七氟烷在非体外循环冠状动脉旁路移植术中对心肌的保护作用

Myocardial Preservation of Sevoflurane in the Off-pump Coronary Artery Bypass Grafting

目的观察七氟烷在非体外循环冠状动脉旁路移植术(OPCABG)中对心肌的保护作用。方法选择择期行OPCABG患者56例,随机分为七氟烷组和丙泊酚组,每组28例。两组麻醉诱导用药和方式相同,明视气管内插管。七氟烷组以七氟烷与芬太尼、维库溴铵行麻醉维持,丙泊酚组以丙泊酚与芬太尼、维库溴铵行麻醉维持。观察两组手术时间和心律失常发生情况,监测入室(t1),插管前(t2),插管后2 min(t3),手术切皮后2 min(t4),锯胸骨后2 min(t5),阻断冠状动脉开始搭桥时(t6),冠状动脉旁路移植后(t7),手术结束后(t8)及冠状动脉旁路移植后2 h(t9)、8 h(t10)、24 h(t11)的血流动力学指标和麻醉开始前(T1)及冠状动脉旁路移植结束即刻(T2)、2 h(T3)、8 h(T4)、24 h(T5)血清心肌肌钙蛋白Ⅰ(cTnⅠ)变化。结果七氟烷组心动过缓发生率低于丙泊酚组(P<0.05),七氟烷组t3、t4时HR低于t1(P<0.05),t10、t11时高于t1(P<0.05),丙泊酚组t3、t4、t6时HR低于t1(P<0.05),t10、t11、高于t1(P<0.05),七氟烷组t6、t7、t8、t9HR高于丙泊酚组(P<0.05)。两组除t9外,其余各时点SBP均呈下降趋势,七氟烷组t2、t3时SBP高于丙泊酚组(P<0.05)。七氟烷组除t5外,丙泊酚组除t4、t5、t9、t11外,其余时点DBP均低于t1,七氟烷组t5时DBP高于丙泊酚组(P<0.05)。七氟烷组除t5、t11外,丙泊酚组除t4、t5、t9、t11外,其余时点MAP均低于t1(P<0.05),七氟烷组t2时MAP高于丙泊酚组。七氟烷组t5、t8时CVP均高于丙泊酚组,七氟烷组除t7外,丙泊酚组除t7、t8外,其余时点CVP与t2比较,差异均有统计学意义(P<0.05)。七氟烷组T5时cTnⅠ低于丙泊酚组,两组T4、T5时cTnⅠ均高于T1、T2、T3时,T5时高于T4时(P<0.05)。结论七氟烷能够明显降低患者术后血清cTnⅠ水平,对心肌保护作用更明显,且对心率有更好的稳定作用,使得血流动力学更加稳定。

Objective To observe effect of myocardial preservation of Sevoflurane in off-pump coronary artery bypass grafting（OPCABG）.Methods A total of 56 patients who would undergo off-pump coronary artery bypass grafting were randomly divided into Propofol group（n = 28,group A） and Sevoflurane group（n = 28,group B）.The medications and methods of anesthesia induction in the two groups were identical under photopic endotracheal intubation.Sevoflurane,Fentanyl and Vecuronium bromide were used for maintenance of anesthesia in group B,while Propofol,Fentanyl and Vecuronium bromide were used in group A.The operative time and arrhythmia occurrences of the two groups were observed.In two groups,the variation of hemodynamics before entering into ventricle（t1）,before intubation tube（t2）,2 min after intubation tube（t3）,2 min after skin incision（t4）,2 min after sternum incision（t5）,at the beginning of bypass surgery for interrupted coronary artery（t6）,after coronary bypass grafting（t7）,surgery over（t8） and 2 h（t9）,8 h（t10） and 24 h（t11） after coronary bypass grafting were observed;and changes of serumal cardiac troponinⅠ（cTnⅠ） before start of anesthesia（T1） and at the end（T2）,after 2 h（T3）,8 h（T4） and 24 h（T5） of coronary bypass grafting were also observed.Results The incidence of bradyarrhythmia of group B was significantly lower than that of group A（P 0.05）,HR of group B at t3 and t4 were lower than that at t1（P 0.05）,but HR of group B at t10and t11 were higher than that at t1（P 0.05）;the HR of group A at t3,t4 and t6 were lower than that at t1（P 0.05）,but HR at t10 and t11 were higher than that at t1（P 0.05）;HR of group B at t6,t7,t8 and t9 were higher than those in group A（P 0.05）.SBP of the two groups were descended except that at t9,moreover the SBP of group B at t2 and t3 were significantly higher than those of group A（P 0.05）.The other time points of DBP in the two groups were all significantly lower than that at t1 except group B at t5,and group A at t4,t5,t9 and t11,moreover the DBP of group B was significantly higher than that of group A at t5（P 0.05）.The other time points of MAP in the two groups were lower that at t1 except group B at t5 and t11,and group A at t4,t5,t9 and t 11（P 0.05）,and MAP of group B was higher than that of group A at t2.CVP of group B at t5 and t8 were higher than those of group A;the other time points of CVP showed significant differences which compared with those at t2 in the two groups except those of group B at t7 and group A at t7 and t8（P 0.05）.cTnⅠof group B was significantly lower than that of group A at T5;cTnⅠof the two groups at T4 and T5 were significantly higher than those at T1,T2 and T3;and cTnⅠof the two groups at T5 were also significantly higher than those at T4（P 0.05）.Conclusion Sevoflurane can obviously reduce the postoperative patients＇ serum level of cTnⅠ,obviously improve cardioprotective effect and offer preferably heart rate and haemodynamics stability.