不同浓度七氟烷对冠心病非心脏手术患者围术期心肌保护效应

Myocardial protection effect of different concentrations of sevoflurane in patients with coronary heart disease undergoing non-cardiac surgery during perioperative period

目的探讨不同浓度七氟烷对冠心病非心脏手术患者围术期心肌保护效应。方法90例择期手术且合并冠心病的胸腹部手术患者作为研究对象,根据使用七氟烷浓度不同分为C组、S1组、S2组,各30例。三组均采用静脉泵入顺苯磺酸阿曲库铵、丙泊酚和瑞芬太尼麻醉维持,依据脑电双频谱指数(BIS)值调整。S1组持续吸入七氟烷1.3%~3%,BIS值维持在45~55;S2组持续吸入七氟烷0.25%~1.3%,BIS值维持在45~55;C组为对照组,不吸入七氟烷,BIS值维持在45~55。比较三组患者术中心血管不良事件发生情况和不同时间点血清高敏心肌肌钙蛋白T(hs-cTnT)、心肌肌钙蛋白T(cTnT)、超敏C-反应蛋白(hs-CRP)水平。结果S1组、S2组高血压发生率分别为3.3%、6.7%,均低于C组的30.0%,差异有统计学意义(P<0.05)。S1组低血压、心动过缓发生率分别为50.0%、30.0%、均高于C组的20.0%、6.7%和S2组的10.0%、3.3%,差异有统计学意义(P<0.05)。S2组心动过速、心肌缺血、期前收缩、心房颤动(房颤)发生率分别为10.0%、10.0%、3.3%、3.3%,均低于C组的36.7%、33.3%、20.0%、20.0%和S1组的33.3%、36.7%、20.0%、23.3%,差异有统计学意义(P<0.05)。S1组、S2组拔管即刻hs-cTnT、hs-CRP及cTnT水平均低于C组,差异具有统计学意义(P<0.05)。S2组拔管即刻hs-cTnT、hs-CRP水平均低于S1组,差异具有统计学意义(P<0.05)。S2组拔管即刻cTnT水平均高于S1组,差异无统计学意义(P>0.05)。三组患者麻醉诱导时、插管即刻的hs-cTnT、cTnT、hs-CRP组间两两比较差异无统计学意义(P>0.05)。三组患者拔管即刻的hs-cTnT、cTnT、hs-CRP均高于麻醉诱导时、插管即刻,差异具有统计学意义(P<0.05)。结论对于合并冠心病的非心脏手术患者,手术麻醉采取低浓度七氟烷吸入比高浓度七氟烷吸入更加安全,可以有效地减少心血管不良事件的发生,更有利于保护患者的心肌功能。

Objective To discuss the myocardial protection effect of different concentrations ofsevoflurane in patients with coronary heart disease undergoing non-cardiac surgery during perioperative period.Methods A total of 90 coronary heart disease patients with selective thoracic and abdominal surgery surgeryas study subjects were divided by different concentrations of sevoflurane into group C, group S1 and groupS2, with 30 cases in each group. All three groups were maintained with intravenous infusion of atracuriumcis-besylate, propofol and remifentanil, and the doses were adjusted according to bispectral index (BIS). Ingroup S1, sevoflurane was inhaled continuously 1.3%-3%, BIS value was maintained at 45-55;in group S2,sevoflurane was inhaled continuously at 0.25%-1.3%, BIS value was maintained at 45-55. Group C was takenas the control group without inhalation of sevoflurane, and BIS value was maintained as 45-55. Comparison wasmade on occurrence of cardiovascular adverse events during operation, levels of high-sensitivity Group C wastaken as the control group without inhalation of sevoflurane, and BIS value was maintained as 45-55. troponin T(hs-cTnT), cardiac troponin T (cTnT) and high-sensitivity C-reactive protein (hs-CRP) at different time pointsin three groups. Results Group S1 and group S2 had lower incidence of hypertension respectively as 3.3% and6.7% than 30.0% in group C, and their difference was statistically significant (P<0.05). Group S1 had incidenceof hypotension and bradycardia respectively as 50.0% and 30.0%, which were higher than 20.0% and 6.7% in group C, and 10.0% and 3.3% in group S2. Their difference was statistically significant (P<0.05). Group S2 hadincidence of tachycardia, myocardial ischemia, premature contraction, atrial fibrillation respectively as 10.0%,10.0%, 3.3% and 3.3%, which were lower than 36.7%, 33.3%, 20.0%, 20.0% in group C, and 33.3%, 36.7%,20.0%, 23.3% in group S1. Their difference was statistically significant (P<0.05). Group S1 and group S2 hadlower hs-cTnT, hs-CRP and cTnT immediately after extubation than those of group C, and their difference wasstatistically significant (P<0.05). Group S2 had lower hs-cTnT and hs-CRP immediately after intubation thanthose of group S1, and the difference was statistically significant (P<0.05). Group S2 had higher cTnT immediatelyafter extubation than that of group S1, but the difference was not statistically significant (P>0.05). There was nostatistically significant difference in hs-cTnT, cTnT and hs-CRP at induction of anesthesia and immediately afterextubation in pairwise comparison among three groups (P>0.05). Three groups had higher hs-cTnT, cTnT andhs-CRP immediately after extubation than those induction of anesthesia and immediately intubation, and theirdifference was statistically significant (P<0.05). Conclusion For patients with coronary heart disease undergoingnon-cardiac surgery, inhalation of low concentration of sevoflurane is safer than that of high concentration ofsevoflurane, and it can effectively reduce the occurrence of adverse cardiovascular events and is more conducive toprotecting the myocardial function of patients.