非体外循环下冠状动脉旁路移植术麻醉诱导期以血管超声法评价琥珀酰明胶注射液行急性容量填充对外周血管灌注的影响

Doppler ultrasound to evaluate the effects of succinylated gelatin on peripheral vascular perfusion during induction of anesthesia in patients undergoing off-pump coronary artery bypass graft

目的采用血管超声的方法测定桡动脉血流,观察非体外循环下行冠状动脉旁路移植术(OPCABG)的患者在麻醉诱导期以琥珀酰明胶注射液行急性高容量填充对患者外周血管灌注和术后恢复情况的影响。方法将30例择期行OPCABG的患者随机分入对照组和容量填充组。对照组:不予容量填充,经中心静脉注射琥珀酰明胶注射液1mL·kg-1·h-1维持静脉通畅。容量填充组:经中心静脉输注琥珀酰明胶注射液0.4mL·kg-1·min-1。两组患者均通过Swan-Ganz导管监测心脏指数(CI),至CI进入平台期即停止静脉输液。记录入手术室(T1)、镇静后(T2)、麻醉诱导后开始填充时(T3)、填充结束手术切皮时(T4)、移植前降支时(T5)、移植边缘支时(T6)、心脏处于直立位移植后降支时(T7)、桥血管开放心脏恢复正常位置时(T8)及术毕(T9)各时间点的桡动脉直径和血流量。并记录T4至T8各时间点的Swan-Ganz导管监测指标数据。结果两组同时间点间及同组各时间点间桡动脉直径的差异均无统计学意义(P值均>0.05)。两组T2、T3时间点的桡动脉血流量均较同组基础值有不同程度的增加(P值均<0.01)。容量填充组在T3至T9时间点的桡动脉血流量均显著高于对照组同时间点(P值分别<0.01、0.05)。容量填充组在T8时间点的CI、中心静脉压(CVP)均显著大于对照组同时间点(P值均<0.05)。容量填充组的去氧肾上腺素用量显著小于对照组(P<0.01)。对照组容量填充后拔除气管插管时间、重症监护病房停留时间均显著长于容量填充组(P值分别<0.05、0.01)。结论行OPCABG的患者在麻醉期诱导期以CI反馈行容量填充不仅增加了有效循环容量和心排血量,同时可改善外周血管灌注,有利于"快通道"的实施和患者术后的恢复。

Objective to determine blood flow in radial artery by vascular Doppler ultrasound, and to evaluate hypervolemic infusion with succinylated gelatin in induction of anesthesia on peripheral vascular perfusion and postoperative recovery in the patients receiving off-pump coronary artery bypass graft （OPCABG）. Methods Thirty patients undergoing elective OPCABG were randomly assigned to control group and hemodilution group （n=15）. In control group, no succinylated gelatin injection was infused. In hemodilution group, succinylated gelatin injection （0.4 mL ; kg-; ; min ;） was infused until cardiac index （CI） achieved the steady state. The Swan-Ganz monitoring was used to evaluate circulatory function and guide gel infusion. The diameter and blood flow of radial artery were measured on baseline （T1）, after sedation （T2）, after intubation （T3）, at the end of volume expansion （T4）, grafting anterior descending branch （T5）, grafting obtuse marginal （T6）, grafting posterior descending branch （T7）, when all the grafts had been de-clamped （T8） and at the end of surgery（T9 ）. Swan-Ganz monitoring parameters were recorded at T4 - T8 . Results There were no significant differences in the diameter of the radial artery between groups and between different time points （all P;〉0. 05）. The flow of radial artery increased significantly at T2 and T3 in either group （P;0.01）. The flow of radial artery in hemodilution group was much higher than that in control group at T3 - T9 （ P;0.01, 0.05）. CI and central venous pressure （CVP） were significantly higher in hemodilution group than those in control group at T8 （all P d0. 05）. The dosage of phenylephrine in hemodilution group was significantly lower than that in control group （all P;0.01）. Both the time of tracheal extubation and ICU stay were significantly shorter in hemodilution group than those in control group （ P〈 0.05, 0.01 ）. Conclusion Adequate volume expansion with succinylated gelatin infusion after anesthetic induction is beneficial to the cardiac insufficiency patients undergoing OPCABG. This strategy can increase not only the capacity of circulation and cardiac output but also the peripheral blood flow, makeing it beneficial to ＂fast tract＂ and postoperative recovery.