高位硬膜外阻滞对体外循环换瓣术患者血流动力学和心功能的影响

Effect of high thoracic epidural anesthesia on hemodynamics and heart function in patients receiving valve replacement under cardiopulmonary bypass

目的:通过观察高位硬膜外阻滞(HTEA)复合全麻对体外循环换瓣手术患者血流动力学和心功能的影响,探讨HTEA的应用价值。方法:选择78例拟在体外循环下行双瓣置换术的风心病患者,分为全麻组(GA组)和高位硬膜外复合全麻组(GEA组)。观察两组患者HR、MAP、CVP、MPAP、PCWP以及CO的变化,分别检测血浆皮质醇浓度和cTn-I浓度,记录血管活性药物的用量以及拔管时间,对术后镇痛进行VAS评分。结果:(1)与GA组比较,GEA组HR、MAP麻醉开始后均明显降低(P<0.05),但其MRAP在T5、T6、T7明显升高(P<0.05),PCWP在T6、T7明显升高(P<0.05),CO和CI在T6明显升高(P<0.05),SVI在T5、T6、T7明显升高(P<0.05)。(2)两组患者血浆皮质醇浓度从T3开始出现显著升高(P<0.01),但GEA组在T3、T5、T6、T7均明显低于GA组(P<0.01)。两组患者cTn-I浓度T6、T7时均高于T0(P<0.05),GEA组在T6、T7均明显低于GA组(P<0.05)。(3)GEA组硝普钠用量明显少于GA组(P<0.05),拔管时间明显比GA组提前(P<0.05),术后24hVAS评分明显低于GA组(P<0.05)。结论:高位硬膜外麻醉和镇痛改善体外循环换瓣手术患者血流动力学和心功能,缩短术后拔管时间并加强术后镇痛,对心脏术后患者恢复和转归能产生积极影响。

Objective To explore the value of high thoracic epidural anesthesia （HTEA） by observing the effect of HTEA combined with general anesthesia on hemodynamics and heart function. Methods 78 patients receiving double-valve replacement under cardiopulmonary bypass were divided into general anesthesia group （GA group） and high thoracic epidural anesthesia group （GEA group）. HR and MAP was recorded before anesthesia （T0）, after intubation （T1）, during sternotomy （T2）, bypass for 30 minutes （T3）, shut off 30 minutes （T4）, shut off 2 hours （T5）, shut off 4 hours （T6）, and shut off 24 hours （T7）. The changes of CVP, MPAP, PCWP, and CO were monitored at T0, T1, T4, T5, T6, and T7 and CI, SVI, SVR, and PVR were calculated. The plasma concentration of cortisol at T0, Tl, T3, T5, T6, and T7, and cTn-I at T0, T5, T6, and T7 were measured. The use of vasoactive drugs, extubation time, and VAS score were noted. Results There was no statistical difference in hemodynamics parameters between the two groups at T0 （P 0.05）. HR was significantly lower in GEA group than in GA group after the start of anesthesia （T4, T5, and T7, P 0.05; Tl, T2, and T6, P 0.01）, and MAP was significantly lower in GEA group than in GA group at Tl, T2, T3, T5, T6, and T7 （P 0.05）. MRAP was significantly higher in GEA group than in GA group at T5, T6, and T7 （P 0.05）. PCWP was significantly higher in GEA group than in GA group at T6 and T7 （P 0.05）. CO and CI were significantly higher in GEA group than in GA group at T6 （P 0.05）, SVI was significantly higher in GEA group than in GA group at T5, T6, and T7 （P 0.05）. Plasma cortisol levels did not differ statisticallly between the two groups before the start of surgery （T0 and T1, P 0.05） but increarsed significantly from T3 （P 0.01）; Them was significantly lower in GEA group than in GEA group at T3, T5, T6, and T7 （P 0.01）. Troponin I did not differ significantly between the two groups at T0 （P 0.05）, but was higher at T6 and T7in two groups （P 0.05）. The plasma cTn-I concentration was significantly lower in GEA Group than in GA group at T6 and T7 （P 0.05）. The total amount of sodium nitroprusside use was significantly less in GEA group than in GA group in the perioperative period （P 0.05）, while the total amount of dopamine use did not differ significantly between the two groups （P 0.05）. The extubation time was significantly shorter in GEA group than in GA group （P 0.05）; and VAS score was significantly lower in GEA group than in GA group （P 0.05）. Conclusions High thoracic epidural anesthesia improves hemodynamics and cardiac function in patients receiving valve replacement under cardiopulmonary bypass, shortens postoperative extubation time and improves postoperative pain relief, which has a positive effect on the recovery of patients after cardiac surgery.