在重症监护病房中通过麻醉维持装置给予七氟烷与静脉给予丙泊酚进行镇静时肾脏的完整性比较

背景在20世纪70年代运用甲氧氟烷后，无机氟化物水平增加以及手术中七氟烷使用延长被认为具有潜在的肾毒性。在重症监护病房（ICU）我们观察通过麻醉维持装置（ACD）短时吸入七氟烷进行手术后镇静对肾脏完整性的影响，并与丙泊酚进行比较。方法前瞻、随机、单盲的研究中，125例接受腹主动脉或胸外手术的患者被分为2组，分别接受ACD给予七氟烷（呼气末浓度0．5-1vol％）（n=64）或静脉给予丙泊酚（n=61）进行手术后24小时镇静：尿α-谷胱甘肽-s-转移酶作为主要观察指标，尿N-乙酰氨基葡萄糖苷酶、血清肌酐以及无机氧聚合物、尿排出量和输液量分别在手术前、手术结束和手术后24、48小时进行测量：结果七氟烷（9．2±4．3小时）组和丙泊酚（9．3±4．7小时）组在ICU镇静时间相当。与手术前比较两组尿α-谷胱甘肽-s-转移酶在手术后24和48小时明显增高，但组间差异无显著性。N-乙酰氨基葡萄糖苷酶、血清肌酐两组都保持不变，两组间尿排出量和肌酐廓清率在整个观察期间都大致相当。使用七氟烷（39±25μmol/L）24小时后与丙泊酚（3±6μmol／L）组比较无机氧化物明显增加（P〈0．001），并且在48小时内保持增高水平（33±26 vs 3±5μmol／L）：每组都有一例患者伴有肾功能不全，住院期间需要加强利啄疗法，但不需要透析；结论手术后无论用ACD给予七氟烷还是用丙泊酚维持的短时镇静都不会对肾脏功能造成负性影响。尽管使用七氟烷后无机氟化物水平较高，但在住院期间肾小球和肾小管仍然保持了完整性。

BACKGROUND： Increased inorganic fluoride levels after methoxyflurane exposure in the 1970s and prolonged intraoperative sevoflurane use have been suggested to be potentiaUy nephrotoxic. In the intensive care unit we evaluated the effect on renal integrity of short-term inhaled postoperative sedation with sevoflurane using the Anesthetic Conserving Device （ACD） compared with propofol. METHODS： In this prospective, randomized, single-blinded study, after major abdominal, vascular or thoracic surgery 125 patients were allocated to receive either sevoflurane （n = 64） via the ACD （end- tidal 0.5 - 1 vol%） or IV propofol （n = 61） for postoperative sedation up to 24 h. Urinary α-glutathione-s-transferase as primary, outcome variable, urinary N-acetyl-glucosaminidase, serum creatinine, and inorganic fluoride concentrations, urine out- put and fluid management were measured preoperatively, at the end of surgery, and at 24 and 48 h postoperatively. RESULTS： The sedation time in the intensive care unit was comparable between the sevoflurane （9.2 ± 4.3 h） and the propofol （9.3 ± 4.7 h） group. Alpha-glutathione-s-transferase levels were significandy increased at 24 and 48 h postoperatively compared with preoperative values in both groups, without significant differences between the groups. N-acetyl-glucosaminidase and serum creatinine remained unchanged in both study groups, and urine output and creatinine clearance were comparable between the groups throughout the study period. Inorganic fluoride levels increased significantly （P 〈 0. 001 ） at 24 h after sevoflurane exposure （39 ± 25 μmol/L） compared with propofol （3 ± 6 μmol/L） and remained elevated 48 h later （33 ± 26 vs 3 ± 5μmol/L）. One patient in each group suffered from renal insufficiency, requiring intensive diuretic therapy, but not dialysis, during hospital stay. CONCLUSIONS： Short-term sedation with either sevoflurane using ACD or propofol did not negatively affect renal function postoperatively. Although inorganic fluoride levels were elevated after sevoflurane exposure, glomerular and tubular renal integrity were preserved throughout the hospital stay.