Cerebrovascular Dıseases In Intensıve Care Unıt
Pakize ÖZÇİFTÇİ YILMAZ* 0000-0002-3420-0460 Cihangir DOĞU** 0000-0003-2581-541x Esra YAKIŞIK ÇAKIR** 0000-0002-6992-5744 Ahmet BİNDAL*** 0000-0002-1971-6856 Zeynep Nur AKÇABOY**** 0000-0003-0748-7889 Işıl ÖZKOÇAK TURAN**0000-0002-0405-0107
*Aydın Devlet Hastanesi Yoğun Bakım Kliniği
**Sağlık Bakanlığı Ankara Şehir Hastanesi Yoğun Bakım Kliniği
***Şanlıurfa Eğitim ve Araştırma Hastanesi Yoğun Bakım Kliniği
****Kırıkkale Üniversitesi, Anestezi ve Reanimasyon ABD
Yazışma Adresi: Pakize ÖZÇİFTCİ YILMAZ
Aydın Devlet Hastanesi Yoğun Bakım Kliniği E-Mail:drpakize@gmail.com
Öz
Amaç: Yoğun bakım kliniğinde takip edilen serebrovasküler hastalık tanısına sahip
hastalarda yutma fonksiyon bozukluğunun görülme oranının ve bu hastalarda perkütan endoskopik gastrostomi (PEG) açılma sıklığının belirlenmesi amaçlandı.
Materyal metod: 1 Mart 2014 – 31 Ekim 2015 tarihleri arasında yoğun bakım
kliniğinde serebrovasüler hastalık (iskemik inme, hemorajik inme ve subaraknoid kanama ) tanıları ile 24 saatten fazla takip edilmiş >18 yaş hastaların dosyaları tarandı.
Bulgular: Çalışmaya 184 hasta alındı. Ortalama yaş 69 yıl, APACHE skoru 14,1 idi. 102
(%55,4) hastada yutma fonksiyon bozukluğu tespit edildi. 49 (%26,6) hastaya PEG açıldı. Yutma bozukluğu olmayan 82 hastanın tamamı taburcu edilmiş olup, disfajisi olan hastalarda bu oran %40,1 idi. Bu fark istatistiksel olarak anlamlı bulundu(p<0,001). PEG açılan hastaların 2’sinde (%4) işlem sonrası kanama nedenli komplikasyon gelişti.
Sonuç: Serebrovasküler hastalık gruplarında yutma fonksiyon bozukluğu konusunda
duyarlılığın artmasının aspirasyon pnömonisi gibi mortalite ile ilişkili komplikasyonları önlemede faydalı olacağı kanaatindeyiz.
Anahtar Kelimeler: Serebrovasküler Hastalık, Yutma Fonksiyon Bozukluğu, Perkütan
endoskopik gastrostomi
Abstract
Objective: In this study, our objective was to determine the incidence of swallowing
dysfunction and percutaneous endoscopic gastrostomy (PEG) in patients diagnosed with cerebrovascular disease and followed up in intensive care unit.
Materials and Methods: The files of patients, who were older than 18 years and
followed up for 24 hours due to cerebrovascular diseases in intensive care unit between March 1st, 2014 and October 31st, 2015, were screened.
Findings: A total of 184 patients were included in the study. The mean age of the
patients was 69 years and the APACHE score was 14.1. Swallowing dysfunction was determined in 102 patients (55.4%). Forty-nine patients (26.6%) underwent PEG. Eighty-two patients, who did not have swallowing dysfunction, were discharged and the rate of discharge was 40.1% among the patients with dysphagia. This difference was statistically significant (p<0.001). Complications were observed in 2 of PEG patients (4%).
Conclusion: We concluded that the increase of the awareness about the swallowing
dysfunction in patients with cerebrovascular disease would be useful for the prevention of complications related to the mortality like aspiration pneumonia.
Keywords: Cerebrovascular Diseases, Swallowing Dysfunction, Percutaneous
Endoscopic Gastrostomy
Geliş Tarihi: 07.05.2020 Kabul Tarihi: 08.07.2020
Introduction
Dysphagia (difficulty in swallowing) is a serious disorder encountered in approx. 80% of the patients diagnosed with cerebrovascular disease (CVD). The disorders like malnutrition, dehydration, aspiration pneumonia, which are associated with swallowing dysfunction, play an important role in the morbidity and mortality (2, 3). Therefore, in most of the centers, PEG is routinely recommended in patients diagnosed with CVD, who cannot take oral food (4). Although it is a common procedure in many centers, its early-phase complications and long-phase results, which are less common compared to the surgical procedure, is not fully investigated in the literature (5). This method could decrease not only complications (particularly aspiration pneumonia) in patients with neurological deficits but also the treatment cost in intensive care units (6).
