作者：隆雨秋1，张莉1，陈均2，赵永军1，曾恒1，王义1

单位：

1.628000 四川省广元市第一人民医院麻醉科　2.628000 四川省广元市第一人民医院心胸外科

Units：

1.Department of Anesthesiology, the First People's Hospital of Guangyuan, Guangyuan 628000, China 2.Department of Cardiothoracic Surgery, the First People's Hospital of Guangyuan, Guangyuan 628000, China

关键词：

心脏瓣膜置换术；体外循环；右美托咪定；舒芬太尼；血流动力学；心肺功能

Keywords：

Heart valve replacement; Cardiopulmonary bypass; Dexmedetomidine; Sufentanil; Hemodynamics;Cardiorespiratory function

CLC：

R 614.2

DOI：

10.12114/j.issn.1008-5971.2021.00.154

Funds：

广元市重点研发项目（19ZDYF0064）

摘要：

背景　心脏瓣膜置换术是否成功与术中心肌保护措施密切相关，而术中心肌损伤主要与手术导致机体 出现强烈应激反应、血流动力学不稳定、心脏供氧失衡等有关。因此，术中保护心肌、抑制应激反应对心脏瓣膜置换 术效果具有重要意义。目的　探讨右美托咪定联合舒芬太尼对体外循环（CPB）下心脏瓣膜置换术患者血流动力学的 影响及心肺功能的保护作用。方法　选取2018 年1 月—2020 年1 月广元市第一人民医院收治的116 例行择期CPB 下 心脏瓣膜置换术的患者作为研究对象，采用随机数字表法分为对照组和观察组，每组58 例。两组均采用静吸复合麻醉， 观察组患者麻醉诱导前及术中、术后采用右美托咪定联合舒芬太尼镇痛，对照组患者仅采用舒芬太尼镇痛。比较两组 患者镇痛效果（包括术后异丙酚用量、静脉自控镇痛药液用量、吗啡使用率），术前、插管后、切皮时、劈胸骨时、 CPB 前、CPB 停机10 min 后血流动力学指标〔包括心率（HR）和平均动脉压（MAP）〕，CPB 前、CPB 停机12 h 后 心肌损伤指标〔包括心肌肌钙蛋白I（cTnI）和肌酸激酶同工酶（CK-MB）〕和肺功能指标〔包括动脉血氧分压（PaO2）、 动脉血二氧化碳分压（PaCO2）和氧合指数（OI）〕；并记录两组患者麻醉相关不良反应发生情况。结果　两组均无 延迟气管导管拔出者。观察组患者术后异丙酚用量少于对照组，吗啡使用率低于对照组（P ＜ 0.05）。时间与方法在 HR、MAP 上存在交互作用（P ＜ 0.05）；时间、方法在HR、MAP 上主效应均显著（P ＜ 0.05）。观察组患者插管后 和劈胸骨时HR 慢于对照组，切皮时和CPB 前HR 快于对照组（P ＜ 0.05）；观察组患者插管后和劈胸骨时MAP 低 于对照组，切皮时和CPB 停机10 min 后MAP 高于对照组（P ＜ 0.05）。观察组患者CPB 停机12 h 后cTnI、CK-MB 水平低于对照组（P ＜ 0.05）。观察组患者CPB 停机12 h 后PaO2 和OI 高于对照组，PaCO2 低于对照组（P ＜ 0.05）； 两组患者CPB 停机12 h 后PaO2、OI 及PaCO2 分别低于本组CPB 前（P ＜ 0.05）。两组患者麻醉相关不良反应发生率 比较，差异无统计学意义（P ＞ 0.05）。结论　右美托咪定联合舒芬太尼用于CPB 下心脏瓣膜置换术患者的镇痛效果 确切，且有利于维持患者血流动力学稳定，保护患者心肺功能，安全性较高。

Abstract：

Background　It is closely related to the protective measures of myocardium that whether the heart valve replacement is successful, and the main causes of myocardial damage intraoperative are the strong stress reaction caused by operation, hemodynamic instability and imbalance of cardiac oxygen supply. Therefore, it is of great significance to protect myocardium and inhibit stress response during operation for heart valve replacement. Objective　To investigate the effect of dextrometramidine combined with sufentanil on hemodynamics in patients undergoing heart valve replacement undercardiopulmonary bypass (CPB) and its protective effect for cardiorespiratory function. Methods　From January 2018 to January 2020, 116 patients undergoing elective cardiac valve replacement under CPB in the First People's Hospital of Guangyuan were selected as the research objects, and they were randomly divided into control group and observation group using random number table method, 58 cases in each group. Both groups of patients were given combined intravenous and inhalation anesthesia. The observation group was given dexmedetomidine combined with sufentanil for analgesia before anesthesia induction, during and after operation, while the control group was only given sufentanil for analgesia. The analgesic effects (including dosage of propofol after operation, dosage of patient-controlled intravenous analgesia liquid medicine, morphine usage rate) , hemodynamic parameters [including heart rate (HR) and average arterial pressure (MAP) ] at different time points (including before operation, after intubation, during skin incision, during sternotomy, before CPB and 10 minutes after CPB shutdown) , myocardial injury markers [including cardiac troponin I (cTnI) and creatine kinase isoenzyme (CK-MB) ] and pulmonary function indexes [including arterial partial pressure of oxygen (PaO2) , arterial partial pressure of carbon dioxide (PaCO2) and oxygenation index (OI) ] before CPB and 12 hours after CPB shutdown were compared between the two groups. And anesthesia related adverse reactions were recorded in the two groups. Results　There was no delayed extubation in both groups. The dosage of propofol in the observation group was less than that in the control group, and the morphine usage rate in the observation group was lower than that in the control group (P < 0.05) . There were statistically significant interaction between time and method in HR and MAP (P < 0.05) ; main effects of time and method were statistically significant in HR and MAP (P < 0.05) . HR in the observation group was slower than that in the control group after intubation and during sternotomy, and HR was faster than that in the control group during skin incision and before CPB (P < 0.05) . MAP in the observation group was lower than that in the control group after intubation and during sternotomy, and MAP was higher than that in the control group during skin incision and 10 minutes after CPB shutdown (P < 0.05) . The levels of cTnI and CK-MB in the observation group were lower than those in the control group 12 hours after CPB shutdown (P < 0.05) . PaO2 and OI of the observation group were higher than those of the control group 12 hours after CPB shutdown, while PaCO2 was lower than that of the control group (P < 0.05) ; PaO2, OI and PaCO2 of the two groups 12 hours after CPB shutdown were lower than those before CPB, respectively (P < 0.05) . There was no significant difference in the incidence of anesthesia related adverse reactions between the two groups (P > 0.05) . Conclusion　Dexmedetomidine combined with sufentanil has definite analgesic effect in patients undergoing heart valve replacement under CPB, and it is conducive to maintain the stability of hemodynamics of patients, protect the cardiopulmonary function of patients, with high safety.

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