右美托咪定对行非体外循环冠状动脉旁路移植术患者肺损伤及血清白细胞介素-10、肿瘤坏死因子-α和克拉拉细胞蛋白16水平的影响

Effects of dexmedetomidine on the lung injury and serum interleukin-10,tumor necrosis factor-αand Clara cell protein 16 levels in patients undergoing off-pump coronary artery bypass grafting

目的探讨右美托咪定(DEX)对非体外循环冠状动脉旁路移植术(OPCABG)患者血清白细胞介素-10(IL-10)、肿瘤坏死因子-α(TNF-α)及克拉拉细胞蛋白16(CC16)水平的影响及DEX对肺的保护作用。方法采用随机数字表法将2016年8月至2018年9月于新乡医学院第一附属医院行OPCABG的112例冠状动脉性心脏病(CHD)患者分为观察组和对照组,每组56例。麻醉诱导前20 min,观察组患者静脉滴注DEX 1μg·kg^(-1),对照组患者静脉滴注等体积的生理盐水;第1支移植血管吻合结束后,观察组患者静脉滴注DEX 0.2~0.5μg·kg^(-1)·h^(-1)至手术结束,对照组患者静脉滴注等体积的生理盐水至手术结束。对2组患者麻醉诱导前30 min(T_(0))、气管插管后即刻(T_(1))、手术结束时(T_(2))、术后12 h(T_(3))、术后24 h(T_(4))、术后48 h(T_(5))时的平均动脉压(MAP)、心率(HR)、脑电双频指数(BIS)、呼吸指数(RI)、氧合指数(OI)及血清IL-10、TNF-α、CC16水平进行比较;术前、术后48 h采用高分辨率计算机体层摄影术(HRCT)行胸部扫描,观察肺损伤情况;观察2组患者不良反应事件及术后吗啡使用情况。结果2组患者T_(0)时MAP、HR、BIS、RI及OI比较差异无统计学意义(P>0.05);观察组患者T_(1)、T_(2)、T_(3)、T_(4)、T_(5)时MAP显著低于T_(0)时(P<0.05);对照组患者T_(1)、T_(4)、T_(5)时MAP显著高于T_(0)时,T_(2)、T_(3)时MAP显著低于T_(0)时(P<0.05);T_(1)、T_(2)、T_(3)、T_(4)、T_(5)时观察组患者MAP显著低于对照组(P<0.05)。观察组患者T_(1)、T_(2)时HR显著低于T_(0)时(P<0.05),对照组患者T_(1)、T_(2)、T_(3)、T_(4)、T_(5)时HR显著高于T_(0)时(P<0.05);T_(1)、T_(2)、T_(3)、T_(4)、T_(5)时观察组患者HR显著低于对照组(P<0.05)。2组患者T_(1)、T_(2)、T_(3)、T_(4)时BIS显著低于T_(0)时(P<0.05),T_(1)、T_(2)、T_(3)、T_(4)、T_(5)时2组患者BIS比较差异无统计学意义(P>0.05)。对照组患者T_(1)、T_(2)、T_(3)、T_(4)、T_(5)时RI显著高于T_(0)时(P<0.05),观察组患者T_(1)、T_(2)、T_(3)、T_(4)时RI显著高于T_(0)时(P<0.05)。T_(1)、T_(2)、T_(3)、T_(4)、T_(5)时观察组患者RI显著低于对照组(P<0.05)。对照组患者T_(2)、T_(3)、T_(4)、T_(5)时OI显著低于T_(0)时(P<0.05),观察组患者T_(2)、T_(3)、T_(4)时OI显著低于T_(0)时(P<0.05)。T_(1)时2组患者OI比较差异无统计学意义(P>0.05);T_(2)、T_(3)、T_(4)、T_(5)时观察组患者OI显著高于对照组(P<0.05)。术前2组患者肺部HRCT图像未见异常;术后48 h,观察组患者肺部HRCT图像可见轻微“毛玻璃”样改变,对照组患者可见较明显“毛玻璃”样改变,且伴实变影。T_(0)时2组患者血清IL-10、TNF-α、CC16水平比较差异无统计学意义(P>0.05)。T_(0)~T_(5),2组患者血清IL-10水平整体呈升高趋势(F=36.759、5.725,P<0.05);T_(3)、T_(4)、T_(5)时观察组患者血清IL-10水平显著高于对照组(P<0.05)。观察组患者T_(4)时血清TNF-α水平显著高于T_(0)时(P<0.05),对照组患者T_(3)、T_(4)、T_(5)时血清TNF-α水平显著高于T_(0)时(P<0.05)。T_(0)、T_(1)时2组患者血清TNF-α水平比较差异无统计学意义(P>0.05);T_(2)、T_(3)、T_(4)、T_(5)时,观察组患者血清TNF-α水平显著低于对照组(P<0.05)。对照组患者T_(3)时血清CC16水平显著高于T_(0)时(P<0.05);T_(3)、T_(4)、T_(5)时观察组患者血清CC16水平显著低于对照组(P<0.05)。2组患者均未出现呼吸抑制、心动过缓、低血压等不良反应事件。对照组和观察组患者术后吗啡使用率分别为19.6%(11/56)、0.0%(0/56),观察组患者术后吗啡使用率显著低于对照组(χ^(2)=12.198,P<0.05)。结论DEX有利于维持行OPCABG患者的血流动力学稳定,抑制机体炎症反应,减轻肺损伤。