In this study, we planned to investigate the incidence of swallowing dysfunction and PEG in patients, who were followed up due to the diagnosis of CVD in intensive care.
Materials and Method
Patients over 18 years, who were followed up with the diagnosis of cerebrovascular disease more than 24 hours in intensive care unit of the Ankara Numune Training and Research Hospital between March 1st, 2014 and October 31st, 2015, were included in this retrospective study. Diagnosis of ischemic stroke, hemorrhagic stroke, and subarachnoid hemorrhage constituted the group of cerebrovascular diseases. The study was approved by the Local Ethics Committee of the Ankara Numune Training and Research Hospital.
Female and male patients, who fulfill the above mentioned inclusion criteria, were enrolled in the study. Patients younger than 18 years and followed up less than 24 hours were excluded. The characteristics of the patients such as age, gender, APACHE II score, hospitalization duration, the type of cerebrovascular disease (ischemic stroke, hemorrhagic stroke and subarachnoid hemorrhage) were recorded. In addition, parameters like the presence of the cranial CT and cranial MRI findings, the need for mechanic ventilation, the development of aspiration pneumonia, the presence of swallowing dysfunction diagnosed during the neurology consultation, the presence of percutaneous endoscopic gastrostomy in patients with swallowing dysfunction and if performed, the day of the intervention and the presence of complications during and after the intervention and the outcome of intensive care (discharge, transfer, death) were recorded. The statistical analysis was done with SPSS v25.0 software package.
Statistical analysis
The statistical software package SPPS v25.0 (IBM Corp. Released 2017. IBM SPSS Statistics for Windows, Version 25.0. Armonk, NY: IBM Corp.) was used for the data evaluation. The variables were expressed in mean±standard deviation and median (maximum-minimum) percentage and frequency values. The comparison of the two groups was done with the Independent 2 Group t-test (Student’s t-test).
If the preconditions were not available, the Mann-Whitney U test was used and the comparison of three or more groups was carried out with the One-Way Variance Analysis and Tukey HSD test (one of the multiple comparison tests). If not sufficient, Kruskal-Wallis test and Bonferroni-Dunn test (one of the multiple comparison tests) were implemented. p<0.05 and p<0.01 were considered as statistically significant.
Results
A total of 184 patients were included in the study. 104 of them were males (56.5%) and 80 were females (43.5%). The mean age was 69.17 years. Regarding the types of cerebrovascular diseases; 99 patients (53.8%) had ischemic CVD, 65 (45.3%) hematoma and 20 (10.9%) had subarachnoid hemorrhage (SAH). Forty-one of hematomas (22.2%) were mostly parenchymal. The mean APACHE II score was 14.14 (Table 1).
Table 1. Average Data Yoğun Bakım Kliniğinde Serebrovasküler Hastalık Nedeni ile Takip Edilen
Hastalarda Yutma Fonksiyon Bozukluğu Görülme ve Perkütan Endoskopik Gastronomi Açılma Sıklığı
The Incıdence Of Swallowıng Dysfunctıon And Percutaneous Endoscopıc Gastrostomy In Patıents Followed Up Due To Cerebrovascular Dıseases In Intensıve Care Unıt
Age (Year) APACHE II Hospitalization time (day) Charlsoncomorbidity score N 184 184 184 184 Mean 69,17 14,14 16,68 4,11 Minimum 20 2 1 0 Maximum 93 40 102 8
The mean hospitalization duration was 16.68 days. 102 of the patients (55.4%) had difficulty in swallowing and 49 of them (48%) underwent PEG. Among the PEG patients, two patients (4.3%) developed hemorrhage. We did not observe any complication in 42 patients (95.7%).
There was no significant difference between the rates of the swallowing dysfunction in respect of the disorders in the left and right cerebral hemispheres and cerebellum. However, we determined swallowing dysfunction in 64% of the patients with shifting and in 70% of the patients with pons disorder (Table 2).
Table 2. Demographic data
Number (n:184) Percent (%) Gender Woman Male 80 104 43,5 56,5 Cranial pathology Ischemic CVD Parenchymal hematoma Subarachnoid hemorrhage Subdural hematoma Epidural hematoma 99 41 20 22 2 53,8 22,3 10,9 12 1,1 Swallowing disorder Yes No 102 82 55,4 44,6 PEG Yes No 49 135 26,6 73,4 Output state Discharged Death 123 61 66,8 33,2
ÖZÇİFTÇİ YILMAZ ve Ark. ÖZÇİFTÇİ YILMAZ et al.
