异丙酚与咪唑安定在婴幼儿体外循环心脏手术期间的抗炎效果与预后比较

Comparison of Anti-inflammation and Prognosis between Propofol and Midazolam during CPB of Cardiac Surgery in Infants

目的比较先天性心脏病患儿应用异丙酚与咪唑安定的抗炎效果和预后情况。方法选择先天性心脏病患儿24例,随机分成异丙酚复合小剂量芬太尼组(PF组)和咪唑安定复合小剂量芬太尼组(MF组)。持续监测血流动力学变化,脉搏血氧饱和度(SPO2)及鼻咽和直肠温度,并记录术后拔管时间及术后重症监护病房(ICU)停留时间,采集入手术室时(t0)、诱导后10 m in(t1)、主动脉夹闭后15 m in(t2)、主动脉开放后15 m in(t3)、主动脉开放后2 h(t4)及术后24 h(t5)的新鲜血,观察细胞因子白细胞介素(IL)-6、IL-8的变化,取不同时点的心肌组织,观察心肌形态学变化以及核因子-κB(NF-κB)和细胞间黏附分子-1(ICAM-1)的表达。结果与MF组比较,PF组术后的拔管及ICU停留时间明显缩短(P<0.05);PF组心肌形态学的变化不如MF组明显,两组的NF-κB和ICAM-1的灰度值在主动脉开放20 m in均低于体外循环手术(CPB)开始之前(P<0.05),但PF组的灰度值高于MF组(P<0.05);PF组血液中IL-6,IL-8在主动脉夹闭及开放后15 m in时较MF组也明显降低(P<0.05)。结论异丙酚和咪唑安定均能抑制NF-κB、ICAM-1及手术中细胞因子的表达,但异丙酚复合小剂量芬太尼麻醉的抗炎效果和预后优于咪唑安定。

Objective To compare the effect between propofol and midazolam on inflammatory response of tissue injury and prognosis in children with conqenital heart disease undergoing correction of ventricular septal defect with CPB. Methods Twenty-four HYHA class Ⅰ-Ⅱ children with congential heart disease, aged from 1 through 7 years old, undergoing elective open heart surgery, were randomly divided into two groups： group PF in which anesthesia were induced with propofol （200 μg·kg^-1） combined with fentanyl （5 μg·kg^-1） and vecuronium （0.15 μg·kg^-1） and maintained with propofol （150 - 200 μg·kg^-1·min^-1） combined with low dose fentanyl （0.025 - 0.075 μg·kg^-1·min^-1） infusion, and group MF in which anesthesia was induced with madazolam （1 mg·kg^-1） combined with fentanyl （5 μg·kg^-1） and vecuronium （0.15 mg·kg^-1） and maintained with midazolam （0.5 - 1 μg·kg^-1·min^-1） combined with low dose fentanyl （0.03 - 0.06 μg·kg^-1·min^-1）. The patient was premedicated with intramusule morphine 0.1 mg·kg^-1 and scopolamine 0.01 mg·kg^-1. Left radial artery and right internal jugular vein were cannulated for MAP and CVP monitoring, and ECG, SPO2, nasopharyngeal and rectal temperature were continuously monitored during anesthesia and operation. The time of tracheal extubation and the period of staying at ICU were recorded. Blood samples were taken before operation （t0）, 10 min after induction （t1）, 15 min after clamping aorta t2, 15min after releasing aorta clamp （t3）, 2 hours after releasing aorta clamp （t4）, and 24 hours after operation （t5） to observe the changes in cytokines in serum. Myocardial samples were collected at different time spots to observe myocardium morphologic changes, the expression of NF-κB and ICAM-1. Results The tracheal extubation time in PF group was significant earlier, and its mean ICU staying time decreased （P 〈 0.05）. The values of NF-κB and ICAM-1＇s gray degree in both groups were decreased, but more decreased in MF group, IL-6 and IL-8 were significantly increased at t3, t4, t5 in both groups （P 〈 0.05）, but the values of cytokines in PF group were lower than MF group （P 〈 0.05）. Conclusion It is shown that propofol combined with low dose fentanyl can reduce inflammatory response and allow earlier recovery with an effect better than midazolam.