七氟烷對(duì)房室缺修補(bǔ)術(shù)患兒心肌肌鈣蛋白和肌酸激酶同工酶的影響

覃　英,黃澤漢,黃　敏

(右江民族醫(yī)學(xué)院附屬醫(yī)院1.麻醉科,2.口腔科,百色533000)

QIN Ying1,HUANG Zehan1,HUANG Min2

(1.Anesthesiology Department,2.Stomatology Department,Affiliated Hospital ofYoujiang Medical University for Nationalities,Baise 533000,China)

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七氟烷對(duì)房室缺修補(bǔ)術(shù)患兒心肌肌鈣蛋白和肌酸激酶同工酶的影響

覃英1,黃澤漢1,黃敏2

(右江民族醫(yī)學(xué)院附屬醫(yī)院1.麻醉科,2.口腔科,百色533000)

【摘要】目的探討全程吸入七氟烷對(duì)房室缺修補(bǔ)術(shù)患兒心肌肌鈣蛋白I(cTn I)和肌酸激酶同工酶(CKMB)的影響。方法選擇擇期行房室缺修補(bǔ)術(shù)患兒30例，隨機(jī)分為兩組，觀察組15例，對(duì)照組15例，分別于麻醉前(T0),主動(dòng)脈開放后1小時(shí)(T1)，主動(dòng)脈開放后6小時(shí)(T2)，主動(dòng)脈開放后12小時(shí)(T3)，主動(dòng)脈開放后24小時(shí)(T4)各個(gè)時(shí)點(diǎn)抽取動(dòng)脈血測定血清cTn I和CKMB數(shù)值。記錄轉(zhuǎn)機(jī)時(shí)間、主動(dòng)脈阻斷時(shí)間、開發(fā)主動(dòng)脈至復(fù)跳時(shí)間、心臟自動(dòng)復(fù)跳率、電除顫率、心律失常發(fā)生率、術(shù)后拔管時(shí)間。結(jié)果兩組患兒體外循環(huán)轉(zhuǎn)機(jī)時(shí)間、主動(dòng)脈阻斷時(shí)間、開放至復(fù)跳時(shí)間比較差異無統(tǒng)計(jì)學(xué)意義(P>0.05)，觀察組術(shù)后拔管時(shí)間顯著短于對(duì)照組(P<0.05)，兩組心臟自動(dòng)復(fù)跳率、電除顫率及心律失常發(fā)生率比較差異無統(tǒng)計(jì)學(xué)意義(P>0.05)。兩組患兒體外循環(huán)前cTn I和CKMB均在正常范圍內(nèi)，cTn I在T0后逐漸升高，CKMB在T0后逐漸降低，T0后兩組間各時(shí)點(diǎn)cTn I、CKMB比較差異有統(tǒng)計(jì)學(xué)意義(P<0.01),觀察組兩個(gè)指標(biāo)的濃度明顯低于對(duì)照組。結(jié)論全程吸入七氟烷可降低房室缺修補(bǔ)術(shù)患兒cTn I和CKMB水平，對(duì)其心肌有保護(hù)作用。

【關(guān)鍵詞】七氟烷；房室缺修補(bǔ)術(shù)；兒童；cTn I；CKMB

七氟烷是常用的吸入性麻醉藥，許多臨床研究都表明七氟烷對(duì)心臟功能的影響較小，適用于心臟手術(shù)的麻醉。心肌肌鈣蛋白I(cTn I)和肌酸激酶同工酶(CKMB)是較為敏感的心肌損傷指標(biāo)，本研究通過觀察心臟手術(shù)麻醉中全程吸入七氟烷對(duì)房室缺修補(bǔ)術(shù)患兒cTn I和CKMB的影響，探討其對(duì)心肌保護(hù)的作用。

1資料與方法

1.1一般資料經(jīng)倫理委員會(huì)及患兒家屬同意后，選擇我院擇期行房室缺修補(bǔ)術(shù)患兒30例，年齡3～10歲，體重12～30 kg，ASAⅡ～Ⅲ級(jí)，除外肝腎功能障礙、酸堿平衡失調(diào)和電解質(zhì)紊亂者，隨機(jī)分為兩組，觀察組15例，男9例，女6例，房間隔缺損(ASD)8例，室間隔缺損(VSD) 7例，年齡(6.87±2.39)歲，體重(19.73±4.98)kg；對(duì)照組15例，男7例，女8例，ASD 10例，VSD 5例，年齡(6.87±1.88)歲，體重(20.07±3.90)kg。兩組患兒一般資料比較差異無統(tǒng)計(jì)學(xué)意義 (P>0.05)，具有可比性。

1.2給藥及麻醉方法兩組患兒均于術(shù)前開放外周靜脈，觀察組予5%七氟烷，待意識(shí)消失后給予舒芬太尼1 μg/kg、咪達(dá)唑侖0.1 mg/kg、羅庫溴銨0.6 mg/kg，肌肉松弛后行氣管插管，麻醉維持予1%～3%七氟烷。對(duì)照組經(jīng)外周靜脈給予丙泊酚3 mg/kg，患兒意識(shí)消失后給予舒芬太尼1 μg/kg、咪達(dá)唑侖0.1 mg/kg、羅庫溴銨0.6 mg/kg，麻醉維持予丙泊酚3～5 mg/kg維持。兩組患兒術(shù)中均根據(jù)手術(shù)需要給予舒芬太尼1 μg/kg和羅庫溴銨0.6 mg/kg。

