右美托咪定复合七氟醚后处理对糖尿病患者心肌缺血-再灌注损伤的影响

Effect of dexmedetomidine combined with sevoflurane postprocessing on myocardial ischemia-reperfusion injury in diabetic patients

目的探讨右美托咪定联合七氟醚后处理对糖尿病患者心肌缺血-再灌注损伤的影响。方法选择2019年6月至2020年12月拟在全麻下行心脏瓣膜置换术的2型糖尿病患者80例,男42例,女38例,年龄41~65岁,BMI 18~25 kg/m^(2),ASAⅡ或Ⅲ级,心功能NYHAⅡ或Ⅲ级,肝、肾功能正常。采用随机数字表法分为四组:七氟醚后处理组(S组)、右美托咪定组(D组)、右美托咪定复合七氟醚后处理组(SD组)和对照组(C组),每组20例。S组于主动脉开放时经体外循环机给予2%七氟醚15 min;D组于手术开始时予右美托咪定0.5μg·kg-1·h^(-1)持续泵注直至手术结束;SD组于手术开始时予右美托咪定0.5μg·kg^(-1)·h^(-1)持续泵注直至手术结束,于主动脉开放时经体外循环机给予2%七氟醚15 min;C组泵注等体积生理盐水且不使用任何吸入性麻醉药。分别于主动脉阻断前(T_(0))和主动脉开放后6 h(T_(1))、24 h(T_(2))、48 h(T_(3))采集中心静脉血样,检测血浆肌酸激酶(CK)、肌酸激酶同工酶(CK-MB)、乳酸脱氢酶(LDH)、超氧化物歧化酶(SOD)的活性和肌钙蛋白I(TnI)、TNF-α、IL-6、NF-κB、血红素氧合酶-1(HO-1)的浓度,记录术中胰岛素使用、心脏起搏器置入、心脏自动复跳情况。结果与T_(0)时比较,T_(1)—T_(3)时四组血浆CK、CK-MB、LDH活性及cTnI、TNF-α、IL-6、NF-κB、HO-1浓度明显升高(P<0.05),SOD活性明显降低(P<0.05)。与C组比较,D组和SD组T_(1)—T_(3)时血浆CK、CK-MB、LDH活性及cTnI、TNF-α、IL-6、NF-κB浓度明显降低(P<0.05),SOD活性、HO-1浓度明升高(P<0.05),胰岛素使用率明显降低(P<0.05),心脏自动复跳率明显升高(P<0.05)。与D组比较,SD组T_(1)—T_(3)时血浆CK、CK-MB、LDH活性及cTnI、TNF-α、IL-6、NF-κB浓度明显降低(P<0.05),SOD活性、HO-1浓度明升高(P<0.05),心脏起搏器置入率明显降低(P<0.05),心脏自动复跳率明显升高(P<0.05)。C组和S组T_(1)—T_(3)时血浆CK、CK-MB、LDH、SOD活性及cTnI、TNF-α、IL-6、NF-κB、HO-1浓度以及胰岛素使用率、心脏起搏器置入率、心脏自动复跳率差异无统计学意义。结论右美托咪定可以减轻糖尿病患者心肌缺血-再灌注损伤,并恢复糖尿病患者的抗炎、抗氧化能力,复合七氧醚后处理可以进一步减轻糖尿病患者心肌缺血-再灌注损伤。

Objective To explore the Effect of dexmedetomidine combined with sevoflurane postprocessing on myocardial ischemia-reperfusion injury in diabetic patients.Methods Eighty patients with type 2 diabetes who were planning to undergo heart valve replacement under general anesthesia from June 2019 to December 2020 were enrolled,42 males and 38 females,aged 41-65 years,BMI 18-25 kg/m^(2),ASA physical statusⅡorⅢ,NYHA cardiac function classificationⅡorⅢ,liver and kidney function are normal.Patients were divided into four groups by using a random number table method:sevoflurane post-treatment group(group S),dexmedetomidine group(group D),dexmedetomidine combined with sevoflurane post-treatment group(group SD)and control group(group C),20 patients in each group.Group S was given 2%sevoflurane via the cardiopulmonary bypass machine for 15 minutes when the aorta was open,group D was given dexmedetomidine 0.5μg·kg^(-1)·h^(-1) at the beginning of the operation until the end of the operation,group SD was given dexmedetomidine 0.5μg·kg^(-1)·h^(-1) at the beginning of the operation until the end of the operation,and 2%sevoflurane was given via the cardiopulmonary bypass machine for 15 minutes when the aorta was open,group C was pumped with the same amount of normal saline and no inhalation was used Anesthetics.Central venous blood samples were collected before aortic clamping(T_(0))and 6 hours(T_(1)),24 hours(T_(2))and 48 hours(T_(3))after aortic declamping.Plasma creatine kinase(CK),creatine kinase isoenzyme(CK-MB),lactate dehydrogenase(LDH),superoxide dismutase(SOD)activity and the concentration of troponin I(TnI),TNF-α,IL-6,NF-κB and heme oxygenase-1(HO-1)were measured.The intraoperative use of insulin,implantation of pacemaker and automatic cardiac resuscitation were recorded.Results Compared with T_(0),plasma CK,CK-MB,LDH activities and cTnI,TNF-α,IL-6,NF-κB,HO-1 concentrations in the 4 groups at T_(1)-T_(3)increased significantly,while SOD activity decreased(P<0.05).Compared with group C,the activities of CK,CK-MB,LDH and the concentrations of cTnI,TNF-α,IL-6 and NF-κB in plasma decreased significantly at T_(1)-T_(3)(P<0.05),SOD and the concentration of HO-1 increased significantly at T_(1)-T_(3)(P<0.05),the utilization rate of insulin decreased significantly(P<0.05),the rate of spontaneous cardiac resuscitation increased significantly(P<0.05)in groups D and SD.Compared with group D,the activity of CK,CK-MB,LDH and the concentration of cTnI,TNF-α,IL-6 and NF-κB in plasma at T_(1)-T_(3)decreased significantly(P<0.05),SOD and the concentration of HO-1 increased significantly at T_(1)-T_(3)(P<0.05),the implanted rate of pacemaker decreased significantly(P<0.05),the rate of spontaneous cardiac resuscitation increased significantly(P<0.05)in group SD.There were no significant differences in plasma CK,CK-MB,LDH,SOD activity and cTnI,TNF-α,IL-6,NF-κB,HO-1 concentration at T_(1)-T_(3),insulin utilization rate,cardiac pacemaker implantation rate,and automatic cardiac resuscitation rate between groups C and S.Conclusion Dexmedetomidine can reduce myocardial ischemia reperfusion injury in diabetic patients,restore the anti-inflammatory and antioxidant abilities of diabetic patients,and alleviate myocardial ischemia reperfusion injury in diabetic patients.