七氟烷复合舒芬太尼麻醉在不停跳冠状动脉搭桥术中对血流动力学和心肌影响的研究

Myocardial and homodynamic effects produced by sevoflurane combined sufentanil anesthesia for patients having off pump coronary artery bypass graft surgery

目的:研究七氟烷复合舒芬太尼麻醉在不停跳冠状动脉搭桥手术中,对血流动力学和心肌的影响。方法:择期行不停跳冠状动脉搭桥术(OPCABG)患者60例,随机分为七氟烷麻醉组(S组,n=30)和丙泊酚麻醉组(P组,n=30)。全组患者麻醉前30 min肌注吗啡0.2 mg/kg,东莨菪碱0.3 mg;S组用4%七氟烷吸入诱导,患者入睡后静脉注射维库溴铵0.2 mg/kg和舒芬太尼1～2μg/kg;P组丙泊酚1～2mg/kg诱导,患者入睡后静脉注射维库溴铵0.2 mg/kg和舒芬太尼1～2μg/kg。S组吸入七氟烷1MAC、静注舒芬太尼0.5～1.5μg.kg-1.h-1、维库溴铵0.1 mg.kg-1.h-1。监测桡动脉血压,连续心排出量(CCO)、右心房压、中心静脉压、肺动脉压(PAP)及肺动脉楔压(PAWP)。分别于麻醉前、术后6 h、20 h、28 h及38h抽取静脉血,测定血浆肌钙蛋白I(cTnI)及心肌酶CK-MB水平。结果:2组患者一般资料差异无统计学意义。CCO、HR、ABP、CVP及PAWP组间差异无统计学意义。P组使用多巴胺维持血压者多于S组。S组舒芬太尼用量少于P组,其平均清醒时间也较短。手术后6 h各组均出现CK-MB和TnI释放量增加,术后20 h S组TnI释放量明显低于P组〔(0.81±0.46)比(0.93±0.46),P<0.05〕,同时S组CKMB释放量也较低〔(21.80±6.88)比(24.73±8.64),P<0.05〕。结论:本研究提示,在不停跳冠状动脉搭桥麻醉管理中,用七氟烷复合麻醉可减轻心肌损伤,减少升压药的使用率。

Objective： To evaluate myocardial metabolic and hemodynamic effect of sevoflurane combined sufentanil anesthesia on off-pump coronary artery bypass graft （OPCABG） surgery. Method：Sixty patients scheduled for elective OPCABG surgery were enrolled and randomly assigned to SA group （ n = 30） or PA group （ n = 30）. In the SA group, anesthesia was induced with 4% sevoflurane, sufentanil 1-2μg/kg and Vacuronium 0.2 mg/kg, followed by IMAC sevoflurane, sufentanil 0.5-1.5μg.kg-1.h^-1 and Vacuronium 0.2 mg·kg-^1·h^-1 were maintained. In the PA group, anesthesia was induced with propofol 1-2 mg/kg,sufentanil 1-2 μg/kg and Vacuronium 0.2 mg/kg, followed by propofol TCI, effective site concentration 1.5 μg/mL and sufentanil 0.5-1.5 μg.kg-1.h^-1 was maintained. Hemodynamic data were recorded after induction of anesthesia and at various time in bypass period. The inotropic and vasodilating agents were given by BP, CI, SVR. At preoperative, postoperative 6, 20, 28, 38 hours, blood samples were collected to measure Tnl and CK-MB. Result： The patients in the SA group had less demand of inotropic agent than those in the PA group. Although there was no statistical difference in preoperative data and hemodynamic measurement, the recovery time in the SA group was Shorter than those in the PA group. Plasma cTnI and CK-MB level in postoperative period were higher comparing with preoperative baseline in both groups. Tnl and CKMB level were significantly higher in PA group than SA group [ （0.81 ± 0.46） vs （0.93 ± 0.46）, （21.80 ± 6.88） vs （24.73 ± 8.64）, P 〈 0.051 at postoperative 20 hour. Conclusion： Our results suggest that sevofluranecombined sufentanil anesthesia provides better management of reduced myocardial injury and less intropic agents usage in OPCABG.