体外循环中全程应用七氟烷对心肌保护作用的随机对照试验

Myocardial Protection of Sevoflurane Used in the Whole Process of Cardiopulmonary Bypass:A Randomized Controlled Trial

目的观察体外循环中全程使用七氟烷对心肌的保护作用。方法采用双盲、随机对照研究方法,将150例18岁以上于2010年1月至2011年11月在阜外心血管病医院体外循环下行心脏手术的患者,分成七氟烷预处理组(A组,n=50)、七氟烷全程使用组(B组,n=50)和全程静脉麻醉组(C组,n=50)。全部患者监测桡动脉压等指标。应用酶联免疫法(ELISA)检测CPB开始时(T1)、开放升主动脉(T2)、开放升主动脉后3 h(T3)及开放升主动脉后24 h(T4)血浆肌钙蛋白Ⅰ(cTnI)等含量。结果 A组,男31例、女19例,年龄(60.43±3.24)岁;B组,男28例、女22例,年龄(59.88±4.12)岁;C组,男31岁、女19岁,年龄(58.76±3.87)岁。三组年龄、性别差异无统计学意义。3组患者平均动脉压(MAP)、中心静脉压(CVP)、肺动脉楔压(PAWP)和心率(HR),组间及组内在各个时间点差异均无统计学意义(P>0.05)。组间比较,在T1和T2时,3组患者心脏指数(CI)差异无统计学意义(P>0.05)。T3时A组与C组间差异无统计学意义(F=3.382,P=0.845),B组CI值高于A组和C组(F=3.382,3.382;P=0.033,0.020);T4时,B组CI值高于A组和C组(F=13.324,13.324;P=0.005,P=0.000),A组高于C组(F=13.324,P=0.024),差异均有统计学意义。T1和T2时的血浆心肌肌酸激酶同工酶(CK-MB)、cTnI、炎性介质白细胞介素-6(IL-6)和肿瘤坏死因子-α(TNF-α)含量3组间差异无统计学意义(P>0.05)。在T3和T4时,CK-MB、TNF-α、IL-6和cTnI均为C组高于A组,A组高于B组,且差异有统计学意义(F=531.616,5.410,3.5813,3.160,1.126,4.702,7.819,5.424,P值均为0.000)。结论体外循环中全程应用七氟烷对心肌损伤有明确的保护作用,效果优于七氟烷预处理。

Objective To observe myocardial protective effect of sevoflurane used in the whole process of cardio- pulmonary bypass （CPB）. Methods A total of 150 patients older than 18 years who underwent cardiac surgery under CPB in Fu Wai Hospital from January 2010 to November 2011 were enrolled in this double-blind and randomized con- trolled study. All the patients were randomly divided into three groups： Sevoflurane pretreatment group （Group A, n=50）, whole-process Sevoflurane group （Group B, n=50）, and whole-process intravenous anesthesia group （Group C, n=50）. Radial artery pressure and other hemodynamic parameters were continuously measured for all the patients. At following time points： CPB beginning （T 1 ）, aortic declamping （T2）, 3 hours after aortic declamping （T3）, and 24 hours after aor- tic declamping （T4）, serum concentrations of cardiac troponin I （cTnI） and other parameters were measured by enzyme- linked immunosorbent assay （ELISA）. Results There were 31 males and 19 females at age of 60.43___ 3.24 years in group A, 28 males and 22 females at age of 59.88±4.12 years in group B, 31 males and 19 females at age of 58.76±3.87 years. There was no statistical difference in mean arterial pressure （MAP）, central venous pressure （CVP）, pulmonary artery wedge pressure （PAWP） and heart rate （HR） at respective time points among the 3 groups （P 〉 0.05）. At T1 and T2, there was no statistical difference in cardiac index （CI） among the 3 groups （P 〉 0.05 ）. At T3, there was no statistical difference in CI between Group A and Group C （F=3.382, P=-0.845 ）, but CI of Group B was significantly higher than that of Group A and C （F=-3.382, 3.382; P=0.033, 0.020）. At T4, CI of Group B was significantly higher than that of Group A and C （F=13.324, 13.324; P=0.005 ,P=0.000）, and CI of Group A was significantly higher than that of Group C （F=13.324, P=-0.024）. At T1 and T2, there was no statistical difference in serum concentrations of creatinine kinase MB （CK-MB）, cTnl, interleukin-6 （IL-6） and tumor necrosis factor alpha （TNF-α） among the 3 groups （P 〉 0.05 ）. At T3 and T4, serum concentrations of CK-MB, TNF-α, IL-6 and cTnI of Group C were significantly higher than those of Group A, and serum concentrations of CK-MB, TNF-α, IL-6 and cTnI of Group A were significantly higher than those of Group B （F=531.616, 5.410, 3.5813, 3.160, 1.126, 4.702, 7.819, 5.424, all P=0.000）. Conclusion Sevoflurane used in the whole process of CPB has definite myocardial protective effect which is stronger than that of Sevoflurane pretreatment.