不同麻醉下老年高血压患者围术期心肌损伤的比较

Effects of sevoflurane and isoflurane on perioperative myocardial injury in elderly hypertensive patients

目的比较不同麻醉下老年高血压患者围术期心肌损伤的程度，为老年高血压患者选择适宜的麻醉方法。方法择期行胸外科手术的老年高血压患者36例，年龄〉64岁，ASAⅡ或Ⅲ级，高血压Ⅱ级，高血压危险程度为中、高危险组，随机分为七氟醚组（S组）、异氟醚组（I组）和异丙酚组（P组），每组12例。插管成功后至术毕，S组和I组呼气末吸入麻醉药浓度分别为1．7％、1．2％；P组静脉靶控输注异丙酚，血浆靶浓度2～3μg/ml。分别于麻醉前、气管插管后、手术探查后、拔除气管导管后即刻记录心电图ST段水平。于麻醉前、手术开始1h、术毕、术后3、6、12、24h抽取上肢静脉血，采用ELISA法测定血浆心肌肌酸激酶同工酶（CK-MB）活性和心肌肌钙蛋白I（cTnI）、白细胞介素-6（IL-6）、C反应蛋白（CRP）、可溶性细胞间粘附分子-I（sICAM-1）的浓度。结果拔除气管导管后即刻P组ST段水平明显低于S组和I组（P〈0．05）；与麻醉前比较，手术开始至术毕24h各组血浆CK-MB活性、cTnI、IL-6、CRP和sICAM-1浓度明显升高（P〈0．05）；S组和I组术后24h血浆cTnI、IL-6、CRP和sICAM浓度明显低于P组（P〈0．05）。结论采用七氟醚或异氟醚复合麻醉时较采用异丙酚复合麻醉时老年高血压患者心肌损伤程度轻，围术期的炎性反应减轻；老年高血压患者宜采用吸入麻醉。

Objective To compare the effects of sevoflurane and isoflurane on pefioperative myocardial injury in elderly hypertensive patients. Methods Thirty-six patients with hypertension of Ⅱ degree aged 〉 64 yr undergoing elective chest surgery were randomly divided into three groups of 12 patients each： group Ⅰ sevoflurane （Sevo）; group Ⅱ isoflurane （Iso） and group Ⅲ propofol （Pro）. The patients were premedicated with intramuscular midazolam 5 mg and iv scopolamine 0.3 mg. Anesthesia was induced with TCI of sufentanil （target Cp = 0.5 ng/ml） and iv midazolam 0.025-0.050 mg/kg. Tracheal intubation was facilitated with pipecuronium as soon as the patients lost consciousness. The patients were mechanically ventilated. PaCO2 was maintained at 30- 40 mm Hg. Anesthesia was maintained with 1.7% sevoflurane, or 1.2% isoflurane or propefol TCI （target Cp = 2-3μg/ml）. ECG, HR, BP, CVP, SpO2 , end-tidal PCO2 and BIS were continuously monitored during operation. BIS was maintained at 40-60. The changes in ST segment were recorded before anesthesia, after intubation and surgical exploration and immediately after extubation. Myocardial ischemia was defined as ST segment depression ≥ 0.1 mV for more than 1 min. Blood samples were obtained from peripheral vein of upper limb, before anesthesia （T0）, 1 h after skin incision （T1 ）, at the end of operation （T2） and 3, 6, 12, 24 h after operation （T3-6） for determination of plasma CK-MB activity and plasma concentrations of cTnI, IL-6, CRP and sICAM-1. Results The ST segment depression was significantly deeper after extubation in group Pro than in group Sevo and Iso. The plasma CK-MB activity and cancentrations of cTnI, IL-6, CRP and sICAM-1 were significantly increased after operation in all 3 groups. The plasma levels of cTnI, IL-6, CRP and sICAM-1 were significantly higher in group Pro than in group Sevo and Iso. Conclusion Myocardial injury is less severe during the first 24 h after chest operation performed under sevoflurane or isoflurane anesthesia than under propofol anesthesia.