七氟烷对老年冠状动脉粥样硬化性心脏病患者围术期血流动力学调控和心肌的影响研究

Influence of Sevoflurane on perioperative hemodynamics and myocardium in elderly patients with coronary heart disease

目的研究七氟烷麻醉对老年冠状动脉粥样硬化性心脏病(冠心病)患者非心脏手术围术期血流动力学调控和心肌的影响。方法将择期行腹腔镜胃肠手术的老年冠心病患者100例随机分为S组(七氟烷组)和P组(丙泊酚组),每组50例;术中通过脑电双频指数(BIS)监测麻醉镇静深度,选取麻醉诱导前(Ta_0)、气管插管前(Ta_1)、气管插管后1 min(Ta_2)、手术开始(Ta_3)、拔管前(Ta_4)及拔管后5 min(Ta_5)6个时间点的平均动脉压(MAP)、心率(HR)、心输出量(CO)、心脏指数(CI)、外周血管阻力(SVR)、左心室做功(LCW);抽取诱导前5 min(Tb_0)、手术结束(Tb_1)、术后12 h(Tb_2)、术后24 h(Tb_3)、术后48 h(Tb_4)5个时间点患者的中心静脉血,测定血清中心肌肌钙蛋白I(c Tn I)、肌酸激酶同工酶(CK-MB)的水平;同时比较术中瑞芬太尼的用量及术后患者VAS评分。结果两组患者的HR、MAP、SVR、LCW在Ta_1、Ta_3时下降,与Ta_0比较,差异有统计学意义(P<0.05),P组Ta_3时的CO,Ta_2、Ta_3时的CI均低于Ta_0;S组Ta_1时间点的HR,Ta_2时间点的MAP均低于P组同时间点,Ta_2、Ta_3时间点的CI高于P组同时间点,差异有统计学意义(P<0.05)。两组c Tn I、CK-MB自手术结束后开始逐渐升高,Tb_2至Tb_4各时间点的c Tn I均高于Tb_0,差异有统计学意义(P<0.05),而S组Tb_2至Tb_4,P组Tb_1至Tb_4的CK-MB均高于Tb_0,且CK-MB于Tb_3时达高峰,后下降;Tb_2至Tb_4各时间点,S组的c Tn I、CK-MB均低于P组,差异有统计学意义(P<0.05)。术中S组瑞芬太尼用量低于P组,差异有统计学意义(P<0.05),而两组患者术后VAS评分比较,差异无统计学意义(P>0.05)。结论在老年冠心病患者非心脏手术麻醉中,七氟烷麻醉能很好地维持围术期血流动力学稳定,减少手术应激,有效降低围术期心肌损伤,更好地保护心肌,提高麻醉质量,值得临床推广。

Objective To investigate the influence of Sevoflurane on perioperative hemodynamics and myocardium in elderly patients with coronary heart disease undergoing noncardiac surgery. Methods One hundred elderly patients with coronary heart disease who received elective laparoscopic surgery were randomly assigned to Sevofurane group （group S） and Propofol group （group P）, each group had 50 patients. Bispectral index （BIS） was used to monitor the depth of sedation in the intraoperative period. Heart rate （HR）, mean arterial pressure （MAP）, cardiac output （CO）, cardiac index （CI）, systemic vascular resistance （SVR）, left cardiac work （LCW） were recorded before induction of anesthesia （Ta0）, before intubation （Ta1）, 1 min after intubation （Ta2）, at the start of surgery （Ta3）, before extubation （Ta4） and 5 min after extubation （Ta5）. Central venous blood was drawn 5 min before induction of anesthesia （Tb0）, at the end of surgery （Tb1）, 12 h （Tb2）, 24 h （Tb3） and 48 h （Tb4） after suegery for measurements of troponin I （cTnI） and creatine kinase isoenzyme （CK-MB）. Intraoperative dosage of Remifentanil and postoperative visual simulation score （VAS） were compared between the two groups. Results HR, MAP, SVR and LCW at Ta1 and Ta3 were lower than those at Ta0 in both groups （P 〈 0.05）. In the group P, CO at Ta3 and CI at Ta2 and Ta3 were lower than those at Ta0 （P 〈 0.05）. HR at Ta1 and MAP at Ta2 in the group S were lower than those in the group P （P 〈 0.05）. CI at Ta2 and Ta3 in the group S were higher than those in the group P （P 〈 0.05）. cTnI and CK-MB levels in postoperative period were signifcantly increased compared with Tb0 values in both groups. However, the level of CK-MB reached the peak at Tb3, descended at Tb4, whereas the level at Tb4 was still higher than that at Tb0 （P 〈 0.05）. Compared with the group P, cTnI and CK-MB at Tb2, Tb3 and Tb4 were signifcantly lower in the group S （P 〈 0.05）. The intraoperative dosage of Remifentanil in the group S was obviously lower than that in the group P （P 〈 0.05）. But the postoperative VAS in the two groups had no signifcant difference （P 〉 0.05）. Conclusions Sevofurane anesthesia has slight effect on the hemodynamic factors, can reduce surgical stress and perioperative myocardial injury, has better myocardial protection in elderly patients with coronary heart disease undergoing noncardiac surgery. We suggest the widespread usage of it in clinic.