1.3觀察指標(biāo)及檢測指標(biāo)分別于麻醉前(T0),主動(dòng)脈開放后1小時(shí)(T1)，主動(dòng)脈開放后6小時(shí)(T2)，主動(dòng)脈開放后12小時(shí)(T3)， 主動(dòng)脈開放后24小時(shí)(T4)各個(gè)時(shí)點(diǎn)抽取動(dòng)脈血測定血清cTn I和CKMB數(shù)值。記錄轉(zhuǎn)機(jī)時(shí)間、主動(dòng)脈阻斷時(shí)間、開放主動(dòng)脈至復(fù)跳時(shí)間、心臟自動(dòng)復(fù)跳率、電除顫率、心律失常發(fā)生率、術(shù)后拔管時(shí)間。

2結(jié)果

2.1兩組患兒轉(zhuǎn)機(jī)時(shí)間、主動(dòng)脈阻斷時(shí)間及復(fù)跳情況比較兩組患兒體外循環(huán)轉(zhuǎn)機(jī)時(shí)間、主動(dòng)脈阻斷時(shí)間、開放至復(fù)跳時(shí)間比較差異無統(tǒng)計(jì)學(xué)意義(P>0.05)，觀察組術(shù)后拔管時(shí)間顯著短于對(duì)照組(P<0.05)，兩組心臟自動(dòng)復(fù)跳率、電除顫率及心律失常發(fā)生率比較差異無統(tǒng)計(jì)學(xué)意義(P>0.05)。見表1。

2.2兩組CKMB、cTn I濃度變化的比較兩組患兒體外循環(huán)前cTn I和CKMB均在正常范圍內(nèi)，cTn I在T0后逐漸升高，CKMB在T0后逐漸降低，T0后兩組間各時(shí)點(diǎn)cTn I、CKMB比較差異有統(tǒng)計(jì)學(xué)意義(P<0.01)，觀察組兩個(gè)指標(biāo)的濃度明顯低于對(duì)照組。見表2。

3討論

小兒不同于成人，心肌在代謝、結(jié)構(gòu)和功能上均尚未發(fā)育成熟，多伴有心功能降低，血流動(dòng)力學(xué)改變明顯，其順應(yīng)性差,對(duì)麻醉藥的耐受力差,手術(shù)和體外循環(huán)的操作、阻斷心臟血供缺血再灌注等都易使之受損傷。CKMB及cTn I是監(jiān)測體外循環(huán)過程中心肌損傷及損傷程度的敏感指標(biāo)，cTn I僅存在于心肌細(xì)胞中，有很高的特異性和敏感性(特異性100%，敏感性>96.6%)，可用于心臟手術(shù)心肌保護(hù)效果的評(píng)價(jià)[1]。在心臟手術(shù)中，心肌損傷的程度越高，術(shù)后血漿cTn I濃度就越高。本研究中兩組體外循環(huán)前cTn I和CKMB在正常范圍內(nèi)，術(shù)后均有不同程度的升高，證實(shí)了體外循環(huán)過程中存在心肌損傷。作為近年來臨床常用的吸入麻醉藥物，七氟烷在臨床麻醉上常用于誘導(dǎo)與維持[2～3]。與其他的吸入麻醉藥相比，七氟烷作為一種新型的吸入麻醉藥，具有血/氣分配系數(shù)低、誘導(dǎo)和蘇醒快、呼吸道刺激小、無明顯毒副作用的優(yōu)點(diǎn)，對(duì)心臟功能的影響較小，適用于心臟手術(shù)的麻醉。吸入麻醉藥不但對(duì)心肌抑制輕，還可明顯降低心臟手術(shù)后患者血清 cTn I濃度及死亡率和心肌梗死發(fā)生率[4]。有研究表明與其他吸入性麻醉藥相比，七氟烷能降低幾倍的心肌梗死發(fā)生率[5]。七氟烷具有缺血預(yù)處理樣的心肌保護(hù)作用，其機(jī)制有可能與保持心肌細(xì)胞能量代謝的平衡和ATP生成與轉(zhuǎn)運(yùn)相關(guān)線粒體蛋白的重構(gòu)有關(guān)[6]。也可能與激活線粒體ATP敏感性 K+通道、阻斷線粒體通透性轉(zhuǎn)運(yùn)孔、激活細(xì)胞外信號(hào)調(diào)節(jié)激酶 1/2(ERK1/2)及磷脂酰肌醇-3-激酶-絲氨酸/蘇氨酸激酶(PI3K-Akt)等有關(guān)[7]。目前認(rèn)為，七氟烷的心肌保護(hù)作用不能僅在心肌缺血前預(yù)處理或心肌再灌注前應(yīng)用，只有在整個(gè)手術(shù)中自始至終吸入七氟烷才能起心肌保護(hù)作用。本研究中觀察組心臟手術(shù)麻醉中全程吸入七氟烷，術(shù)后cTn I和CKMB的釋放明顯低于對(duì)照組，提示心肌損傷程度較輕，與文獻(xiàn)結(jié)果一致[1，8]，證實(shí)七氟烷可能對(duì)心肌具有保護(hù)作用。

