依托咪酯和咪唑安定对不停跳冠状动脉搭桥术患者气管插管期间血流动力学的影响及对心肌的保护作用

Comparison of effects of etomidate versus midazolam on hemodynamics and protection of myocardium during tracheal intubation in patients undergoing off-pump coronary artery bypass grafting

目的探讨依托咪酯和咪唑安定对不停跳冠状动脉搭桥术(OPCAB)患者气管插管期间血流动力学的影响及对心肌的保护作用。方法选取2017年1月至2019年7月在焦作市人民医院择期行OPCAB的患者78例,根据随机数字表法分为依托咪酯组(A组,39例)和咪唑安定(B组,39例)。A、B组分别静脉注射依托咪酯、咪唑安定,再静脉注射芬太尼+哌库溴铵进行麻醉诱导,然后予以异丙酚+哌库溴铵+芬太尼进行麻醉维持。麻醉期间监测血流动力学[心率(HR)、平均动脉压(MAP)、平均肺动脉压(MPAP)、肺动脉楔压(PAWP)]、血管阻力[体循环血管阻力指数(SVRI)、肺循环血管阻力指数(PVRI)]、氧代谢[混合静脉血氧饱和度(SvO2)、氧供指数(DO2I)、氧耗指数(VO2I)],于气管插管前(T0)、插管即刻(T1)、插管后1 min(T2)、插管后5 min(T3)、插管后10 min(T4)记录上述指标。分别于麻醉前、术毕及术后6、12、24 h检测患者血清心肌肌钙蛋白I(cTnI)水平。结果与T0时比较,两组患者T1、T2时HR、MAP升高,且A组HR低于B组;A组患者T3、T4时HR降低,且低于B组;B组患者T3、T4时MAP降低,且低于A组(P<0.05)。与T0时比较,A组T1~T3时、B组T1~T4时SVRI、PVRI降低(P<0.05),A组患者T1~T4时SVRI、PVRI高于B组(P<0.05)。与T0时比较,两组患者T1~T4时SvO2升高,VO2I、DO2I降低(P<0.05),但两组间比较差异未见统计学意义(P>0.05)。与麻醉前比较,两组患者术毕及术后6、12、24 h的血清cTnI水平均升高(P均<0.05),但两组间比较差异未见统计学意义(P>0.05)。结论与咪唑安定比较,OPCAB患者在麻醉诱导时使用依托咪酯更有利于维持气管插管期间的血流动力学稳定,两者在氧代谢平衡和心肌保护方面的作用相当。

Objective To investigate the effects of etomidate and midazolam on hemodynamics and protection of myocardium during tracheal intubation in patients undergoing off-pump coronary artery bypass grafting(OPCAB).Methods Seventy-eight patients with OPCAB hospitalized in Jiaozuo People’s Hospital from January 2017 to July 2019 were selected,and they were divided into etomidate group(group A,39 cases)and midazolam group(group B,39 cases)according to the random number table method.Group A and group B were intravenously injected with etomidate and midazolam respectively;and both groups were intravenously injected with fentanyl+pipecuronium bromide for anesthesia induction,and then were given propofol+piperacium bromide+fentanyl for anesthesia maintenance.The hemodynamics,such as heart rate(HR),mean arterial pressure(MAP),mean pulmonary artery pressure(MPAP),pulmonary artery wedge pressure(PAWP),vascular resistance,such as systemic vascular resistance index(SVRI),pulmonary vascular resistance index(PVRI),and oxygen metabolism,such as mixed venous oxygen saturation(SvO2),oxygen supply index(DO2I),oxygen consumption index(VO2I),were monitored during anesthesia.The above indicators were recorded before tracheal intubation(T0),after intubation immediately(T1),at 1 min after intubation(T2),5 min after intubation(T3)and 10 min after intubation(T4).Serum cardiac troponin I(cTnI)level was measured before anesthesia,at the end of surgery and at 6,12 and 24 h after surgery.Results Compared with levels at T0,the HR and MAP were increased at T1 and T2 in both groups,and the HR in group A was lower than that in group B(P<0.05);at T3 and T4,the HR in group A was decreased,lower than that in group B(P<0.05);and the MAP in group B was decreased at T3 and T4,lower than that in group A(P<0.05).Compared with indicators at T0,the SVRI and PVRI were decreased in group A at T1 to T3 and in group B at T1 to T4(P<0.05);and the SVRI and PVRI in group A were higher than those in group B at T1 to T4(P<0.05).Compared with levels at T0,the SvO2 was increased,while the VO2I and DO2I were decreased in the two groups at T1 to T4(P<0.05),but there were no significant differences between the two groups(P>0.05).Compared with levels before anesthesia,the serum cTnI levels in the two groups were increased at the end of surgery and at 6,12 and 24 h after surgery(P<0.05),but there was no significant difference between the two groups(P>0.05).Conclusions Compared with midazolam,etomidate is more beneficial to sustaining hemodynamic stability during tracheal intubation in patients with OPCAB during anesthesia induction,and their roles in oxygen metabolism balance and myocardial protection are comparable.