瑞芬太尼预处理对体外循环二尖瓣置换术患者围术期心肌的保护作用

Cardioprotective effects of remifentanil preconditioning in patients undergoing mitral valve replacement under cardiopulmonary bypass

①目的探讨瑞芬太尼预处理对体外循环(CPB)下二尖瓣置换术(MVR)患者心肌的保护作用。方法择期CPB下MVR患者40例,ASAⅡ级或Ⅲ级。随机分为两组(n=20):瑞芬太尼组(R组)和异丙酚组(P组)。麻醉维持:P组靶控输注异丙酚,血浆靶浓度2～3μg/L,芬太尼2～3μg/(kg·h);R组夹闭主动脉前,以4μg/(kg·min)的速率输注瑞芬太尼5min,间隔5min后重复输注共3次,夹闭主动脉后靶控输注异丙酚,血浆靶浓度2～3μg/L。芬太尼2～3μg/(kg·h)。于切皮前即刻、CPB前即刻、CPB后即刻、回ICU后即刻、6、12h记录心率(HR)、平均动脉压(MAP)、中心静脉压(CVP)、心脏指数(CI)、体循环血管阻力指数(SVRI)。于麻醉诱导前,回ICU后即刻、6、12、24h采集静脉血,测定血清心肌肌钙蛋白I(cTnI)浓度。结果两组各时点MAP、CVP、HR和SVRI比较差异无统计学意义(P>0.05),与切皮前即刻和P组比较;R组回ICU后各时点CI升高(P<0.05)。与P组比较,R组回ICU后各时点cTnI浓度降低(P<0.05)。两组患者术后均无死亡,两组心肌梗死、房颤和心肌缺血的发生率差异无统计学意义(P>0.05);R组cTnI浓度>2μg/mL的发生率低于P组(P<0.05)。结论瑞芬太尼预处理对CPB下MVR患者围术期心肌具有一定的保护作用。

Objective To investigate the protective effect of remifentanil preconditioning on myocardium in patients undergoing mitral valve replacement（MVR） under cardiopulmonary bypass（CPB） . Methods Forty ASAⅡ or Ⅲ patients scheduled for MVR under CPB were randomly divided into 2 groups（n = 20） ： remifentanil group（group R） and propofol group（group P） . Anesthesia was maintained with propofol by target-controlled infusion（TCI） （plasma concentration 2 ～ 3μg/L） and Fentanyl infusion 2 ～ 3μg/（kg·h） in group P,while the patients in the group R received 3 episodes of 5 min remifentanil infusion at 4μg/（kg·min） at 5 min interval before aortic clamping,and TCI by propofol（plasma concentration 2 ～ 3μg/L） and fentanyl 2 ～ 3 μg/（kg·h） after aortic cross clamping. Heart rate（HR） ,mean arterial pressure（MAP） ,central venous pressure（CVP） ,cardiac index（CI） ,and systemic vascular resistance index（SVRI） were recorded before the start of surgery（baseline） ,before the start of CPB,after the end of CPB,at arrival in the intenive care unit（ICU） （T0） ,6（T6） and 12（T12） hours after arrival in ICU. Blood samples were taken before the induction of anesthesia,T0,T6,T12,and 24 hours after arrival in ICU（T24） for determination of serum concentration of cardiac troponin I（cTnI） . Results The two groups were comparable with respect to MAP,CVP,HR and SVRI（P 0. 05）;Compared with in group P and its baseline,CI was significantly increased postoperatively in group R（P 0. 05） . Serum cTnI concentrations were significantly lower postoperatively in group R than in group P（P 0. 05） . There was no significant difference in the incidences of myocardial infarction,atrial fibrillation and myocardial ischemria between the two groups（P 0. 05） ,but the incidence of serum cTnI concentration 2ng/mL was lower in group R than in group P（P 0. 05） . Conclusion Remifentanil preconditioning possessed a certain cardioprotective effect in patients undergoing MVR under CPB.