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Advances in Natural and Applied Sciences, 8(9) August 2014, Pages: 53-56
AENSI Journals
Advances in Natural and Applied Sciences
ISSN:1995-0772 EISSN: 1998-1090
Journal home page: www.aensiweb.com/ANAS
Renal Function in On-pump Versus Off-pump Coronary-Artery Bypass Surgery
1
Mehdi Dehghani Firoozabadi, 2Ahmad Ebadi, 3Mohammad Ebadi, 3Saeid Ebadi
1
Assistant Professor of Cardiac Anesthesiology MD, Department of anesthesiology, Shahid Sadoughi University of Medical Sciences-Yazd,
Iran.
2
Associate Professor of Cardiac Anesthesiology MD, Department of Cardiac Anesthesiology, Atherosclerosis Research Center Golestan
Hospital, and Pain Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.
3
Department of Ophthalmology, Semmelweis University Budapest, Tomo u. 25-29, Budapest H-1083, Hungary.
ARTICLE INFO
Article history:
Received 25 June 2014
Received in revised form
8 July 2014
Accepted 31 August May 2014
Available online 15 September 2014
Keywords:
CABG, Renal failure, Sodium,
Potassium, Creatinine, CPB Pump
ABSTRACT
Background: Acute renal failure is the most common complication found in coronary
artery bypass surgery. One important treatment aspect of management of these patients
lies in electrolyte balance. Despite the importance of electrolyte balance, electrolyte
changes after coronary artery bypass graft surgery was not studied much, the present
study aimed to compare changes in renal function in patients undergoing CABG with or
without CPB method Materials and Methods: this is a retrospective study. we referred
to archive of Golestan hospitals, gathered files of patients with CAGB in 2013 and
extracted required data from them. Data gathering instrument was researcherconstructed questionnaire including patients’ demographic information. Results:
changes in both levels of sodium (p <0.05) and creatinine (p <0.05) were significantly
lower in the group that underwent surgery without CPB. Nevertheless, this difference
was not significant in terms of potassium (p> 0.05). Conclusion: Due to increased cases
of renal failure, higher levels of creatinine and sodium in the group using CPB, it seems
that coronary artery bypass surgery technique without CPB may cause fewer side
effects. However, it is suggested to conduct further studies to generalize this data.
© 2014 AENSI Publisher All rights reserved.
To Cite This Article: Mehdi Dehghani Firoozabadi, Ahmad Ebadi, Mohammad Ebadi, Saeid Ebadi., Renal Function in On-pump Versus
Off-pump Coronary-Artery Bypass Surgery. Adv. in Nat. Appl. Sci., 8(9): 53-56, 2014
INTRODUCTION
Cardiac surgery is one of the most frequent surgical procedures nowadays (Firoozabadi et al., 2014). More
than 800,000 Coronary Artery Bypass Grafting (CABG) operations are conducted globally every year. These
operations are associated with different morbidity and mortality rates (Leong J-Y et al., 2005; .Myles PS et al.,
2008 ). Advances in management of the patients with cardiac surgery necessitate improved intraoperative
monitoring (Roediger L JJ et al., 2006). Coronary artery disease is one of the most common types of
cardiovascular diseases. It is also a major cause of death. American Heart Association has estimated that 1.2
million Americans are annually affected by myocardial infarction in which 25% die either in the emergency
department or before reaching the hospital (Puskas et al. , 2003). Coronary artery bypass graft surgery is usually
conducted using two methods, which include with cardio - pulmonary pump or without using this pump. The
experts have different viewpoints regarding outcomes of these two methods (Puskas et al., 2004). One important
treatment aspect of management of these patients lies in electrolyte balance. Despite the importance of
electrolyte balance, electrolyte changes after coronary artery bypass graft surgery was not studied much (Inoue
et al., 2004). Potassium is an important electrolyte whose role in development of cardiac arrhythmias is
identified properly, particularly in atrial fibrillation (Silva et al., 2004; Wilkes et al., 2002 ). Acute renal failure
is the most common complication found in coronary artery bypass surgery. Even a small increase in serum
creatinine levels in these patients is associated with increased mortality (Brown et al., 2006; Aronson et al.,
2007). Acute renal failure is a major concern in patients with CKD who underwent Coronary Artery Bypass
Grafting surgery (CABG). The incidence of Acute Kidney Injury (AKI) after cardiac surgery varies from 1% to
3% depending on the characteristics of patients studied (Mangan et al., 1998). Many studies have reported that
an increase in preoperative serum creatinine level is associated with increased morbidity and mortality in
patients undergoing CABG with cardiac – pulmonary pump (Lee et al., 2005). Many studies have compared
these two groups on terms of incidence of renal failure; however, the occurrence of renal failure in the group
Corresponding Author: Ahmad Ebadi, Associate Professor of Cardiac Anesthesiology MD, Department of Cardiac
Anesthesiology, Atherosclerosis Research Center Golestan Hospital, and Pain Research Center,
Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.
