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中国人民解放军总医院老年心血管病研究所
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中华老年多器官疾病杂志编辑委员会
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创刊人 王士雯
总编辑 范利
副总编辑 陈韵岱
执行主编 叶大训
编辑部主任 王雪萍
ISSN 1671-5403
CN 11-4786
创刊时间 2002年
出版周期 月刊
邮发代号 82-408
友情链接
吴卞梁,黄义洲,刘月,袁林芳,赵文静.体外循环下心脏瓣膜置换术后应用右美托咪定联合氯胺酮或瑞芬太尼的脑保护作用[J].中华老年多器官疾病杂志,2018,17(9):641~646
体外循环下心脏瓣膜置换术后应用右美托咪定联合氯胺酮或瑞芬太尼的脑保护作用
Cerebral protection by dexmedetomidine-ketamine and dexmedetomidine-remifentanil after cardiac valve replacement under cardiopulmonary bypass:a comparative study
投稿时间:2018-03-07  修订日期:2018-05-27
DOI:10.11915/j.issn.1671-5403.2018.09.148
中文关键词:  体外循环;心脏瓣膜置换术;氯胺酮;右美托咪定;瑞芬太尼
英文关键词:cardiopulmonary bypass; cardiac valve replacement; ketamine; dexmedetomidine; remifentanil
基金项目:六大人才高峰省级D类资助项目(2009059);徐州市科技厅课题(KC16SY150)
作者单位E-mail
吴卞梁 徐州医科大学附属医院重症医学科,徐州 221000;徐州医科大学附属医院麻醉科,徐州 221000  
黄义洲 徐州医科大学附属医院麻醉科,徐州 221000  
刘月 徐州医科大学附属医院麻醉科,徐州 221000  
袁林芳 徐州医科大学附属医院麻醉科,徐州 221000  
赵文静 徐州医科大学附属医院重症医学科,徐州 221000 zhaowj886@sina.com 
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中文摘要:
      目的 比较体外循环下心脏瓣膜置换术(CVR)后应用右美托咪定联合氯胺酮或瑞芬太尼的脑保护作用。方法 选择2017年3月至2018年2月在徐州医科大学附属医院麻醉科择期行体外循环下CVR的患者90例,术后返回重症监护室(ICU)进行镇静。根据镇静剂的不同将患者分为右美托咪定联合氯胺酮组(DK组)和右美托咪定联合瑞芬太尼组(DR组),各组45例。其中DK组给予右美托咪定0.2~0.7 μg/(kg·h)、氯胺酮0.3~0.5 mg/(kg·h)静脉泵注;DR组右美托咪定用法与DK组相同,瑞芬太尼以2.5~5.0 μg/(kg·h)静脉泵注。监测患者的血流动力学指标平均动脉压(MAP)和平均心率(MHR),并分别于镇静前(T0)、镇静后2 h(T1)、6 h(T2)、12 h(T3)、24 h(T4)检测脑损伤指标中枢神经特异蛋白S100β及神经元特异性烯醇化酶(NSE)的浓度;记录在ICU期间患者谵妄情况,右美托咪定、地佐辛及氟哌啶醇用量,苏醒时间、拔管时间、ICU停留时间、术后住院时间及不良事件发生率。采用SPSS 19.0软件进行统计分析。组间比较采用t检验、χ2检验或秩和检验,组内比较采用重复测量方差分析。结果 T1~4时2组患者S100β及NSE水平较T0均显著降低(P<0.05),且相较于DR组,DK组在T1~4时的S100β及T1~3时的NSE下降更明显,差异有统计学意义(P<0.05)。镇静前2组患者MAP及MHR差异不显著,镇静后DK组患者30 min~9 h的MAP及30 min~8 h的MHR显著高于DR组,差异有统计学意义(P<0.01)。且DK组患者MAP及MHR较DR组波动较平缓。与DR组比较,镇静过程中DK组患者右美托咪定[(374.3±52.7) vs (504.6±69.3)μg]、地佐辛[(9.6±2.7) vs (15.6±3.3)mg]及氟哌啶醇[(29.7±3.2) vs (46.6±3.4)mg]、低血压率[6.6%(3/45) vs 24.4%(11/45)]、心动过缓[4.4%(2/45) vs 20.0%(9/45)]、苏醒时间[(457.2±14.5) vs (504.2±16.9)min]、拔管时间[(511.7±15.9) vs (553.5±20.9)min]显著降低(P<0.05),但谵妄比例、恶心/呕吐、ICU停留时间及术后住院时间差异无统计学意义(P>0.05)。结论 体外循环下CVR后患者应用右美托咪定联合氯胺酮或瑞芬太尼具有相似的镇静镇痛效果,但前者脑保护作用更加显著,其血流动力学更合理、平稳,且不良反应发生率明显下降。
英文摘要:
      Objective To compare the brain protection by the combination of dexmedetomidine with ketamine or remifentanil in the patients after cardiac valve replacement(CVR) under cardiopulmonary bypass. Methods Ninety patients were selected for the study, who were transferred to ICU for sedation after elective CVR under cardiopulmonary bypass in the Anesthesiology Department of Xuzhou Medical University Hospital from March 2017 to February 2018. The patients were divided