吗啡和芬太尼对心内直视手术患者全身炎性反应和心脏功能影响的比较

Comparison of morphine and fentanyl on systemic inflammatory reaction and myocardial function in cardio-valve replacement surgery under CPB

目的比较吗啡和芬太尼对在体外循环（CPB）下行瓣膜置换术患者全身炎性反应和心脏功能的影响。方法选取ASA分级Ⅱ~Ⅲ级、拟行心脏瓣膜置换术患者30例,随机分为吗啡组（M组）和芬太尼组（F组）,每组15例。依次静注咪唑安定0.1mg/kg、芬太尼3~4μg/kg（F组）或吗啡300~400μg/kg（M组）、哌库溴胺0.1mg/kg诱导麻醉,行气管内插管控制呼吸。术中按需间断静注咪唑安定和哌库溴胺维持镇静和肌松,并于切皮前、CPB转机前及主动脉开放后追加等效剂量的芬太尼或吗啡。于麻醉前（T0）、切皮前（T1）、主动脉阻断前（T2）、CPB停止2h（T3）、6h（T4）和术后24h（T5）取动脉血,应用分光光度法检测血清超氧化物歧化酶（SOD）活性和丙二醛（MDA）水平,应用抗原抗体法检测肿瘤坏死因子-α（TNF-α）、白细胞介素-6（IL-6）、白细胞介素-8（IL-8）和白细胞介素-10（IL-10）的浓度,应用生化分析法测定血清肌酸激酶同工酶（CK-MB）活性和肌钙蛋白I（cTnI）水平,并观察心脏复跳情况等。结果两组血清SOD活性、MDA水平、TNF-α、IL-6、IL-8和IL-10水平、血浆CK-MB活性和cTnI水平于CPB后不同时点均有不同程度升高（P均〈0.05）;M组血清MDA、TNF-α、IL-6和IL-8含量、CK-MB活性、cTnI水平的升高幅度低于F组（P均〈0.05）。两组心脏复跳情况及心血管活性药物使用剂量等无统计学差异（P〉0.05）。结论尽管吗啡和芬太尼的保护效应对临床心脏功能恢复无差异性,但等效镇痛剂量的吗啡较芬太尼更能减少CPB心脏手术期间氧自由基释放、减轻全身炎性反应,增强心肌保护功能。

Objective：To compare the effects of morphine and fentanyl on systemic inflammatory reaction and myocardial function in patients undergoing cardiovalve replacement under cardiopulmonary bypass（CPB）.Methods：Thirty patients（ASAⅡ-Ⅲ） undergoing cardio-valve replacement surgery under CPB were randomly divided into two groups（n=15）.Anesthesia was induced with intravenous injection of midazolam,morphine（group M） or fentanyl（group F） and subsequently pipecuronium,and was maintained with interval injection of morphine（group M） or fentanyl（group F） and pipecuronium.Serum SOD,MDA,TNF-α,IL-6,IL-8,IL-10,CK-MB and cTnI was detected before anesthesia（T0）,before skin incision（T1）,before aortic-clamping（T2）,2 h（T3） and 6 h（T4） after CPB and 24 hafter surgery（T5）.Results：Serum levels of SOD activity,MDA,TNF-α,IL-6,IL-8,IL-10, CK-MB activity and cTnI increased at different time points of post-CPB（P0.05-0.01）,and the extent,except for serum SOD activity,in group M was lower than that in group F（P0.05）.There were no differences in cardiac recovery and usage of cardiovascular activators between the two groups.Conclusion：The findings of the present study demonstrate that morphine can inhibit the release of oxygen free radicals and the inflammatory response,and protect the myocardium more than fentanyl in patients undergoing cardiovalve replacement under CPB.