丙泊酚静脉麻醉对血液流变学的影响

Effects of Propofol on Hemorheology During Intravenous Anesthesia

目的观察食道癌根治术中持续泵注不同剂量丙泊酚与吸入异氟醚麻醉患者血液流变学的变化规律,探索丙泊酚静脉麻醉对血液流变学的影响,为围麻醉手术期改善微循环提供实验依据。方法选择36例ASA分级为I-II级择期行食道癌根治术（开胸）的患者,术前无高血压病史、糖尿病病史;无肺部疾患;无严重肝、肾功能障碍;无合并感染及免疫系统疾病,随机分为A、B、C3组,A、B两组分别持续泵注丙泊酚4 mg/（kg.h）、8 mg/（kg.h）,C组吸入异氟醚,吸入浓度1%~2%。3组患者均用瑞芬太尼0.2μg/（kg.m in）和维库溴铵0.03 mg.kg-1维持镇痛和肌松。所有患者于颈内静脉穿刺后（T1）（麻醉前）,切皮后60分钟（T2）、120分钟（T3）、180分钟（T4）抽取中心静脉血各12 mL检测血液流变学有关指标。监测血液流变学指标：上述各时间点的全血粘度（高切、中切、低切）、血浆粘度、全血还原粘度（髙切、低切）、红细胞压积、红细胞聚集指数、红细胞刚性指数、纤维蛋白原。统计学处理：应用专业统计软件SPSS11.5对数据进行统计分析,计量资料以均数±标准差（x-±s）表示,多组间比较采用单因素方差分析,组内比较采用两两比较的q检验,与常值比较应用单样本t检验,比较取P〈0.05为差异有显著性。结果血液流变学指标：组内比较：A组患者全血高、中、低切粘度和全血高、低切还原粘度、血浆粘度以及红细胞聚集指数、红细胞刚性指数在T2、T3、T4均比T1显著降低（P〈0.05）,纤维蛋白原T4比T1显著降低（P〈0.05）;B组患者全血高切粘度、全血髙切还原粘度、血浆粘度T3、T4比T1显著降低（P〈0.05）,全血中切粘度T4比T1显著降低（P〈0.05）,全血低切粘度、全血低切还原粘度、红细胞刚性指数和红细胞聚集指数各时间点无显著差异（P〉0.05）,纤维蛋白原T4比T1显著降低（P〈0.05）;C组全血高切粘度、全血髙切还原粘度、红细胞刚性指数T2、T3、T4均比T1显著降低（P〈0.05）,全血中、低切粘度和全血低切还原粘度T3、T4比T1显著降低（P〈0.05）,血浆粘度和纤维蛋白原均略有增高,但各时间点无显著差异（P〉0.05）。结论 （1）术中持续输注4 mg/（kg.h）丙泊酚可以有效降低全血粘度、血浆粘度、全血还原粘度、红细胞聚集指数、红细胞刚性指数、纤维蛋白原;（2）术中持续输注4 mg/（kg.h）丙泊酚在维持麻醉同时对血流动力学的干扰较小,并且对血液流变学的影响比持续输注8 mg/（kg.h）更有宜,因此建议丙泊酚输注速度为4 mg/（kg.h）;（3）食道癌患者术前均为高粘血症。

Objective To observe the different effect of continuously infusion with transfer pump of propofol and inhalation of isoflurane on blood rheology in patients undergoing radical esophageal cancer removal operation,and to explore the possible mechanism of the effect of these two ways of anesthesia on the blood rheology,therefore to provide proof for modifying microcirculation system during such operations.Methods Thirty-six patients who＇s ASA graded were I-II,without history of hypertension,diabetes mellitus,lung disease,and without severe dysfunction of liver and kidney were chosen,also had no infectious and immune system disease,underwent radical elective esophageal cancer removal operation under general anesthesia were divided in group A,B and C.Group A and B continuously infused with propofol 4 mg/（kg·h）,8 mg/（kg·h） respectively,group Cinhaled with 1%-2%isoflurane propofol or isoflurane anesthesia.All these three groups were given remifentany 0.2 μg/（kg·min） and vecuronium 0.03 mg·kg-1 for maintaining the anesthesia.All the patients accepted internal jugular venous puncture before anesthesia induction（T1）,12 mL of blood samples were taken from central venous catheter at 60（T2）,120（T3）,180（T4） mins after skin incision made for the purpose of determining related haemorheological index.The monitoring parameters included hemorrheology index,whole blood viscosity（WBV）,plasma viscosity,blood revert viscosity（BRV）,hematocrit（HCT）,RBC aggregation index,RBC rigidity index and fibrinogen were also tested at T1,T2,T3 and T4 time points to analysis the variation of blood rheology.All the data were analyzed by SPSS11.5.All values were expressed as mean SD.One-way analysis of variance（ANOVA） was used to analysis the measurement data,multiple comparison was carried out with q test,P0.05 considered statistically different.Results Hemorrheology indexes： In group A,whole blood viscosity（WBV）,plasma viscosity,blood revert viscosity（BRV）,hematocrit（HCT）,RBC aggregation index,and RBC rigidity index were significantly decreased at T2,T3,T4（P0.05） vs T1.Fibrinogen was significantly decreased at T4（P0.05） vs T1.In group B,the changes of blood rheology displayed a similar trend of decrease during the anesthesia.But there was no statistical difference in low-blood viscosity,low-blood revert viscosity,RBC rigidity index and RBC aggregation index between other time point and baseline in group B.There is a slight increasement in plasma viscosity and fibrinogen in group C,but no statistical difference compared with T1.There was a higher degree of decreasement in high-blood viscosity,low-blood viscosity,plasma viscosity,blood revert viscosity,RBC aggregation index and RBC rigidity index in group A than that in group C.RBC rigidity index was significantly lower in group A and group B than that in group C.Conclusions Propofol is an effective anesthetic for decreasing the blood viscosity during the operation.Compared with the older patients who anesthetized with isoflurane or patients had a potential blood hyper viscosity but anesthetized with propofol,propofol is of great benefit to ameliorate the microcirculation among these cases.Intravenous anesthesia with infusion of propofol 4 mg/（kg·h）r is likely to be a better choice,because it can maintain more steady-going haemodynamics.