中长链脂肪乳丙泊酚对老年腹腔镜手术患者血浆内皮素和降钙素基因相关肽浓度的影响

Effects of medium-long-chain triglyceride propofol intravenous anesthesia on blood lipid metabolism on ET and CGRP concentration in elderly patients undergoing laparoscopic surgery

目的探讨中长链脂肪乳丙泊酚静脉麻醉下超4h的老年腹腔镜手术患者血脂代谢对血浆内皮素(ET)、降钙素基因相关肽(CGRP)浓度的影响。方法选择择期在全凭静脉全身麻醉下行腹腔镜直肠癌根治术的患者40例,男24例,女16例,年龄65~80岁,BMI 19.5~29.4kg/m^2,ASAⅠ或Ⅱ级,按丙泊酚脂肪乳剂型不同随机分为两组:长链脂肪乳丙泊酚组(L组)和中长链脂肪乳丙泊酚组(M组),每组20例。丙泊酚血浆浓度2~3μg/ml诱导与维护,意识消失后静脉注射芬太尼和维库溴铵,行气管插管,辅助瑞芬太尼维持麻醉镇痛,维持BIS值50~60,二氧化碳气腹压力12~15mmHg,术毕前5min停止输注静脉麻醉药。记录两组手术时间、意识消失浓度、术中丙泊酚总用量和平均用药量,记录术前1d和术后1d总胆红素(TBIL)、直接胆红素(DBIL)、间接胆红素(IBIL)、ALT、AST、谷氨酰转肽酶(GGT)、碱性磷酸酶(ALP)等肝功能指标和总胆固醇(TC)、甘油三脂(TG)、高密度脂蛋白(HDL)、低密度脂蛋白(LDL)等血脂指标;记录术前(T_0)、气腹后30min时(T_1)、气腹后60min时(T_2)、气腹后240min时(T_3)和术毕30min时(T_4)血浆ET、CGRP浓度。结果两组意识消失浓度、术中丙泊酚总用量和平均用药量、不同时点肝功能和血脂指标差异无统计学意义。与T_0时比较,T_2时L组,T_1—T_3时M组ET_明显降低(P<0.01或P<0.05);T_1、T_2和T_4时L组,T_3时M组CGRP明显升高(P<0.01或P<0.05);与M组比较,T_1、T_2和T_4时L组ET,T_2和T_4时L组CGRP明显升高(P<0.01或P<0.05)。结论在4h腹腔镜高龄直肠癌根治术中,长链与中长链脂肪乳丙泊酚输注对肝功能及血脂代谢差异无统计学意义,脂溶性长链脂肪乳使血浆CGRP浓度增加,水溶性的中长链脂肪乳抑制血浆ET浓度,可能减轻二氧化碳气腹后对血管内皮系统的损伤。

Objective To investigate the effects of blood lipid metabolism to on plasma endothelial （ET）and calcitonin gene-related peptide （CGRP）concentration in older patients over 4-hour laparoscopic surgery under medium-long-chain triglyceride propofol intravenous anesthesia.Methods Forty patients undergoing elective surgery in laparoscopic radical resection of rectal cancer receiving total intravenous anesthesia,males 24 and females 16,aged 60-80 years,with BMI 19.5-29.4 kg/m2,falling into ASA physical statusⅠorⅡ,were randomly divided into long-chain triglyceride propofol group （group L）and medium-long-chain triglyceride propofol group （group M）,20 cases in each group.Plasma propofol concentration was 2-3μg/ml during induction of anesthesia and maintenance.Intravenous fentanyl and vecuronium was given after loss of consciousness （LOC）before tracheal intubation.Remifentanil was supplemented to maintain analgesia,BIS value of 50-60 and carbon dioxide pneumoperitoneum pressure 12-15 mmHg till 5 minutes before the end of surgery.The duration of operation,concentration of LOC,total and average amount of propofol,total bilirubin （TBIL）,direct bilirubin （DBIL）,indirect bilirubin （IBIL）,alanine aminotransferase （ALT）,aspartate aminotransferase （AST）,Glutamyl transpeptidase （GGT）,serum alkaline phosphatase （ALP）and total cholesterol （TC）,triglyceride （TG）,high density ester protein （HDL）,low density ester protein （LDL）were compared between the two groups 1 dbefore and after surgery.The concentrations of ET and CGRP at pre-operative time point （T0）,30 minutes （T1）,60 minutes （T2）,240 minutes （T3）after pneumoperitoneum and 30 minutes after surgery （T4）were compared.Results Concentration of LOC,the average amount of propofol,the total amount of propofol,liver function and lipid concentration 1 dbefore and after surgery were not significantly different between the two groups;Compare with T0,ET concentrations were significantly lower at T2 of group L,at T1-T3 of group M in plasma （P〈0.05 or P〈0.01）;plasma CGRP concentration significantly higher at T1,T2 and T4 in group L and at T3 in group M （P〈0.05 or P〈0.01）.Compare with group M,plasma ET concentrations of group L were higher at T1,T2 and T4 and plasma CGRP concentrations of group L were significantly higher at T2 and T4 of group M （P〈0.05 or P〈0.01）.ConclusionDuring 4 hlaparoscopic radical resection of rectal cancer,there was no difference in liver function and lipid metabolism between long chain fat emulsion and medium and long chain fat emulsion infusion.The plasma CGRP concentration was increased by fat soluble long chain fat emulsion.Water soluble medium and long chain fat emulsion inhibits plasma ET concentration and may reduce the damage to vascular endothelial system after carbon dioxide pneumoperitoneum.