123 patients (76.8%) were discharged and 61 (33.2%) died. All of the ceased patients and 33.3% of the discharged patients had difficulty in swallowing. This difference was statistically significant (p<0.001) (Table 3). All of these patients discharged after PEG was implemented.
The enteral nutrition is a system, which depends on the intestinal mucosal barrier and prevents the translocation in the gastrointestinal tract (13). It was reported that its early implementation decreased the mortality rate about 5-8% (14). George et al. (15) stated that the timing of PEG, which decreased the mortality and the possible complications and increased the quality of life in CVD patients, is critical. Therefore, they suggested that factors like age, use of anticoagulants, features of the tracheostomy, the presence of sepsis should be taken into consideration and the implementation time of PEG should be between 7 days and 3 weeks.
In the last 15 years, the principles of the stroke care are changed and the morbidity and mortality rates are decreased significantly depending on the factors like the introduction and widespread use of tissue plasminogen activators and the increase in the number of the stroke departments (10, 16). This is one of the reasons for the early diagnosis of dysphagia and consequently, the rate of PEG increased in these patients. After their study on 340 stroke patients, Li et al. (17) have concluded that the majority of the patients who could be orally fed in the short term, needed PEG in the long term.
Lee et al. (18) determined that mortality rate was relatively higher in CVD patients, who had serum albumin levels lower than 31.5 g/L and CRP levels higher than 21.5 mg/dL, and PEG was associated with higher complication risks in these patients compared to the normal patients. In another study, the gastrointestinal bleeding rate was 3.5% in patients, who underwent PEG (19). Our results were consistent with the results in the literature.
Conclusions
Dysphagia is an important finding in CVD patients, which plays a critical role in morbidity and mortality. PEG implementation - as a solution for dysphagia - and its timing are important factors for the management of these patients.
Table 3. Prevalence of Swallowing Dysfunction
Swallowing Dysfunction
Yes No Total
Cranial pathology localization
Right pathology Left pathology Cerebellar pathology Pons pathology Shift 53 (%56,3) 55 (%53,4) 4 (%44,4) 7 (%70) 22 (%64,7) 41 (%43,7) 48 (% 46,6) 5 (%55,6) 3 (%30) 12 (%35,3) 94(%100) 103 (%100) 9 (%100) 10 (%100) 34 (%100) Output state Discharged Death 41 (%33,3) 61 (%100) 82 (%66,7) 0 (%0) 123 (%100) 61 (%100) Discussion
PEG, which was first described by Gaudere et al. (7), is an important method and can be implemented in patients, who cannot be orally fed but have a regularly functioning gastrointestinal system (8). It is considered an ideal method in patients, who cannot ingest orally, are weak and have malign or neurological disorders. Although there is currently no standard definition regarding the patients suitable for PEG, it is recommended by the American Gastroenterological Association for the patients, who have a functioning gastrointestinal tract, cannot be orally fed and are expected to live longer than 30 days after the intervention (9). The CVD patients are considered as ideal candidates for the PEG feeding due to the risks of malnutrition and aspiration pneumonia (4). One of the aims of the usage of the percutaneous endoscopic gastrostomy catheter in CVD patients is to increase the quality of life. According to the results of a study, approximately 3-6% of the patients diagnosed with ischemic CVD required PEG (10). We also observed that 26.6% of our patients diagnosed with CVD needed PEG.
In addition, the timing of PEG is quite important in CVD patients. Wilmskoetter et al. (11) conducted a study on patients with ischemic and hemorrhagic CVD and reported that PEG was performed in the 15th (ischemic CVD) and 26th day (hemorrhagic CVD) of the hospitalization in the intensive care unit. In our study, the mean implementation time of PEG was 23 days. The reasons for the PEG implementation in earlier phases are rather speculative and it can be generally considered for the patients, who cannot tolerate nasogastric (NG) tube and prefer alternative nutrition at the early stage (12).
References
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Yoğun Bakım Kliniğinde Serebrovasküler Hastalık Nedeni ile Takip Edilen Hastalarda Yutma Fonksiyon Bozukluğu Görülme ve Perkütan Endoskopik Gastronomi Açılma Sıklığı
The Incıdence Of Swallowıng Dysfunctıon And Percutaneous Endoscopıc Gastrostomy In Patıents Followed Up Due To Cerebrovascular Dıseases In Intensıve Care Unıt