七氟烷和丙泊酚麻醉对体外循环脑氧代谢及术后认知功能的比较

Comparison of Sevoflurane and Propofol on Cerebral Oxygen Metabolism and Postoperative Cognitive Function During Cardiopulmonary Bypass

目的观察以七氟烷为主的静吸复合麻醉与丙泊酚为主的全凭静脉麻醉对体外循环（CPB）下瓣膜置换术中脑氧供需平衡和术后认知功能的影响。方法择期CPB下瓣膜置换术50例,美国麻醉医师协会（ASA）Ⅱ或Ⅲ级,年龄40-65岁,随机分为七氟烷组（S组）与丙泊酚组（P组）,每组25例。麻醉诱导两组患者相同：依次缓慢静注咪唑安定0.1 mg·kg-1、舒芬太尼0.7μg·kg^-1、维库溴铵0.1 mg·kg^-1、依托咪酯0.2 mg·kg^-1快速诱导后行气管内插管。麻醉维持：术中S组持续吸入七氟烷,浓度3%-4%,P组静脉持续泵注丙泊酚4-6 mg·kg^-1·h^-1,两组均间断静注咪唑安定、舒芬太尼和维库溴铵来维持麻醉。分别在CPB开始前（t1）、鼻咽温降至低温恒定期（t2）、鼻咽温升至恒定期（t3）、CPB结束后1 h（t4）、CPB结束后6 h（t5）抽取桡动脉血及颈内静脉球部血分别测血气,并进行术前、术后24和48 h的简易智力状况调查（MMSE）评分。结果两组均观察到在t2时点颈静脉氧饱和度（SjvO2）明显增高,动静脉血氧含量差（AVDO2）和氧摄取率（O2ER）则明显降低,而在t3时点两组SjvO2明显降低,AVDO2和O2ER则明显增加（P〈0.05）,但两组在t2和t3时点组间比较均差异无统计学意义（P〉0.05）。MMSE评分比较显示术后24和48 h均低于术前,但在24 h测定值七氟烷组高于丙泊酚组,差异有统计学意义（t=4.34,P〈0.05）。结论两种麻醉方法均能满足CPB下瓣膜置换手术的需要,都能维持CPB期间脑氧供需平衡,但七氟烷组对术后精神神经功能改变的影响减少。

Objective To observe the effects of sevoflurane and propofol on cerebral oxygen metabolism and postoperative cognitive function during cardiopulmonary bypass（ CPB）. Methods Fifty ASA Ⅱ or Ⅲ patients aged 40- 65 years old scheduled for cardiac valve replacement surgery with CPB were randomly assigned into two groups,sevoflurane group（ group S） and propofol group（ group P）,25 in each group.Two groups of patients used the same method of anesthesia induction：midazolam 0.1 mg·kg^-1,sufentanil 0.7 μg·kg-1,vecuronium 0.1 mg·kg-1,and etomidate 0.2 mg·kg-1were intravenously injected successively,and then tracheal intubation was performed.For maintenance of anesthesia,patients of group S continuously inhaled 3%-4% sevoflurane,and patients of group P were intravenous pumped with propofol 4- 6 mg · kg^-1·h^-1via vein;midazolam,sufentanil and vecuronium bromide were intermittently injected in both groups.At the time points of pre-bypass（ t1）,nasopharynx temperature dropping to constant temperature regularly（ t2）,nasopharynx temperature rising to constant temperature regularly（ t3）,1 h after the end of CPB（ t4）,and 6 h after the end of CPB（ t5）,blood from radial artery and right jugular bulb was harvested for blood gas analysis,and mini-mental state examination（ MMSE） score were evaluated before and 24 and 48 h after the surgery. Results The jugular venous bulb oxygen saturation（ Sjv O2） in the two groups were both increased during T2 period and then decreased during t3 period,but arteriovenous oxygen content difference（ AVDO2） and oxygen extraction rate（ O2ER） were both decreased during t2 period and then increased during t3 period.There was no significant difference between the two groups during t2 and t3period（ P〉0.05）. MMSE scores of the two groups after operation were all less than those before operation,but that was significantly higher in the sevoflurane group than in the propofol group 24 h after the surgery（ t = 4.34,P〈0.05）. Conclusion The two anesthesia methods can meet the need of valve replacement surgery and maintain the cerebral oxygen balance during CPB period,but sevoflurane anesthesia has fewer influences in post-operation mental nerve functional changes.