Djaiani George, Ali Mohamed, Borger Michael A, Woo Anna, Carroll Jo, Feindel Christopher, Fedorko Ludwik, Karski Jacek, Rakowski Harry
Department of Anesthesiology, Toronto General Hospital, Eaton North 3-410, 200 Elizabeth Street, Toronto, ON M5G 2C4, Canada.
Anesth Analg. 2008 Jun;106(6):1611-8. doi: 10.1213/ane.0b013e318172b044.
Patients with aortic atheroma are at increased risk for neurological injury after coronary artery bypass graft (CABG) surgery. We sought to determine the role of epiaortic ultrasound scanning for reducing cerebral embolic load, and whether its use leads to changes of planned intraoperative surgical management in patients undergoing CABG surgery.
Patients >70-yr-of-age scheduled for CABG surgery were prospectively randomized to either an epiaortic scanning (EAS) group (aortic manipulation guided by epiaortic ultrasound) or a control group (manual aortic palpation without EAS). All patients received a comprehensive transesophageal echocardiographic examination. Transcranial Doppler (TCD) was used to monitor the middle cerebral arteries for emboli continuously from 2 min before aortic cannulation to 2 min after aortic decannulation. Neurological assessment was performed with the National Institute of Health stroke scale before surgery and at hospital discharge. The NEECHAM confusion scale was used for assessment and monitoring of patient global cognitive function on each day after surgery until hospital discharge.
Intraoperative surgical management was changed in 16 of 55 (29%) patients in the EAS group and in 7 of 58 (12%) patients in the control group (P = 0.025). These changes included adjustments of the ascending aorta cannulation site for cardiopulmonary bypass (CPB), the avoidance of aortic cross-clamping by using ventricular fibrillatory arrest during surgery, or by conversion to off-pump surgery. During surgery, 7 of 58 (12%) patients in the control group crossed over to the EAS group based on the results of manual aortic palpation. The median [range] TCD detected cerebral embolic count did not differ between the EAS and control groups during aortic manipulations (EAS, 11.5 [1-516] vs control, 22.0 [1-160], P = 0.91) or during CPB (EAS, 42.0 [4-516] vs control, 63.0 [5-758], P = 0.46). The NEECHAM confusion scores and National Institute of Health stroke scale scores were similar between the two groups.
These results show that the use of EAS led to modifications in intraoperative surgical management in almost one-third of patients undergoing CABG surgery. The use of EAS did not lead to a reduced number of TCD-detected cerebral emboli before or during CPB.
主动脉粥样硬化患者在冠状动脉旁路移植术（CABG）后发生神经损伤的风险增加。我们试图确定主动脉超声扫描在减少脑栓塞负荷中的作用，以及其使用是否会导致接受CABG手术患者计划中的术中手术管理发生改变。
将计划接受CABG手术的70岁以上患者前瞻性随机分为主动脉超声扫描（EAS）组（由主动脉超声引导主动脉操作）或对照组（无EAS的手动主动脉触诊）。所有患者均接受全面的经食管超声心动图检查。在主动脉插管前2分钟至主动脉拔管后2分钟，使用经颅多普勒（TCD）连续监测大脑中动脉的栓子。在手术前和出院时，使用美国国立卫生研究院卒中量表进行神经学评估。在术后直至出院的每一天，使用NEECHAM意识模糊量表评估和监测患者的整体认知功能。
EAS组55例患者中有16例（29%）、对照组58例患者中有7例（12%）的术中手术管理发生改变（P = 0.025）。这些改变包括调整体外循环（CPB）时升主动脉插管部位、手术期间通过使用室颤停搏或转为非体外循环手术避免主动脉交叉钳夹。手术期间，对照组58例患者中有7例（12%）根据手动主动脉触诊结果转至EAS组。在主动脉操作期间（EAS组为11.5 [1 - 516]，对照组为22.0 [1 - 160]，P = 0.91）或CPB期间（EAS组为42.0 [4 - 516]，对照组为63.0 [5 - 758]，P = 0.46），EAS组和对照组经TCD检测到的脑栓塞计数中位数[范围]无差异。两组的NEECHAM意识模糊评分和美国国立卫生研究院卒中量表评分相似。
这些结果表明，在几乎三分之一接受CABG手术的患者中，使用EAS导致术中手术管理发生改变。在CPB前或期间，使用EAS并未减少经TCD检测到的脑栓塞数量。