into dexmedetomidine-ketamine group (DK group) and dexmedetomidine-remifentanil group (DR group), with 45 patients in each group. Both groups received dexmedetomidine 0.2-0.7 μg/(kg·h) via intravenous pumping, but ketamine 0.3-0.5 mg/(kg·h) was administered in the DK group and remifentanil 2.5-5.0 μg/(kg·h) in DR group via intravenous pumping. The patients were monitored for the hemodynamic parametersincluding the mean arterial pressure (MAP) and mean heart rate (MHR). The brain injury severity indices including central nerve specific protein (S100β) and neuron-specific enolase (NSE) were measured before sedation (T0), and 2 h (T1), 6 h (T2), 12 h (T3) and 24 h (T4) after sedation. Records were kept of the delirium incidence, dosage of dexmedetomidine, haloperidol and dezocine, awakening time, extubation time, duration of ICU stay, postoperative hospital stay and incidence of adverse events. SPSS statistics 19.0 was used for data processing. Student′s t test, Chi-square test or rank-sum test were used for intergroup comparison, and repeated measurement variance analysis for intragroup.Results The levels of S100β and NSE at T1-4 in both groups were significantly lower than those at T0 (P<0.05). The decrease of S100β at T1-4 and the NSE at T1-3 in the DK group was greater than that in the DR group, difference being statically significant (P<0.05). There was no significant difference in MAP and MHR between 2 groups before sedation. MAP at 30 min-9 h and MHR 30 min-8 h after sedation in the DK group were significantly higher than those in the DR group, and the differences were statistically significant (P<0.01). The fluctuation of MAP and MHR in the DK group was more moderate than in the group DR. During sedation, the recordings in the DK group were significantly lower than those in the DR group of the concentration of dexmedetomidine [(374.3±52.7) vs (504.6±69.3)μg], dezocine [(9.6±2.7) vs (15.6±3.3)mg] and haloperidol [(29.7±3.2) vs (46.6±3.4)mg]; occurrences of hypotension [6.6%(3/45) vs 24.4%(11/45)] and bradycardia [4.4%(2/45) vs 20.0%(9/45)]; and awakening time [(457.2±14.5) vs (504.2±16.9)min] and extubation time [(511.7±15.9) vs (553.5±20.9)min] (P<0.05), but no significant differences were observed in delirium ratio, nausea/vomiting, ICU stay time and postoperative hospital stay (P>0.05). Conclusion Dexmedetomidin-ketamine and dexmedetomidin-remifentanil have similar sedative and analgesic effects after CVR with cardiopulmonary bypass, but the former provides more significant cerebral protection with more reasonable and stable hemodynamics and significantly decreased occurrences of adverse reactions.
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