表1　兩組患兒轉(zhuǎn)機(jī)時(shí)間、主動(dòng)脈阻斷時(shí)間及復(fù)跳情況比較(n=15)

表2　兩組CKMB、cTn I濃度變化的比較

注：組內(nèi)與術(shù)前比較，aP<0.01;與對(duì)照組相應(yīng)時(shí)點(diǎn)比較，bP<0.01。

參考文獻(xiàn)

[1]郭訓(xùn),李恒,劉玉妍，等.七氟烷吸入麻醉對(duì)嬰幼兒心臟手術(shù)圍術(shù)期心肌損傷標(biāo)志物的影響[J].中國體外循環(huán)雜志,2014,12(2):103-105,109.

[2]Tsuruta S,Satsumae T,Mizutani T,et al.Minimum alveolar concentrations of sevoflurane for maintaining bispectral index below 50 in children[J].Paediatr Anaesth,2011,21(11):1124-1127.

[3]Sungur Ulke Z,Kartal U,Orhan Sungur M,et al.Comparison of sevoflurane and ketamine for anesthetic induction in children with congenital heart disease.Paediatr Anaesth,2008,18(8):715-721.

[4]Bignami E,Biondi-Zoccai G,Landoni G,et al.Volatile anesthetics reduce mortality in cardiac surgery[J].J Cardiothorac Vasc Anesth,2009,23(5):594-599.

[5]Yu CH,Beattie WS.The effects of volatile anesthetics on cardiac ischemic complications and mortality in CABG:a meta-analysis[J].Can J Anaesth,2006,53(9):906-918.

[6]Xiao YY,Chang YT,Ran K,et al.Delayed preconditioning by sevoflurane elicits changes in the mitochondrial proteome in ischemia-reperfused rat hearts[J].Anesth Analg,2011,113(2):224-232.

[7]劉祥,景桂霞.七氟烷后處理的心肌保護(hù)作用及其機(jī)制[J].國際麻醉學(xué)與復(fù)蘇雜志,2012,33(1):57-61.

[8]張曉華,張利東,程曉峰，等.全程吸入七氟烷在體外循環(huán)手術(shù)中的應(yīng)用研究[J].中國體外循環(huán)雜志,2012,10(2):84-86.

(編輯：梁明佩)

Effect of sevoflurane on cardiac troponin and creatine kinase isoenzyme of patients with repair of atrioventricular septal defect

QINYing1,HUANGZehan1,HUANGMin2

(1.AnesthesiologyDepartment,2.StomatologyDepartment,AffiliatedHospitalofYoujiangMedicalUniversityforNationalities,Baise533000,China)

【Abstract】ObjectiveTo evaluate the influence of total inhalation of sevoflurane on cardiac troponin I(cTn I) and creatine kinase isoenzyme (CKMB) of patients with repair of atrioventricular septal defect(ASD).Methods30 children undergoing selective ASD were selected and randomly divided into observation group and control group with 15 cases in each.Then,cTn I and CKMB of both groups were detected before anesthesia(T0),one hour after aortic opening(T1),6 hours after aortic opening(T2),12 hours after aortic opening(T3) and 24 hours after aortic opening(T4),respectively.In addition,transit time,aortic cross-clamp time,time of opening aorta to double jump,rate of spontaneous return of heartbeat,defibrillation rate,incidence of arrhythmia and postoperative extubation time were recorded.ResultsDifference of external cycle transit time,aortic cross-clamp time and time of opening aorta to double jump of the two groups was not statistically significant(P>0.05).Postoperative extubation time of the observation group was significantly shorter than that of the control group(P<0.05).There was no statistically significant difference in rate of spontaneous return of heartbeat,defibrillation rate and incidence of arrhythmia between the two groups(P>0.05).cTn I and CKMB of both groups were within normal range,cTn I gradually increased after T0,while CKMB gradually decreased after T0.After T0,there were significant differences in cTn I and CKMB between the two groups at each time point(P<0.01),concentrations of the two indexes of the observation group were significantly lower than those of the control group.ConclusionTotal inhalation of sevoflurane can reduce levels of cTn I and CKMB of children with repair ASD,which has myocardial protective effects.

【Key words】sevoflurane;ASD;children;cTn I;CKMB

(收稿日期：2016-02-25修回日期：2016-04-27)

中圖分類號(hào)：R730.53

文獻(xiàn)標(biāo)識(shí)碼：A

DOI:10.3969/j.issn.1003-1383.2016.02.019

作者簡介：覃英，女，主治醫(yī)師，醫(yī)學(xué)碩士，研究方向：臨床麻醉。E-mail:63423597@qq.com