等剂量舒芬太尼和芬太尼用于冠脉搭桥手术麻醉的比较

A Comparison of Equal Dose Sufentanil and Fentanyl in Coronary Artery Bypass Grafting Anesthesia

目的：对比观察同等剂量的舒芬太尼（10ug／kg）和芬太尼（10ug／kg）用于冠脉搭桥病人手术中血流动力学变化情况及术后拔管时间及镇静程度。 方法：择期冠脉搭桥病人35例，分为舒芬太尼组（S组）17例和芬太尼组（F组）18例。术前一小时口服安定10mg，术前半小时肌注东莨菪碱0．3mg，吗啡10mg。麻醉诱导咪达唑仑0.03mg／kg，哌库漠铵0．15mg／kg，S组舒芬太尼5ug／kg，F组芬太尼5ug/kg，维持麻醉药间断给予哌库溴铵，在切皮前和劈胸骨前共给予S组舒芬太尼5ug／kg、F组芬太尼5ug／kg。两组术中持续泵注丙泊酚，根据血压调节剂量。在切皮前和劈胸骨前根据情况追加咪达唑仑，两组术中持续泵入血管活性药多巴胺和硝酸异山梨酯，当血压小于术前30％时给予去氧肾上腺素，心率小于45次，分时给予654-2。用Edwards Vigilance CCO记录两组术前，麻醉前，麻醉后1、3、5、10分钟，切皮前，切皮后，劈胸骨前、搭桥葡、搭桥后、关胸前及术毕的MAP、HR、CVP、MPAP、CCO，SVO2、CI、SVR、PVR、PCWP，并记录麻醉药和血管活性药的用量，术后记录拔管时间，镇静程度及麻醉药的用量。 结果：诱导到诱导后10min，两组HR和MAP较入室都有明显下降（P〈0.05）。切皮后1min及劈胸骨前F组MAP组高较明显（P〈0．01）。但S组变化不明显（P〉0．05）。HR在开始搭桥后两组都较切皮前有明显升高（P〈0．05）。CO及CI两组都较术前有明显升高，但S组（P〈0．01）升高的较F组（P〈0．05）更明显（P〈0．01）。SVRS组较术前有明显下降（P〈0.01），且两组间有统计学差异（P〈0．01）。两维术中持续泵注多巴胺和硝酸异山梨酯的最无明显差异（P〉0．05），单次推注去氧肾上腺素和654—2的量无统计学差异（P〉0．05），但两组丙泊酚和咪达唑仑的用量S组明显少于F组（P〈0．01）。两组术后拔管时间无统计学差异，但S组术后病人疼痛程度明显小于F组（P〈0．05）。而且镇静程度明显好于F组（P〈0．01）。结论：等剂量的舒芬太尼用于无急性心梗的冠脉搭桥病人优于芬太尼，它不仅可以减少术中及术后其它麻醉药的用量，而且血流动力学更加平稳。同时术后病人的镇静程度明显增加，并不影响拔管时间。

Objective： To compare the effects of equal dose sufentanil with fentanyl in coronary artery bypass grafting anesthesia. Method： thirty-five patients scheduled for coronary artery bypass grafting were randomly divided into two groups, group sufentanil （S） and group fentanyl （F）. Before one hour of operation all the patients orally diazepam 10mg and scopolamine 0.3mg IM and morphine 10mg IM. Anesthesia were inducted with midazolam 0.03mg/kg, pipecuronium 0.15mg/kg. Sufentanil 5ug/kg in S group and fentanyl 5ug/kg in F group was given intravenously after pipecuronium. Anesthesia was maintained with propofol continuous infusion. Sufentanil 5ug/kg in S group and fentanyl 5ug/kg in F group was added before incision and sternum splitting. Midazolam was given before incision and sternum splitting if needed. Dopamine and isosorbide were continuous infused during operation in both groups. When blood pressure decreased more than 30% of baseline and HR less than 45/min, phenylephrine and 654-2 were given. MAP, HR, CVP, MPAP, CCO, SVO2, CI, SVR, PVR, PCWP were measured by Edwards Vigilance Monitor. The dosage of narcotic, the time of extubation and the degree of sedation were recorded. Results： HR and MAP in two group were decreased significantly after induction （P〈0.05） . MAP in group F were increased significantly over baseline （P〈0.01） after incision and before sternum splitting, but in group S there were no different than before anesthesia （P〉0.05） . Before grafting HR in two group was increased significantly than before incision （P〈0.05） , and there was no different between two groups （P〉0.05） . CO and CI in group S increased significantly more than that in group F （P〈0.05） . SVR in group S decreased significantly than group F （P〈0.01） . The dosages of dopamine, isosorbide, phenylephrine and 654-2 were no significantly different between two groups. But propofol and midazolam in group S were significantly less than group F （P〈0.01） . The degree of sedation in group S was deeper than group F （P〈0.01）. Conclusion： Equal dosage of sufentanil is superior to the fentanyl in coronary artery bypass grafting anesthesia. It not only can reduced the dosage of narcotic in the operation, but also keep hemodynamics more stable, increase the degree of sedation after operation than fentanyl without influence to the time of intubation.