Kurylenko Ya.V. “Improvement of technologies of perioperative monitoring and intensive therapy for coronary artery bypass grafting in patients with ischemic heart disease”. – Qualifying scientific work on manuscript rights.
Key words: ischemic heart disease, coronary artery bypass grafting, heart failure, acute left ventricular failure, cardiopulmonary bypass, anesthesia, perioperative management, differentiated approach, phasagraphy, rehabilitation, levocarnitine, arginine, fructose-1,6-diphosphate, protocol.
Dissertation for obtaining higher education for the degree of Doctor of Philosophy on the topic: Doctor of Philosophy in the field of knowledge 22 "Health care" in the specialty 222 "Medicine" - State Institution of Science “Research and Practical Center of Preventive and Clinical Medicine” State Administrative Department (SIS “RPC PCM” SAD). Kyiv, 2022.
The dissertation proposed, based on the study of clinical, instrumental and laboratory data, to develop a protocol for the perioperative management of cardiac surgical patients. The relevance of the goal is due to the prevalence of acute left ventricular failure after coronary artery bypass grafting operations with cardiopulmonary bypas the need to improve methods of diagnosis and correction of acute heart failure after coronary artery bypass grafting operations with cardiopulmonary bypas (onpump CABG).
The work was carried out in two directions. In the first direction, it was decided to develop the principles of a differentiated approach to the prevention and treatment of acute left ventricular failure in patients after coronary artery bypass surgery in cardiopulmonary bypass, which was divided into three stages. In the second direction, it was decided to systematize and generalize the protocols of perioperative anesthetic management of patients with the same pathology, which was divided into two stages.
The first stage of the first direction - 80 patients who were hospitalized to the SIS “RPC PCM” SAD for onpump CABG.. The main group is 35 patients with hemodynamic disorders in the early postoperative period. Stabilization of hemodynamics - dobutamine, metabolic support - levocarnitine-arginine. Control group - 45 people without hemodynamic disorders. The patients were examined on the Fazagraph device. In the main group, the LF/HF indicator before the operation significantly exceeded this indicator in the control group, which indicates a clear predominance of irritation of the sympathetic nervous system in the main group. In the stabilization period, when the use of adrenomimetic support in the main group ended, the LF/HF values of both groups became almost the same.
In the main and control groups, the βT indicator before and after the operation did not change statistically and corresponded to the "threshold value" of the myocardial health indicator. By the time the patients in the main group were discharged from acute heart failure, the βT indicator already corresponded to a "healthy" myocardium.
The second stage of the first direction - 60 patients with preoperative hypophosphatemia, who were hospitalized at the SIS “RPC PCM” SAD for onpump CABG. Two groups of 30 people. Corrections of the level of phosphates in the main group - Fructose-1,6-diphosphate. Correction of the level of phosphates in the control group was not carried out. Administration of fructose-1,6-diphosphate increased the level of phosphates in the main group. In the control group, on the contrary, a statistically significant decrease in phosphates was observed after cardiopulmonary by-pass. In the case of acute heart failure in the postoperative period, the recovery time in the main group was two times shorter than in the control group, and the total dose of the consumed isotropic drug was 2.6 times less.
The third stage of the first direction - 60 patients with postoperative acute left ventricular failure, who were hospitalized to the SIS “RPC PCM” SAD for the onpump CABG. Two groups of 30 people. Stabilization of hemodynamics in the main group - dobutamine, metabolic support - levocarnitine-arginine. Stabilization of hemodynamics in the control group - dobutamine. It was found that venous saturation in patients in the main group after overcoming hemodynamic disorders was higher than in the control group. In the main group, hemodynamic recovery time was 1.3 times less than in the control group, and the total dose of the used inotropic drug was 1.33 times less.
At the first stage of second direction, approaches to the intraoperative management of cardiac surgical patients were systematized and generalized. An anesthesia protocol was developed.
At the second stage of second direction, approaches to the postoperative management of cardiac surgical patients were systematized and generalized. A protocol for postoperative management of the patient with ischemic heart disease was developed.
