术前鞘内注射吗啡对老年患者胸腔镜肺叶切除术后心肌损伤的影响

Effect of intrathecal morphine on myocardial injury in elderly patients undergoing thoracoscopic surgery

目的探讨术前鞘内注射吗啡对老年患者胸腔镜肺叶切除术后心肌损伤的影响。方法选择拟行胸腔镜肺叶切除术老年患者55例,男28例,女27例,年龄65~85岁,BMI 18.5~27.9 kg/m^(2),ASAⅠ或Ⅱ级。采用数字随机分配法将患者分为两组:对照组(C组,n=28)和鞘内注射吗啡组(M组,n=27)。M组麻醉诱导前于L_(2-3)间隙行蛛网膜下腔穿刺并推注吗啡4μg/kg。两组均采用全身麻醉,双腔气管插管行单肺通气。分别于麻醉诱导前、术后24、48 h取静脉血测定N末端B型利钠肽前体(NT-proBNP)、肌酸激酶同工酶(CK-MB)、高敏肌钙蛋白T(hs-TnT)和C型反应蛋白(CRP)浓度。记录非心脏手术心肌损伤(MINS)发生例数、术中瑞芬太尼用量,并评估术后6、12、24及48 h静息和活动时的VAS疼痛评分。记录术后48 h内PCIA有效按压次数、总按压次数、补救镇痛例数。记录术后不良反应(呼吸抑制、恶心呕吐、尿潴留、皮肤瘙痒)发生情况、术后30 d随访心血管不良事件发生情况。结果与术前比较,两组术后24、48 h血清NT-proBNP、CK-MB、hs-TnT和CRP浓度均明显升高(P<0.05)。与C组比较,M组术后24、48 h血清NT-proBNP、CK-MB、hs-TnT和CRP浓度明显降低(P<0.05),hs-TnT绝对值变化明显减少(P<0.05),MINS发生率明显降低(P<0.05)。与C组比较,M组术后6、12、24 h活动时及术后12、24 h静息时VAS疼痛评分、术后补救镇痛率明显降低(P<0.05),术中瑞芬太尼用量、术后PCIA有效按压次数、总按压次数明显减少(P<0.05)。两组术后不良反应发生率差异无统计学意义。结论术前鞘内注射小剂量吗啡可降低老年患者胸腔镜肺叶切除术后心肌损伤标志物升高程度,对此类患者有一定的心肌保护作用。

Objective To investigate the myocardial injury effects of intrathecal morphine injection in elderly patients undergoing thoracoscopic lobectomy.Methods Fifty-five elderly patients undergoing elective thoracoscopic lobectomy,28 males and 27 females,aged 65-85 years,BMI 18.5-27.9 kg/m^(2),ASA physical statusⅠorⅡ,were divided into two groups using the digital random allocation method:the control group(group C,n=28)and intrathecal morphine group(group M,n=27).Group M was given a single injection of morphine 4μg/kg in the L_(2-3) space before surgery.General anesthesia was used in both groups,and single-lung ventilation was performed with double-lumen endotracheal intubation.Venous blood was collected before induction,24 and 48 hours after the operation to measure the levels of N-terminal brain natriuretic peptide precursor(NT-proBNP),creatine kinase isoenzyme(CK-MB),high-sensitivity troponin T(hs-TnT)and C-reactive protein(CRP).The incidence of myocardial injury after noncardiac surgery(MINS)was recorded.The intraoperative remifentanil dosage was recorded and the VAS pain scores at rest and during activity at 6,12,24,and 48 hours postoperatively were evaluated.The number of effective patient-controlled intravenous analgesia(PCIA)compressions,the total number of PCIA compressions,the times of remedial analgesia in the postoperative period of 48 hours,as well as the incidence of postoperative adverse reactions(respiratory depression,nausea and vomiting,urinary retention,and pruritus)were recorded.Postoperative 30-day major adverse cardiovascular and cerebrovascular events were recorded.Results Compared with preoperative,the levels of serum NT-proBNP,CK-MB,hs-TnT,and CRP were significantly higher in both groups at 24 and 48 hours postoperatively(P<0.05).Compared with group C,the elevated levels of serum NT-proBNP,CK-MB,hs-TnT,CRP,and absolute hsTnT changes were significantly lower in group M 24 and 48 hours after operation(P<0.05),the incidence of MINS was significantly lower in group M(P<0.05).Compared with group C,the VAS pain scores of patients in group M were decreased significantly 6,12 and 24 hours during activity and 12 and 24 hours at rest after surgery(P<0.05),the dosage of intraoperative remifentanil,the number of effective and total postoperative PCIA compressions,and the incidence of need for postoperative remedial analgesia were significantly reduced in group M(P<0.05).There was no significantly difference in the incidence of postoperative adiverse recations between the two groups.Conclusion Intrathecal morphine can reduce the levels of markers of myocardial injury in elderly patients undergoing thoracoscopic lobectomy,which plays a partial role in myocardial protection.