异丙酚和瑞芬太尼靶控输注用于不停跳冠状动脉搭桥术麻醉

Target-controlled infusion of propofol and remifentanil for off-pump coronary bypass grafting

目的研究异丙酚和瑞芬太尼靶控输注全凭静脉麻醉用于不停跳冠状动脉搭桥手术麻醉的可行性.方法择期不停跳冠状动脉搭桥手术患者24例,男14例,女10例,年龄48～75岁.麻醉前穿刺桡动脉、放置Swan-Ganz导管,连续监测血流动力学.麻醉诱导分别以异丙酚和瑞芬太尼血浆靶控输注,异丙酚起始靶浓度为1.0μg/ml,每2分钟增加0.5μg/ml至脑电双频指数(BIS)≤55;瑞芬太尼靶浓度为3 ng/ml,并静脉注射维库溴胺1.2 mg/kg.麻醉维持为调节异丙酚靶浓度,保持BIS为40～55;瑞芬太尼靶浓度根据血压和手术刺激强度调节为1～5 ng/ml.术中以硝酸甘油、氨力农、间羟胺调控血流动力学.结果麻醉诱导时间为(9.2±1.4)min.麻醉诱导后,所有患者收缩压(SBP)和心率(HR)显著下降,其中6例SBP＜85 mm Hg(1 mm Hg=0.133 kPa),3例HR＜45次/min,而心脏指数(CI)无明显变化.术中吻合回旋支、右冠状动脉等心脏背面血管需翻动心脏或心脏需固定在非正常位置时,SBP、CI和混合静脉血氧饱和度(SvO2)显著下降,平均肺动脉压(MPAP)和中心静脉压(CVP)升高,但HR变化不明显.桥血管全部开放、心脏回复正常位置后,各项指标恢复正常,而CI水平上升显著高于麻醉前.结论异丙酚和瑞芬太尼靶控输注全凭静脉麻醉可安全、方便地用于不停跳冠状动脉搭桥术麻醉.

Objective To evaluate the feasibility of total intravenous anesthesia （TIVA） with target- controlled infusion（TCI） of propofol and remifentanil for off-pump coronary bypass grafting. Methods Twenty-four patients （14 male, 12 female） aged 48-75 yr, underwent elective off-pump coronary bypass grafting. Before anesthesia, a catheter was inserted into radial artery and a Swan-Ganz catheter was inserted into pulmonary artery via right jugular vein for continuous monitoring of hemodynamics. Anesthesia induction was conducted with TCI of propofol and remifentanil respectively and intravenous bolus of 0.12 mg/kg vecuronium. Propofol plasma target concentration was started from 1μg/ml and increased 0.5μg/ml every 2 min step by step to the level which made bispectral index （BIS） decrease to less than 55, and remifentanil plasma concentration 3 ng/ml. During anesthesia, propofol target concentration was adjusted to maintain BIS at 40-55, and remifentanil target concentration at 1-5 ng/ml according to the blood pressure and operation stimulation. Simultaneously, nitroglycerin, amrinone and metaraminol were used to modulate the hemodynamics. Results Anesthesia induction time was （9. 2±1.4） min. After induction, the systolic blood pressure （SBP） and heart rate （HR） decreased significantly in all patients （SBP was less than 85 mm Hg in 8 patients and HR less than 45 beats per minute in 3 patients）, but change of cardiac index （CI） was not significant. During the blood vessel anastomosis on dorsum of heart or when the heart was fixed at non-normal position, SBP, CI and SvO2 decreased markedly, mean pulmonary artery pressure （MPAP） and central venous pressure （CVP） increased significantly, and the HR was unchanged. After the grafting vessel reperfused and the heart recovered to the normal position, the hemodynamic parameters recovered to normal levels, and CI increased much more than the level before anesthesia. Conclusions TIVA with TCI of propofol and remifentanil can be safely and feasibly used for off-pump coronary artery bypass grafting.