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以脑钠肽评价琥珀酰明胶于OPCABG麻醉诱导期行不同容量填充策略对心功能的影响
Effects of different stragty of hypervolemic iinfusion with gelofusine during induction of anesthesia on cardiac function in patients undergoing off-pump coronary artery bypass graft

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DOI:
作者:
董榕
Dong Rong, Bao Chengrong, Yu Buwei
作者单位:
上海交通大学医学院附属瑞金医院麻醉科
Department of anesthesiology,Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200025,China
关键词:
容量填充；非体外循环下冠状动脉搭桥术；脑钠肽；心肌蛋白酶
Hypervolemic hemodilution；Off-pump coronary artery bypass graft, brain natriuretic peptide, myocardial enzyme series
摘要:
目的：通过测定血浆脑钠肽(BNP)及心肌蛋白酶浓度，评价非体外循环下行冠状动脉旁路移植术(OPCABG)患者麻醉诱导期以琥珀酰明胶注射液（Gel）行急性高容量填充时不同填充策略对患者心功能和术后恢复情况的影响。 方法：将40例行择期非体外循环下OPCABG术患者随机分为两组。麻醉诱导后置入Swan-Ganz导管测得心指数（CI）基础值，即行容量填充：组I经验法容量填充，于切皮前30min静脉输注Gel 12 mL/kg；组II目标靶控填充,以CI作反馈于切皮前静脉输注Gel 0.4mL/kg/min（请与正文中的描述一致已修改，谢谢）直至CI进入平台期即停止输注。分别于患者入室(T1)，容量填充前(T2)，容量填充中(T3)、容量填充后(T4)、桥血管开放时(T5)、手术结束时(T6)及术后24h(T7)各期留取血样本测定血浆脑钠肽。记录术后3 天的心肌蛋白酶浓度。同时记录液体输注总量、术后气管插管拔管时间、重症监护病房(ICU)停留时间、术后住院天数和总住院天数。结果（请与正文中的描述一致已修改，详见正文对应结果，谢谢）：用于容量填充的琥珀酰明胶注射液量，组Ⅱ多于组Ⅰ，差异有统计学意义(958±113mL vs. 797±126mL，P=0.036)。两组患者术后24h(T7)时刻血浆BNP浓度组I明显高于组Ⅱ，差异有显著统计学意义(849±393pg/mL vs. 250±35pg/mL， P<0.01)。术后第1、2天，组Ⅰ的肌酸激酶同工酶及肌钙蛋白I浓度均明显高于组Ⅱ(P<0.01)。术后拔管时间组Ⅱ短于组Ⅰ(P<0.05) ，ICU停留时间组Ⅱ明显短于组Ⅰ (P<0.01) ，差异均有统计学意义。结论：OPCABG患者行麻醉诱导时，以CI反馈施行目标靶控的容量填充是安全、有效的。血浆脑钠肽的浓度测定证实,适当的扩容方法不影响心脏的泵功能且能明显缩短术后气管导管的拔管时间和ICU停留时间，从而有利于“快通道”的实施和患者术后的恢复。
Objectives: The aim of this study was to investigate the effects of hypervolemic infusion of gelofusine by different stragty on cardiac function during off-pump coronary artery bypass graft (OPCABG). The measurement of plasma concentrations of brain natriuretic peptide (BNP) and myocardial enzyme series have been used to evaluate patients’ cardiac function. Methods: Forty male patients (50～80 years old, ASAⅡ～Ⅲ) undergoing elective off-pump coronary artery bypass graft were randomLy assigned into 2 groups. After induction, the basic cardiac index (CI) was obtained by Swan-Ganz. GroupⅠ(n=20): 12mL/kg of succinylated gelatin injection was infused within 30 minutes. Group Ⅱ (n=20): 0.4mL/kg of succinylated gelatin injection was infused until CI was achieved the steady state. The plasma concentrations of BNP, and the dosage of fluid used were assessed on baseline (T1), before fluid expansion (T2), during fluid expansion (T3), and at the end of fluid expansion (T4), all of the bypass blood vessels de-clamped (T5), at the end of surgery (T6) and 24 hours after operation (T7). Meanwhile, the plasma concentrations of myocardial enzyme series were record after the operations. The duration of operation, time to tracheal extubation, intensive care unit (ICU) stay and hospital stay were also analyzed. Results: There was no significant difference in the patients’ demography between the groups. The amount of gelofusine used in group Ⅱ was much higher than that in groupⅠ (958±113mL vs. 797±126mL, P=0.036). The plasma concentrations of BNP at the timepoint of T7 in guoup Ⅰ was much higher than that in group Ⅱ (849±393pg/mL vs. 250±35pg/mL, P<0.01). Plasma concentrations of CK-MB and TnI in group Ⅰwas much higher than that in group Ⅱ one or two days after the operations (P<0.01).The time to tracheal extubation and ICU stay were obviously shorter in group Ⅱ than in groupⅠ (tracheal extubation: P<0.05, ICU stay: P<0.01). Conclusions: Adequate volume expansion with succinylated gelatin infusion after induction of anesthesia is beneficial to the cardiac insufficiency patients who are undergoing OPCABG. BNP and myocardial enzyme series monitoring guided fluid expansion are safer and more efficient than estimated amount of fluid infusion based on clinical experierane. This process also abbreviated the time to tracheal extubation and ICU stay

 

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