目标导向灌注策略对心脏瓣膜置换手术患者的脑保护作用

Brain protective effect of goal-directed perfusion on patients undergoing cardiac valve replacement surgery

目的研究体外循环(CPB)期间目标导向灌注策略(GDP)对心脏瓣膜置换手术患者的脑保护作用。方法50例在CPB下接受心脏瓣膜置换手术的患者,以随机数字表法分为GDP组和传统灌注策略(TP)组,各25例。GDP组应用氧供-氧耗指标管理并设定导向目标,TP组应用体表面积-流量匹配管理。比较两组患者的灌注目标结果[晶体液预充量、甘露醇预充率、苯肾上腺素用量、血液浓缩器使用率、超滤总量、CPB中最低血红蛋白(Hb)、CPB中最低泵流量、CPB中最低氧供(DO_(2))],不同时间段[入室时(Ta)、手术开始时(Tb)、CPB开始后60 min(Tc)、手术结束时(Td)]的平均动脉压(MAP)水平,不同时间段[麻醉诱导后CPB开始前(T1)、CPB开始后60 min(T2)、手术结束时(T3)、术后第3天(T4)]的脑组织损伤标志物[中枢神经特异蛋白(S-100β)、神经元特异性烯醇化酶(NSE)]水平,不同时间段[术前1 d(T0)、T4、术后第5天(T5)]的认知水平及神经功能恢复评分[简易精神状态评价量表(MMSE)及美国国立卫生研究院卒中量表(NIHSS)评分]。结果两组患者CPB中最低Hb比较,差异无统计学意义(P>0.05);GDP组的晶体液预充量(0.64±0.14)L、甘露醇预充率20.0%、苯肾上腺素用量(0.86±0.64)mg低于TP组的(0.92±0.16)L、60.0%、(1.76±0.54)mg,血液浓缩器使用率100.0%、超滤总量(1.10±0.17)L、CPB中最低泵流量(2.30±0.42)L/(m^(2)·min)、CPB中最低DO2(296.17±59.32)ml/(m^(2)·min)高于TP组的48.0%、(0.42±0.50)L、(1.71±0.41)L/(m^(2)·min)、(260.14±50.12)ml/(m^(2)·min),差异具有统计学意义(P<0.05)。两组患者Ta、Tb时的MAP比较,差异无统计学意义(P>0.05);GDP组患者Tc、Td时的MAP分别为(78.2±3.2)、(80.2±3.2)mm Hg(1 mm Hg=0.133 kPa),高于TP组的(70.6±3.5)、(78.8±1.2)mm Hg,差异有统计学意义(P<0.05)。两组T1、T2、T3时的S-100β、NSE比较,差异无统计学意义(P>0.05);两组T2、T3、T4时的S-100β、NSE均高于本组T1时,GDP组T4时的S-100β(88.24±4.23)pg/ml、NSE(20.51±2.01)ng/ml均低于TP组的(95.46±4.26)pg/ml、(22.41±2.61)ng/ml,差异具有统计学意义(P<0.05)。两组患者T0时的MMSE、NIHSS评分比较,差异无统计学意义(P>0.05);T4、T5时,两组患者的MMSE评分均低于本组T0时,NIHSS评分均高于本组T0时,且GDP组的MMSE评分均高于TP组,NIHSS评分均低于TP组,差异具有统计学意义(P<0.05)。结论CPB期间对心脏瓣膜置换手术患者应用GDP可较好地发挥对脑组织的保护作用并维持血流动力学稳定,有助于改善患者术后认知功能,对促进患者预后恢复具有积极意义。

Objective To study the brain protective effect of goal-directed perfusion during cardiopulmonary bypass(CPB)on patients undergoing cardiac valve replacement surgery.Methods A total of 50 patients undergoing cardiac valve replacement surgery under CPB were divided into GDP group and TP group according to the random numerical table,with 25 patients in each group.The GDP group applied oxygen supply and consumption index management and set guidance goals,while the TP group applied body surface area flow matching management.Both groups were compared in terms of perfusion target results[crystalloid priming,mannitol priming rate,phenylephrine dosage,hemoconcentrator usage rate,ultrafiltration volume,minimum CPB hemoglobin(Hb),minimum CPB pump flow,minimum CPB oxygen delivery(DO_(2))],mean arterial pressure(MAP)levels at different time periods[at room admission(Ta),at the start of surgery(Tb),60 min after the start of CPB(Tc),the at the end of surgery(Td)],brain tissue injury markers[S-100βprotein,neuron-specific enolase(NSE)]at different time periods[before the start of CPB after induction of anesthesia(T1),60 min after the start of CPB(T2),at the end of surgery(T3),and on postoperative day 3(T4)],cognition and neurological recovery score[Mini-Mental State Examination Scale(MMSE)and National Institutes of Health Stroke Scale(NIHSS)scores]at different time periods[1 d preoperatively(T0),T4,and on postoperative day 5(T5)].Results There was no statistically significant difference in and minimum CPB Hb between the two groups(P>0.05).GDP group had crystalloid priming of(0.64±0.14)L,mannitol priming rate of 20.0%,and phenylephrine dosage of(0.86±0.64)mg,which were lower than those of(0.92±0.16)L,60.0%,and(1.76±0.54)mg in TP group;GDP group had hemoconcentrator usage rate of 100.0%,ultrafiltration volume of(1.10±0.17)L,minimum CPB pump flow of(2.30±0.42)L/(m^(2)·min),minimum CPB DO2 of(296.17±59.32)L/(m^(2)·min),which were higher than those of 48.0%,(0.42±0.50)L,(1.71±0.41)L/(m^(2)·min),(260.14±50.12)ml/(m^(2)·min)in TP group;the differences were statistically significant(P<0.05).There was no statistically significant difference in MAP at Ta and Tb between the two groups(P>0.05).MAP at Tc and Td were(78.2±3.2)and(80.2±3.2)mm Hg(1 mm Hg=0.133 kPa)in GDP group,which were higher than those of(70.6±3.5)and(78.8±1.2)mm Hg in TP group,and the differences were statistically significant(P<0.05).The differences in S-100βand NSE at T1,T2 and T3 between the two groups were not statistically significant(P>0.05).S-100βand NSE at T2,T3 and T4 in both groups were higher than those at T1 in this group;S-100βof(88.24±4.23)pg/ml and NSE of(20.51±2.01)ng/ml at T4 in GDP group were lower than those of(95.46±4.26)pg/ml and(22.41±2.61)ng/ml in TP group;the differences were statistically significant(P<0.05).The differences in MMSE and NIHSS scores at T0 between the two groups were not statistically significant(P>0.05).At T4 and T5,MMSE scores of both groups were lower than that of this group at T0,and NIHSS scores were higher than that of this group at T0;MMSE scores of the GDP group were higher than that of the TP group,and the NIHSS scores were lower than that of the TP group;the differences were statistically significant(P<0.05).Conclusion Applying the GDP model to patients undergoing cardiac valve replacement surgery during CPB can better play a protective role in brain tissue and maintain hemodynamic stability,contribute to improving postoperative cognitive function of patients,and have positive significance in promoting their recovery and prognosis.