七氟烷与丙泊酚麻醉对先天性心脏病患儿围术期肾血流的影响

Effects of sevoflurane and propofol anesthesia on renal blood flow during perioperative period in children with congenital heart disease

目的观察七氟烷与丙泊酚麻醉对先天性心脏病患儿围术期肾血流的影响。方法选取2019年1-9月复旦大学附属儿科医院收治的60例体重<10 kg的先天性心脏病患儿,ASA分级为Ⅱ至Ⅳ级,采用随机数字表法将其分为七氟烷组和丙泊酚组,每组30例。两组患儿使用相同的麻醉诱导药物,予气管插管后行机械控制通气。麻醉维持:七氟烷组予七氟烷(吸入浓度为1%~3%)+舒芬太尼[1~5μg/(kg·h)静脉泵注],丙泊酚组予丙泊酚[4~12 mg/(kg·h)]+舒芬太尼[1~5μg/(kg·h)静脉泵注]。术中根据需要予间断静脉注射罗库溴铵。在麻醉诱导前(T 0)、麻醉后15 min(T 1)、手术结束时(T 2)和术后24 h(T 3)4个时间点对患儿行肾脏超声血流动力学监测。采集中心静脉血检测血清肌酐(sCr)和血清中性粒细胞明胶酶相关脂质运载蛋白(NGAL)水平,判断是否发生急性肾损伤(AKI)。结果在麻醉过程中,七氟烷组肾血流量逐渐下降而丙泊酚组呈逐渐上升趋势,在T 2时间点丙泊酚组的肾血流量显著高于七氟烷组(P<0.05);七氟烷组有4例发生AKI,丙泊酚组无1例发生AKI,两组患儿AKI发生率的差异无统计学意义(P>0.05)。在T 2时间点肾血流速和血清NGAL水平ROC曲线的AUC分别为0.842(95%CI为0.657~1.000)和0.924(95%CI为0.806~1.000),最佳截断值分别为4.19和55.01。即麻醉后肾血流速<4.19 cm 3/min时,预测发生AKI的灵敏度为87.5%,特异度为75.0%,阳性似然比为3.50;术后2 h血清NGAL水平>55.01μg/L时,预测发生AKI的灵敏度为100%,特异度为73.2%,阳性似然比为3.73。结论与七氟烷相比,丙泊酚麻醉下先天性心脏病患儿手术后的肾脏血流动力学更稳定。

Objective To compare the effects of sevoflurane and propofol anesthesia on perioperative renal blood flow in children with congenital heart disease.Methods Sixty children with congenital heart disease,body weight<10 kg,American Society of Anesthesiologists(ASA)graded asⅡ-Ⅳ,admitted to our hospital from January to September 2019,were randomly divided into sevoflurane group and propofol group(n=30).Anesthesia was induced in the same way in both groups,and ventilation was controlled mechanically after endotracheal intubation.Anesthesia was maintained with sevoflurane(inhalation concentration 1%-3%)in the sevoflurane group and with propofol[4-12 mg/(kg·h)]intravenously in the propofol group.Sufentanil[1-5μg/(kg·h)]was infused intravenously and rocuronium was administered as needed intermittently during the operation in both groups.Ultrasound renal blood flow was measured before anesthesia induction(T 0),15 min after anesthesia(T 1),at the end of surgery(T 2)and 24 h after surgery(T 3).Central venous blood was collected to measure serum creatinine(sCr)and neutrophil gelatinase-associated lipid carrier protein(NGAL)and determine acute kidney injury(AKI).Results During anesthesia,renal blood flow in the sevoflurane group decreased gradually while that in the propofol group increased gradually.Renal blood flow in the propofol group was significantly higher than that in the sevoflurane group at T 2(P<0.05).AKI occurred in 4 patients in the sevoflurane group and none in the propofol group,with no statistically significant differences were obsenved in the incidence of AKI between two groups(P>0.05).At T 2,the AUC of renal blood flow rate and serum NGAL were 0.842(95%CI:0.657-1.000)and 0.924(95%CI:0.806-1.000),respectively,and the best cutoff values were 4.19 and 55.01.In other words,when the renal blood flow rate was lower than 4.19 cm 3/min after anesthesia,the sensitivity,specificity and positive likelihood ratio of AKI were 87.5%,75.0%and 3.50,respectively.The sensitivity,specificity and positive likelihood ratio of AKI were 100%,73.2%and 3.73 when serum NGAL level was higher than 55.01μg/L 2 h after operation.Conclusion Compared to sevoflurane anesthesia,propofol anesthesia provides more stable renal hemodynamics in children undergoing congenital heart disease surgery.