瑞芬太尼联合右美托咪定对心肺转流下瓣膜置换术患者左室功能影响的观察

Effect of Remifentanil Combined with Dexmedetomidine on Left Ventricular Function in Patients Undergoing Cardiopulmonary Bypass Valve Replacement

目的:观察瑞芬太尼联合右美托咪定(Dex)对瓣膜置换术患者心肺转流(CPB)下左室功能的影响。方法:择期行CPB下心脏瓣膜置换术患者92例,随机分为RD组和R组各46例。RD组麻醉诱导前静脉缓慢泵入Dex 0.4μg·kg^(-1);R组静脉缓慢泵入等量的0.9%氯化钠溶液。两组镇痛药均为瑞芬太尼1.5μg·kg^(-1);。比较手术开始(T1)、CPB结束(T2)、术毕(T3)各时点两组患者的左室面积变化分数(FAC)、左室射血分数(EF)、左室舒张末容积(EDV)、左室重量指数(LVMI)、平均动脉压(MAP)、心率(HR)等指标变化,以及手术前后两组患者的C-反应蛋白(CRP)、白细胞介素-6(IL-6)、肿瘤坏死因子-α(TNF-α)、心脏型脂肪酸结合蛋白(F-ABP)、肌酸激酶同工酶(CK-MB)、肌钙蛋白I(cTnI)水平变化。记录两组术中血管活性药物使用量/使用率。结果:(1) T1~T3时RD组MAP低于R组(P<0.05);T1时RD组HR低于R组(P<0.05)。与T1比较,T2、T3时RD组FAC、EF降低,EDV升高(P<0.05);与R组比较,T2、T3时RD组FAC明显下降(P<0.05)。与T1比较,两组T2、 T3时LVMI升高(P<0.05),但两组间差异无统计学意义(P>0.05)。(2)两组患者术后1 d、3 d、7 d的血清CRP、IL-6、TNF-α、F-ABP、CK-MB、cTnI水平均较术前明显增高(P<0.05),但RD组术后1 d、3 d、7 d时上述指标均明显低于R组(P<0.05)。(3) RD组多巴胺、去甲肾上腺素和肾上腺素的使用量/使用率均低于R组(P<0.05)。结论:在瑞芬太尼基础上增加Dex可减小CPB下瓣膜置换术患者血流动力学波动和心肌做功,抑制炎性因子释放,减轻CPB对心肌细胞的损害,有利于左室功能的恢复。

Objective:To observethe effect of remifentanil combined with dexmedetomidine(Dex) on left ventricular function in patients undergoing cardiopulmonary bypass(CPB) valve replacement.Methods:Ninty-two patients for elective cardiac valve replacement under CPB were randomly divided into RD group and R group, with 46 cases each. RD group was slowly pumped into Dex 0.4 g·kg^(-1);before anesthesia induction, and the same amount of 0.9% sodium chloride solution was slowly pumped into the veins of R group. The analgesics in both groups were remifentanil 1.5 g·kg^(-1);. Left ventricular area change score(FAC), left ventricular ejection fraction(EF), left ventricular end-diastolic volume(EDV), left ventricular mass index(LVMI), mean arterial pressure(MAP), heart rate(HR) at the beginning of the operation(T1), CPB completion(T2), at the end of the operation(T3) and the serum levels of C-reactive protein(CRP), interleukin 6(IL-6), tumor necrosis factor-α(TNF-α), heart type fatty acid binding protein(F-ABP), creatine kinase isoenzyme(CK-MB), troponin I(cTnI) before and after surgery were compared between the two groups. Intraoperative use of vasoactive drugs was recorded in both groups.Results:(1) At T1-T3, the MAP of RD group was lower than that of R group(P<0.05). At T1, HR in RD group was lower than that in R group(P<0.05). Compared with T1, FAC and EF were decreased and EDV was increased in RD group at T2 and T3(P<0.05). Compared with R group, FAC in RD group decreased significantly at T2 and T3(P<0.05). Compared with T1, LVMI was increased at T2 and T3 in both groups(P<0.05), but there was no statistical difference between the two groups(P>0.05).(2) Compared with the preoperative level, CRP, IL-6, TNF-α, F-ABP, CK-MB and cTnI were significantly increased at 1 d, 3 d and 7 d after operation in the two groups(P<0.05), but were significantly decreased at 1 d, 3 d and 7 d after operation in the RD group compared with the R group(P<0.05).(3)The use amount of dopamine and norepinephrine, the use rate of epinephrine in RD group were significantly lower than those in R group(P<0.05). Conclusion:Dex on the basis of remifentanil can reduce hemodynamic fluctuation and myocardial work in patients undergoing CPB valve replacement, inhibit the release of inflammatory factors, reduce CPB damage to myocardial cells, and facilitate the recovery of left ventricular function.