterioration in 5/18 (27,78%) of MK and 12/18 (66,67%) of S (p = 0,0220). The change in accuracy in sequential reation time 1 (p = 0,0100), and sequential reation time 2 (p = 0,0970) and the cumulative accuracy was better with MK than S(p = 0,0020).

Chemical markers: Over groups 14,8% of patients had a poor NSE and 61,9% a poor S-100b outcome. Within groups a poor NSE outcome was found in 14,8% of MK and 14,8% of S (p = 1,0000), and 4,8% of CABG but 23,8% of VR (p = 0,1840). Within groups as adverse S-100b outcome was found in 42,9% of MK but 81,0% van S (p = 0,0250; Fisher's exact test), and 66,7% of CABG and 57,1% of KV (p = 0,7510. According to area under the curve of corrected NSE, CABG had a better outcome than VR (p = 0,0040). According to both maximum S-100b level and the area under the curve of S-100b, an interaction occurred between the anaesthetic technique and the procedure, with VR doing better with MK while CABG did significantly better with S (p = 0,0180 en 0,0040 respectively).

Conclusion, shortcomings, significance and contribution

This study has shown that, in as far as brain damage is concerned, the outcome was probably better with MK than with S, and CABG better than VR. An interaction was found between the anaesthetic technique and the type of operation.

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  00front.pdf 197.68 Kb 00:00:54 00:00:28 00:00:24 00:00:12 00:00:01
  01chapter1.pdf 144.21 Kb 00:00:40 00:00:20 00:00:18 00:00:09 < 00:00:01
  02chapter2.pdf 141.80 Kb 00:00:39 00:00:20 00:00:17 00:00:08 < 00:00:01
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  05chapter5.pdf 191.96 Kb 00:00:53 00:00:27 00:00:23 00:00:11 00:00:01
  06chapter6.pdf 168.41 Kb 00:00:46 00:00:24 00:00:21 00:00:10 < 00:00:01
  07chapter7.pdf 600.61 Kb 00:02:46 00:01:25 00:01:15 00:00:37 00:00:03
  08chapter8.pdf 696.04 Kb 00:03:13 00:01:39 00:01:27 00:00:43 00:00:03
  09chapter9.pdf 163.72 Kb 00:00:45 00:00:23 00:00:20 00:00:10 < 00:00:01
  10appendix.pdf 259.51 Kb 00:01:12 00:00:37 00:00:32 00:00:16 00:00:01
  11references.pdf 499.64 Kb 00:02:18 00:01:11 00:01:02 00:00:31 00:00:02

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