去甲肾上腺素对重症瓣膜病瓣膜置换术的血流动力学影响

The hemodynamic effects of norepinephrine during valve replacement surgery in severely ill patients

目的研究去甲肾上腺素(NA)对重症瓣膜病患者CPB下行心脏瓣膜置换术的血流动力学影响。方法择期CPB下行心脏瓣膜置换术患者27例,根据所使用的血管活性药物分为:NA+多巴酚丁胺(Dob)组(NA组,n=12);肾上腺素(AD)+Dob组(AD组,n=15)。术中监测脉搏指示剂连续心排血量(PiCCO)和动脉血气分析对两组血流动力学的影响。分别在术前(T0)、CPB结束时(T1)、术后6h(乳酸最高时,T2)、术后24h(T3)记录HR、MAP、CVP、连续心排血量(CCO)、心脏指数(CI)、每搏量指数(SVI)、外周血管阻力指数(SVRI)、血管外肺水指数(EVLWI)、肺毛细血管通透性(PVPI)、中心静脉氧饱和度(ScvO2),动脉氧分压(PaO2)、乳酸(Lac)及其清除率(LCR),并对供氧量(DO2)、耗氧量(VO2)、氧摄取率(ERO2)进行计算和比较。结果 T2、T3时两组CI持续升高,且AD组明显高于NA组(P<0.05),NA组SVRI明显高于AD组(P<0.05);HR慢于AD组(P<0.05)。T2,T3两组DO2差异无统计学意义。与AD组比较,T3时NA组的VO2、ERO2明显升高(P<0.05),而LCR和尿量差异无统计学意义。结论重症瓣膜患者术后循环衰竭应用去甲肾上腺素时无HR增快,减少心脏做功,提高CPB后组织氧利用能力,但需要PiCCO监测下调整其输注剂量及速度。

Objective To study hemodynamic effects of noradrenaline during valve replacement in severely ill patients. Methods Twenty-seven valvular heart disease patients undergoing valve replacements were divided into two groups based on their vasoactive drugs： group NAl-noradrenaline （NA） and dobutamine （Dob）,n= 123 and group AD [adrenaline （AD） and dobutamine （Dob）, n= 153. Pulse induced continuous cardiac output （PiCCO）and arterial/vein blood gas analysis were monitored at the follow point： before operation （T0）, the end of CPB （T1）, 6 h after operation（T2 ）, 24 h after operation （T3）. HR, MAP, CVP, and continuous cardiac output （CCO）, cardiac index （CI）, stroke volume index（SVI）, peripheral vascular resistance index （SVRI）, extravascular lung water （ EVLWI ）, pulmonary capillary permeability （ PVPI ）, central venous oxygen saturation （ScvO2）, arterial oxygen partial pressure （PaO2）, blood lactic acid （Lac） and lactate clearance rate （LCR）, and the amount of oxygen delivery （DOz）, oxygen consumption （VO2）, the rate of oxygen utilization （ERO2） were calculated and compared. Results CI in group NA increased from T2, T3 but lower than those in the group AD （P〈20.05）. SVRI in group NA increased obviously compared with group AD （P〈20. 05） ,but SVRI from T2, T3 was lower than baseline value in either group. HR in group NA was lower than that of the group AD （P〈20.05）. T2, T3 DO2 had no significant difference between two groups. VOz and ERO2 in group NA increased obviously than those in group AD at T3 （P 〈20. 05）. There was no difference in LCR and urine volume between the two groups. Conclusion HR and heart work will decrease and tissue oxygen utilization will increase in the presence of norepinephrine in hypotensive patients after valve replacement surgery. However the administrating dose and rate should be directed by PiCCO.