丙泊酚和咪达唑仑对脑损伤术后应激指标的影响

Effects of propofol and midazolam on stress indicators in patients after craniocerebral injury operation

目的观察丙泊酚、咪达唑仑对脑损伤术后β-内啡肽（β—EP）、热休克蛋白70（HSP70）、血乳酸、血糖的影响，以证实以上两种药物可能通过影响应激指标而产生脑保护的作用。方法选择2009年9月至2014年11月入住贵州医科大学附属医院重症加强治疗病房（ICU）的脑损伤开颅术后患者180例，按随机数字表法分为阴性对照组（48例）、咪达唑仑组（44例）、丙泊酚组（42例）、咪达唑仑联合丙泊酚组（46例）。测定4组患者转入ICU即刻及转入后24、48、72h的β—EP、HSP70、血乳酸，在转入即刻至转入后72h内每4h测定1次血糖值。结果转入即刻4组β—EP、HSP70、血乳酸、血糖水平比较差异均无统计学意义（均P〉0．05）。转入后24、48、72h使用麻醉药物的3个组β—EP、HSP70、血乳酸值均较不用药的阴性对照组明显降低，联合用药组的降低程度优于咪达唑仑组及丙泊酚组两个单独用药组，且以转入后72h的降低程度更显著[β—EP（ng／L）：27．54±4．38比61．20±4．71、41．99±5．47；HSP70（ng／L）：185．72±83．87比272．65±81．81、259．69±82．14；血乳酸（mmol／L）：1131±0．70比1．60±0．95、1．71±0．79，均P〈0．05]。咪达唑仑组、丙泊酚组、联合用药组仅转入后即刻出现血糖较阴性对照组明显下降外（mmol／L：9．29±1．73、9．61±1．71、9．16±1．86比1．58±2．65，均P〈0．05），其余时间点血糖值虽较未用药的阴性对照组下降，但差异均无统计学意义（均P〉0．05）。结论咪达唑仑、丙泊酚均可降低脑损伤术后应激反应过程中β—EP、HSP70、血乳酸、血糖水平。丙泊酚在脑损伤术后应激反应中降低β—EP优于咪达唑仑，联合用药组降低β—EP、HSP70程度大于咪达唑仑组和丙泊酚组。

Objective To study the effects of propofol, midazolam on β-endorphin （β-EP）, heat shock protein 70 （HSP70）, blood lactic acid and blood glucose in patients after craniocerebral injury surgery. Methods One hundred and eighty patients with brain injury after cranintomy admitted into department of critical care medicine in Affiliated Hospital of Guizhou Medicine University from September 2009 to November 2014 were enrolled. They were randomly divided into negative control group （8 cases）, midazolam group （44 cases）, propofol group （42 cases） and midazolam combined with propofol group （46 cases）. The β-EP, HSP70 and lactic acid were detected at the moment the patient was transferred into intensive care unit （ICU） immediately and a, 24, 48 and 72 hours later, and the blood glucose was measured once every 4 hours after entrance in ICU for 72 hours in each group. Results There were no statistically significant differences in β-EP, serum HSP70, blood lactic acid and blood glucose levels among four groups at the moment the patients being immediately transferred into ICU （all P 〉 0.05）. At 24, 48, 72 hours later, the β -EP, HSP70 and blood lactic acid levels in the three groups with anesthetic drugs in the operation were significantly lower than those in negative control group （without using anesthetics）, the degrees of decrease in the above indexes in the combination of midazolam and propofol group were superior to those in simply using midazolam or propofol group, the amplitudes of decrease in the combined group being the most obvious at 72 hours after transfer [β -EP （ng/L）： 27.54 ± 4.38 vs. 61.20 ± 4.71, 41.99 ± 5.47; HSP70 （ng/L）： 185.72 ± 83.87 vs. 272.65 ± 81.81, 259.69 ± 82.14; lactic acid （mmol/L）： 1.31 ± 0.70 vs. 1.60 ± 0.95, 1.71 ± 0.79, all P 〈 0.05]. Except at 4 hours after transfer into ICU, the blood glucose levels in midazolam, propofol and combined groups were significantly lower than that in negative control group （mmol/L： 9.29 ± 1.73, 9.61 ± 1.71, 9.16 ± 1.86 vs. 11.58 ± 2.56, all P 〈 0.05）, the blood glucose values at the remaining time points in the above three groups were lower than those in the negative control group, but the differences were not statistically significant （all P 〉 0.05）. Conclusions Midazolam and propofol can reduce the levels of β -EP, HSP70, blood lactic acid and blood glucose in the course of stress reaction after traumatic brain injury operation. The reducing effect of propofol on β -EP in stress response of patients after the operation was superior to that of midazolam. The decreasing effect of combined application of propofol and midazolam on the levels of β -EP and HSP70 was greater than that of using either propofol or midazolam alone.