E-mail: [email protected]
54
Mehdi Dehghani Firoozabadi et al,2014
Advances in Natural and Applied Sciences, 8(9) August 2014, Pages: 53-56
without cardiac – pulmonary pump was not addressed in these studies (Weerasinghe et al., 2005; Hix et al.,
2006). Nevertheless, the required data to generalize this information to all treatment groups is not adequate. As a
result, it is essential to further study this issue. Therefore, the present study aimed to compare changes in renal
function in patients undergoing CABG with or without CPB method.
Methods:
This study is a descriptive epidemiologic study. The statistical population included the patients who
underwent CABG in Ahvaz Golestan Hospital. After obtaining approval from the Ethics Committee of Ahvaz
Jundishapur University of Medical Sciences, the records of patients who had undergone cardiac surgery were
collected. Then, the required information was obtained from the records. Data collection tool for this study was
a researcher-made questionnaire, which includes both demographic data and variables studied. It should be
noted that all patients received routine surgery as follows: the patients received 0.1 mg/kg of intramuscular
morphine and 25 mg intramuscular promethazine on arrival to the operating room. The patients also received
their common cardiac medication the day before surgery (except ACE-I and anti-platelets). They also received
1.5 g intravenous cefazolin every 8 hours for 24 hours, which is a prophylaxis antibiotic. Anesthetic medication
began with 2-3 mg kg (3-5 mg) thiopental and atracurium (0.5 mg/kg) and midazolam (0.1 mg/kg). CVP =
central venous arterial line-NG tube-fully- pressure and esophageal temperature probe were inserted for EKG
patients. Then, they were monitored. In addition, circular membrane oxygenator pump was used. Prime solution
with one-liter NORMAs molar Ringer’s solution and 500 ml glucose 5% solution and a vial of sodium
bicarbonate and 100 cc of 18% mannitol were given to the patients before aortic clamping. The flow rate was
adjusted, so that mean arterial pressure was maintained between 80-60 mmHg throughout the operation.
Systolic, diastolic, mean arterial pressures, heart rate, central venous pressure (CVP), arterial oxygen pressure
(PaO2), arterial PH and arterial oxygen saturation (SaO2) were measured and recorded in the previous stage,
during connecting CPB, before entering the recovery and 2 hours after surgery. Blood pressure was measured in
an aggression form. In addition, the pressure was measured using CVP. Arterial blood gases including PH,
PaO2 and SaO2 were also measured. In the group with CPB, the patients were evaluated in terms of duration of
pump connection. If the systolic blood pressure was less than 90 mmHg during CPB separation, 0.01-0.1
μg/kg/min inotrope medication was used, which is actually the dilute adrenaline. Additional ringer was
prescribed in order to maintain the constant fluid level. Hemodilution was also done in order to maintain a
minimum level of 7g/dl-Hg. Myocardial protection was done using intermittent backward and forward cardio
hemiplegia with cold blood. At the end of surgery with CPB, the entire circuit was returned to the patient. After
surgery, the patient was transferred to ICU in both intubated and sedated conditions in order to keep the patients
in the sedation state. Then, propofol was prescribed before rewarming. If the hemodynamic stability, alertness
and pain control were in normal conditions, the patient was removed from mechanical ventilation. The patient's
hemodynamic was managed as MAP> 65 using crystalloid and colloid dopamine infusion or epinephrine, if
necessary. At the end, the data was entered into the computer and was analyzed using SPSS. Descriptive
statistics was used to present the tables and graphs. Moreover, analytical statistics such as chi-square was used
in order to compare the conditions in terms of two different sexes and various ages.
