异氟醚和七氟醚对非体外循环冠状动脉旁路移植术患者心肌保护作用的比较

Comparison of myocardial protective effects of isoflurane versus sevoflurane in patients undergoing offpump coronary artery bypass grafting

目的 比较异氟醚和七氟醚对非体外循环冠状动脉旁路移植术患者的心肌保护作用.方法 择期行非体外循环冠状动脉旁路移植术患者40例,性别不限,年龄40～55岁,体重55～94 kg,ASA分级Ⅱ或Ⅲ级,NYHA分级Ⅱ或Ⅲ级.采用随机数字表法,将患者随机分为2组（n=20）：异氟醚组（Ⅰ组）和七氟醚组（S组）.麻醉诱导：静脉注射咪达唑仑0.08 mg/kg、舒芬太尼2μg/kg和维库溴铵0.1 mg/kg,气管插管后行机械通气.麻醉维持：Ⅰ组吸入异氟醚,初始呼气末浓度1.2%;S组吸入七氟醚,初始呼气末浓度1.7%;两组静脉输注舒芬太尼0.04μg·kg^-1·min^-1和维库溴铵0.8μg·kg^-1·min^-1.通过调节异氟醚或七氟醚的呼气末浓度,维持BIS值40～50.分别于切皮前即刻、术毕、术后2和4 h时,采集中心静脉血样,测定血浆MB型肌酸激酶同工酶（CK-MB）的活性和心肌肌钙蛋白Ⅰ（cTnI）的浓度.记录术中心血管不良事件的发生情况.结果 与Ⅰ组比较,S组术中室性早搏、心动过速、心动过缓、室颤和S-T段抬高＞0.1 mV的发生率升高,术后血浆CK-MB活性和cTnI浓度升高（P＜0.05）.结论 非体外循环冠状动脉旁路移植术患者异氟醚的心肌保护作用优于七氟醚.

Objective To compare the myocardial protective effects of isoflurane versus sevoflurane in patients undergoing off-pump coronary artery bypass grafting （OPCABG）. Methods Forty ASA Ⅱ or Ⅲ patients （NYHA Ⅱ or Ⅲ ） of both sexes, aged 40-55 yr, weighing 55-94 kg, scheduled for elective OPCABG, were randomly divided into 2 groups （ n = 20 each）： isoflurane group （ group Ⅰ） and sevoflurane group （ group S）. Anesthesia was induced with midazolam, sufentanil and vecuronium. Patients were tracheal intubated and mechanically ventilated. Anesthesia was maintained with inhalation of isoflurane or sevoflurane and infusion of sufentanil and vecuronium. In group Ⅰ, the initial end-tidal concentration of isoflurane was 1.2%. In group S, the initial end-tidal concentration of sevoflurane was 1.7 %. BIS value was maintained at 40-50 by adjusting the end-tidal concentration of isoflurane or sevoflurane. The central venous blood samples were collected immediately before skin incision, at the end of surgery, 2 and 24 h after surgery for determination of plasma creatine kinase-MB （CK-MB） activity and cardiac troponin Ⅰ （cTnI） concentration. The adverse cardiovascular events were recorded. Results The incidences of ventricular premature beat, tachycardia, bradycardia, ventricular fibrillation and S-T segment elevation （ 〉0.1 mV） during surgery and the plasma CK-MB activity and cTnI concentration after surgery were significantly higher in group S than in group Ⅰ （ P 〈 0.05）. Conclusion Isoflurane has better myocardial protective effect than sevoflurane in patients undergoing OPCABG.