Objective To investigate the effect of dexmedetomidine(DEX)on the levels of serum interleukin-10(IL-10),tumor necrosis factor-α(TNF-α)and Clara cell protein 16(CC16)in patients undergoing off-pump coronary artery bypass grafting(OPCABG)and the protective effect of DEX on lung.Methods A total of 112 patients with coronary heart disease(CHD)who underwent OPCABG in the First Affiliated Hospital of Xinxiang Medical University from August 2016 to September 2018 were randomly divided into observation group and control group by random digits table,with 56 cases in each group.Twenty minutes before anesthesia induction,the patients in the observation group were intravenously injected with DEX 1μg·kg^(-1),and the patients in the control group were intravenously injected with equal volume of normal saline.After the anastomosis of the first graft vessel,the patients in the observation group were given DEX 0.2-0.5μg·kg^(-1)·h^(-1) by intravenous drip to the end of the operation,and the patients in the control group were given the same volume of normal saline to the end of the operation.The mean arterial pressure(MAP),heart rate(HR),bispectral index(BIS),respiratory index(RI),oxygenation index(OI)and the levels of serum IL-10,TNF-αand CC16 at 30 minutes before anesthesia induction(T_(0)),immediately after endotracheal intubation(T_(1)),the end of operation(T_(2)),and postoperative 12 hours(T_(3)),24 hours(T_(4)),48 hours(T_(5))were compared between the two groups.The lung injury was observed by high resolution computed tomography(HRCT)before operation and 48 hours after operation.The adverse reaction events and postoperative morphine using were observed in the two groups.Results There was no significant difference in the MAP,HR,BIS,RI and OI between the two groups at T_(0)(P>0.05).The MAP at T_(1),T_(2),T_(3),T_(4) and T_(5) in the observation group was significantly lower than that at T_(0)(P<0.05).The MAP at T_(1),T_(4) and T_(5) was significantly higher than that at T_(0),and the MAP at T_(2) and T_(3) was significantly lower than that at T_(0) in the control group(P<0.05).The HR at T_(1) and T_(2) was significantly lower than that at T_(0) in observation group(P<0.05).The HR at T_(1),T_(2),T_(3),T_(4) and T_(5) was significantly higher than that at T_(0) in the control group(P<0.05).The HR in the observation group was significantly lower than that in the control group at T_(1),T_(2),T_(3),T_(4) and T_(5)(P<0.05).The BIS at T_(1),T_(2),T_(3) and T_(4) was significantly lower than that at T_(0)(P<0.05).There was no significant difference in BIS between the two groups at T_(1),T_(2),T_(3),T_(4) and T_(5)(P>0.05).The RI at T_(1),T_(2),T_(3),T_(4) and T_(5) was significantly higher than that at T_(0) in the control group(P<0.05).The RI at T_(1),T_(2),T_(3) and T_(4) was significantly higher than that at T_(0) in the observation group(P<0.05).The RI in the observation group was significantly lower than that in the control group at T_(1),T_(2),T_(3),T_(4) and T_(5)(P<0.05).The OI at T_(2),T_(3),T_(4) and T_(5) was significantly lower than that at T_(0) in the control group(P<0.05).The OI at T_(2),T_(3) and T_(4) in the observation group was significantly lower than that at T_(0)(P<0.05).There was no significant difference in the OI between the two groups at T_(1)(P>0.05).The OI in the observation group was significantly higher than that in the control group at T_(2),T_(3),T_(4) and T_(5)(P<0.05).The HRCT images of lung were normal before operation in the two groups.Forty-eight hours after operation,the slight"ground glass"like changes could be seen in the HRCT images of the lung of the patients in the observation group,and more obvious"ground glass"like changes with consolidation shadow could be seen in the control group.There was no significant difference in the levels of serum IL-10,TNF-αand CC16 between the two groups at T_(0)(P>0.05).From T_(0) to T_(5),the level of serum IL-10 in the two groups increased as a whole(F=36.759,5.725;P<0.05).The level of serum IL-10 in the observation group was significantly higher than that in the control group at T_(3),T_(4) and T_(5)(P<0.05).The level of serum TNF-αat T_(4) was significantly higher than that at T_(0) in the observation group(P<0.05).The level of serum TNF-αat T_(3),T_(4) and T_(5) was significantly higher than that at T_(0) in the control group(P<0.05).There was no significant difference in serum TNF-αlevel between the two groups at T_(0) and T_(1)(P>0.05).The level of serum TNF-αin the observation group was significantly lower than that in the control group at T_(2),T_(3),T_(4) and T_(5)(P<0.05).The level of serum CC16 at T_(3) was significantly higher than that at T_(0) in the control group(P<0.05).The level of serum CC16 in the observation group was significantly lower than that in the control group at T_(3),T_(4) and T_(5)(P<0.05).There were no adverse events such as respiratory depression,bradycardia and hypotension in the two groups.The postoperative utilization rate of morphine in the control group and the observation group was 19.6%(11/56)and 0.0%(0/56),respectively.The postoperative utilization rate of morphine in the observation group was significantly lower than that in the control group(χ^(2)=12.198,P<0.05).Conclusion DEX is helpful to maintain the hemodynamic stability of patients undergoing OPCABG,inhibit the inflammatory response and reduce lung injury.