非体外循环冠脉搭桥术中的血液动力学和氧代谢的变化

The changes of hemodynamics and oxygen metabolism in patients undergoing off-pump coronary artery bypass grafting

目的观察非体外循环冠脉搭桥术(OPCABG)中的血液动力学及氧代谢参数的变化,并分析其麻醉处理特点。方法择期行OPCABG手术患者87例。均采用芬太尼、异氟醚、笑气、异丙酚行静吸复合全麻。采用肺动脉漂浮导管和连续心排血量方法测定血液动力学,分别在手术前(T1)、锯胸骨后(T2)、吻合血管桥前(T3)、吻合前降支时(T4)、吻合后降支或右冠状动脉时(T5)、吻合左回旋支或对角支时(T6)、血管吻合完成并恢复心脏自然位置(T7)、闭合胸骨前(T8)及手术结束时(T9)等时间点测定及计算血液动力学参数;分别在上述的T1、T2、T3、吻合开始后1.5h(T4-)、及T9的5个时间点检测动脉、混合静脉血气,并进一步计算氧代谢参数包括氧供8指数(DO2I)、氧耗指数(VO2I)、氧摄取率(ERO2)等。记录术后拔气管导管时间及ICU停留时间。结果与T1相比,T2与T3的HR、CO、CI、PAWP、MPAP、LVWI、RVWI、RVSWI、DO2I、SO2、PO2均显著增加(P<0.05或0.01),而VO2I与ERO2明显降低(P<0.05或0.01),但SI、LVSWI和PVRI无显著性改变(P>0.05)。在吻合靶血管过程中(T4、T5、T6),CI、SI、MAP、LVWI、LVSWI、RVWI、RVSWI、DO2I、SO2、PO2、VO2I等不同程度地降低(P<0.05或0.01),而HR、RAP、MPAP、PAWP和ERO2则显著增高(P<0.05或0.01)。血管吻合完毕后至术毕(T7、T8、T9)各项参数均逐渐恢复至T1水平或明显改善。术后平均6.5±2.3h拔除气管导管,ICU停留时间为2.6±1.4d。结论在可靠的血液动力学监测和合理使用血管活性药物情况下,OPCABG病人可安全地渡过吻合靶血管时的循环波动期,恢复机体的氧供需平衡。

Objective To observe the changes of hemodynamics and oxygen metabolism in patients undergoing off-pump coronary artery bypass grafting （OPCABG）, and analyzed its characteristics in anesthetic management. Methods From January 2002 to December 2006,87 cases with coronary heart disease underwent off-pump coronary artery bypass grafting （OPCABG）in selective period. The fentanyl, isoflurane, N20 and propofol were used to perform inhalation combined with intravenous anesthesia in all cases. Hemodynamics were determined by Swan-Granz catheter and continuous cardiac output method. The every time point and hemodynamic parameters were detected as follows： before operation （%）, after sternotomy （T2）, before the beginning of graft anastomoses （T3）, during anterior descending artery grafting （T4）, during right coronary artery or posterior descending artery grafting （T5）, during left circumflex or diagonal branch artery grafting （T6）, after finished vascular anastomoses, and the heart returned to normal position （T7）, before the chest closure （T8）, and at the end operation （T 9）. Aterial and mixed venous blood samples were taken to do blood gas analysis, and DO2I, VO2I and ERO2 were calculated at the T1, T2, T3, 1.5 h after the beginning of graft anastomoses （T4-8） and Tg. postoperative removing tracheal catheter time and satying ICU time were recorded. Results HR, CO, CI, PAWP, MPAP, LVWI, RVWI, RVSWI, DO2I, SO2 and PO2 were increased significantly while VO2I and ERO2 were decreased significantly at T2 and T3 compared with that at T1 （P〈0.05 or 0.01）, but there were no significant changes in SI, LVSWI and PVRI （P 〉 0.05）. During graft anastomoses （T4,T5,T6）, CI, SI, MAP, LVWI, LVSWI, RVWI, RVSWI, DO2I, SO2, PO2 and VO2I were decreased in different degree, but HR, RAP, MPAP, PAWP and ERO2 were increased significantly （P〈0.05 or 0.01 ）. From T7 to Tg, the parameters above were restored gradually to T1 level or were improved obviouly. The average postoperative removing times of tracheal catheter and staying ICU time were 6.5＋2.3h and 2.6＋1.4 d. Conclusion Under reliable hemodynamic monitoring and reasonable use of vasoactive agents, OPCABG can be performed uneventfully during graft anastomoses.