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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 55 Mehdi Dehghani Firoozabadi et al,2014 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. REFERENCES Firoozabadi, M., Dehghani, A. Ebadi, 2014. Effect of Relaxation on Postoperative Pain in Patients after Coronary Artery Bypass Grafting (CABG) Surgery." NATIONALPARK-FORSCHUNG IN DER SCHWEIZ (Switzerland Research Park Journal), 103: 1.185-191. Leong, J.Y., R.A. Baker, P.J. Shah, V.K. Cherian, J.L. Knight, 2005. Clopidogrel and bleeding after coronary artery bypass graft surgery. The Annals of thoracic surgery, 80(3): 928-33. Myles, P.S., J. Smith, J. Knight, D.J. Cooper, B. Silbert, J. McNeil, et al., 2008. Aspirin and Tranexamic Acid for Coronary Artery Surgery (ATACAS) trial: rationale and design. American heart journal, 155(2): 22430. Roediger, L.J.J, M. Senard, R. Larbuisson, J.L. Canivet, M. Lamy, 2006. The use of pre-operative intrathecal morphine for analgesia following coronary artery bypass surgery. Anaesthesia, 61: 838-44. 56 Mehdi Dehghani Firoozabadi et al,2014 Advances in Natural and Applied Sciences, 8(9) August 2014, Pages: 53-56 Puskas, J., W. Williams, P. Duke, J. Staples, K. Glas, J. Marshall, et al., 2003. Off-pump coronary artery bypass grafting provides complete revascularization with reduced myocardial injury, transfusion requirements, and length of stay: a prospective randomized comparison of two hundred unselected patients undergoing offpump versus conventional coronary artery bypass grafting. J Thorac Cardiovasc Surg. 125: 797- 808. Puskas, J., W. Williams, E. Mahoney, P. Huber, P. Block, P. Duke, et al., 2004. Off-pump vs. conventional coronary artery bypass grafting: early and 1-year graft patency, cost, and quality-of-life outcomes: a randomized trial. JAMA, 291: 1841-1849. Inoue, S., S. Akazawa, Y. Nakaigawa, R. Shimizu, N. Seo, 2004. Changes in plasma total and ionized magnesium concentrations and factors affecting magnesium concentrations during cardiac surgery. J Anesth, 18 (3): 216-219. Silva, R., G. Lima, A. Laranjeira, A. Costa, E. Pereira, R. Rodrigues, 2004. Risk factors, morbidity and mortality, associated with atrial fibrillation in the postoperative period of cardiac surgery. Arq Bras Cardiol, 83 (2): 105-110. Wilkes, N., S. Mallett, T. Peachey, C. Di Salvo, R. Walesby, 2002. Correction of ionized plasma magnesium during cardiopulmonary bypass reduces the risk of postoperative cardiac arrhythmia. Anest Analg, 95(4): 828- 834. Brown, J., R. Cochran, L. Dacey, 2006. Perioperative increases in serum creatinine are predictive of increased 90-day mortality after coronary artery bypass graft surgery. Circulation, 200(114): 1409-1413. Aronson, S., M. Fontes, Y. Miao, 2007. Risk index for perioperative renal dysfunction/failure. Circulation, 115: 733-742. Mangan, C.M., L.S. Diamondstone, J.C. Ramsay, et al., 1998. multicenter study of preoperative Ischemia Research Group Renal dysfunction after my condiel revascularisatives is at el Ann mten Med, 128:194-203 Lee, S.Y., J.B. Choi, M.K. Lee, 2005. Changes of Renal Function and Treatment after CABG in Patients with Elevated Serum Creatinine. Korean J Thorac Cardiovasc Surg, 38(2): 146-151. Weerasinghe, A., T. Athanasiou, S. Al-Ruzzeh, 2005. Functional renal outcome in on-pump and off-pump coronary revascularisation: a propensity-based analysis. Ann Thorac Surg. 79: 1577-1583. Hix, J, C. Thakar, E. Katz, 2006. Effect of off-pump coronary artery bypass graft surgery on postoperative acute kidney injury and mortality. Crit Care Med, 34: 2979- 2983. Abu-Omar, Y., F.J.M. Taghavi, A. Navaratnarajah, A. Ali, L.M. Shahir, C.K. Yu, Choong, D. Taggart. 2012 ."The impact of off-pump coronary artery bypass surgery on postoperative renal function." Perfusion, 27(2): 127-131. Ooi, Joanna S.M. Mohd R. Abdul Rahman, Shamsul A. Shah, and Z. Mohd Dimon, 2008. Renal outcome following on-and off-pump coronary artery bypass graft surgery." Asian Cardiovascular and Thoracic Annals, 16(6): 468-472. Møller, Christian H. Mario J. Perko, Jens T. Lund, Lars W. Andersen, Henning Kelbæk, Jan K. Madsen, Per Winkel, Christian Gluud and A. Daniel, 2010. Steinbrüchel. "No Major Differences in 30-Day Outcomes in High-Risk Patients Randomized to Off-Pump Versus On-Pump Coronary Bypass Surgery The Best Bypass Surgery Trial." Circulation, 121(4): 498-504.