Results:
Among the cases, 150 cases were fully recorded and examined. Among the 150 patients participating in this
study, 75 patients underwent on-pump surgery while 75 patients underwent off-pump surgery. The statistical
results showed that the two groups were not statistically different in terms of age, gender, height, weight, history
of hypertension, history of hyperlipidemia, history of chronic obstructive airway, ejection fraction below 50%,
creatinine, sodium and potassium (Table I).
Table 1: Preoperative characterizations.
Variable
Age
Male sex
Weight
Stature
Hypertension
Hyperlipidemia
COPD
Ejection fraction < 50%
Preop Cre
Preop Na
Preop K
Off pump
group
(n = 75)
59.24+8.21
46
75.16, 14.04
160.34+7.49
35
41
4
32
0.8
140.5
4.20
On pump
group
(n = 75)
60.03+8.62
42
73.80+12.52
164.24+8.09
33
39
7
37
0.78
141
4.26
P Value
0.65
0.71
0.317
0.743
0.87
0.54
0.189
0.362
0.84
0.71
0.876
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Advances in Natural and Applied Sciences, 8(9) August 2014, Pages: 53-56
However, the examinations conducted after the surveys showed that changes in both levels of sodium (p
<0.05) and creatinine (p <0.05) were significantly lower in the group that underwent surgery without CPB.
Nevertheless, this difference was not significant in terms of potassium (p> 0.05) (Table 2).
Table 2: post-operative characterizations.
Variable
Postop Cre
Postop Na
Postop K
Off pump
group
(n = 75)
1.05
144.5
4.8
On pump
group
(n = 75)
1.7
149
4.7
P Value
0.001
0.01
0.3
It should also be noted that duration of surgery (p> 0.05), extubation time (p> 0.05), medications during
surgery (p> 0.05) and consumption of blood products after the surgery (p> 0.05) did not differ significantly
between the two groups.
Discussion:
As the results of this study showed, changes in serum creatinine level was much lower in OPCAB surgery
group. In contrast, significant increases in serum creatinine were observed in the counter group. In addition,
changes in sodium levels were significantly different in the two groups. However, there was no significant
difference in terms of potassium. Studied variables showed the importance of renal function in the surgery. The
factors that increase the risk of renal failure should be avoided as much as possible due to complications caused
by renal failure and reduced outcomes after renal injury. Then, alternative methods that are less hazardous
should be used. Creatinine was the most important variable examined in our study. Therefore, it was attempted
to compare the results obtained in this research with those obtained in other similar studies in which both onpump and off-pump patients with coronary artery bypass surgery were examined. Abu Omar et al conducted a
study entitled as the impact of off-pump coronary artery bypass surgery on postoperative renal function. They
showed that creatinine clearance was significantly lower in on-pump surgery group. This result is consistent
with those obtained in our study (Abu-Omar et al. 2012). In addition, Ooi et al conducted a study titled as Renal
Outcome Following On-and Off-Pump Coronary Artery Bypass Graft Surgery. They showed that creatinine
clearance in OPCAB was closer to ground level while this factor was not suitable in the first, second and fourth
days after the surgery in on-pump group. No significant differences were observed between the two groups.
These results were consistent with those obtained in our study (Ooi et al., 2008). So far, the results obtained in
similar studies were in line with those obtained in our study. However, contradictory results were obtained in
few studies in which the patients were monitored for longer periods. For example, Moller et al conducted a
study titled as No Major Differences in 30-Day Outcomes in High-Risk Patients Randomized to Off-Pump
Versus On-Pump Coronary Bypass Surgery. They showed that renal failure and dialysis requirement were not
significantly different in patients on and off-pump. This finding is contrary to those obtained in our study
(Møller et al., 2010).
Conclusion:
Due to increased cases of renal failure, higher levels of creatinine and sodium in the group using CPB, it
seems that coronary artery bypass surgery technique without CPB may cause fewer side effects. However, it is
suggested to conduct further studies to generalize this data.
ACKNOWLEDGEMENT
Authors acknowledge the support by Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.
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