CAJ | 학술논문

目的：探讨七氟醚预处理对先天性心脏病（先心病）患儿围术期心肌缺血/再灌注损伤（ myocardial ischemia/reperfuison injury，MI/RI）的影响及其机制。方法择期拟行先心病手术患者40例，ASAⅠ或Ⅱ级，随机分为2组：对照组（ C组，n=20），不给予吸入性麻醉药；七氟醚预处理组（ S组，n=20），于劈开胸骨后持续吸入2MAC （2×1.71%）浓度的七氟醚，至体外循环（ cardiopulmonary bypass，CPB）开始前结束。2组均采用咪唑安定0.08~0.12mg/kg、芬太尼5~10μg/kg、维库溴铵0.1mg/kg行全身麻醉诱导，3min后气管内插管。术中按需追加咪唑安定、芬太尼及维库溴铵。分别记录主动脉阻断时间、体外循环时间、自动复跳及电除颤情况。于麻醉后切皮前（T0）、主动脉开放后10min（T1）、CPB停机即刻（T2）、CPB停机后6h（T3）和CPB停机后24h（T4）5个时间点抽取桡动脉血，检测血浆肌酸磷酸激酶同工酶（ creatine phosphokinase isoenzyme，CK-MB）、心肌肌钙蛋白I（ cardiac troponin I，cTnI）、丙二醛（ malondialdehyde，MDA）水平和超氧化物歧化酶（ superoXide dismutase，SOD）活性。结果2组CPB时间、主动脉阻断时间以及射血分数差异均无统计学意义（ p＞0.05）。2组cTnI、CK-MB、MDA水平均于T1时升高，T3时达到峰值，T4时出现下降。组内比较，在T1~4时cTnI、MDA水平均高于T0（p＜0.01）；各时点cTnI、MDA水平组间比较，T0时差异无统计学意义（p＞0.05），T1~4时S组cTnI、MDA水平低于C组（p＜0.01）。各时点CK-MB水平组间比较，T0~3时差异无统计学意义（p＞0.05），T4时S组CK-MB水平低于C组（p＜0.01）。C组SOD活性于T1时开始降低，T2时达最低值，T3时出现回升，T4时恢复T0水平；T1、T2及T3时SOD活性均低于T0（ p＜0.01），S组T1~4时SOD活性与T0比较差异无统计学意义（ p＞0.05）；各时点SOD活性组间比较，T0、T4时差异无统计学意义（p＞0.05），T1~3时S组SOD活性高于C组（p＜0.01）。结论七氟醚预处理对先心病患儿心内直视手术的心肌具有保护作用，能减轻MI/RI后心肌细胞的损伤。目的：探討七氟醚預處理對先天性心髒病（先心病）患兒圍術期心肌缺血/再灌註損傷（ myocardial ischemia/reperfuison injury，MI/RI）的影響及其機製。方法擇期擬行先心病手術患者40例，ASAⅠ或Ⅱ級，隨機分為2組：對照組（ C組，n=20），不給予吸入性痳醉藥；七氟醚預處理組（ S組，n=20），于劈開胸骨後持續吸入2MAC （2×1.71%）濃度的七氟醚，至體外循環（ cardiopulmonary bypass，CPB）開始前結束。2組均採用咪唑安定0.08~0.12mg/kg、芬太尼5~10μg/kg、維庫溴銨0.1mg/kg行全身痳醉誘導，3min後氣管內插管。術中按需追加咪唑安定、芬太尼及維庫溴銨。分彆記錄主動脈阻斷時間、體外循環時間、自動複跳及電除顫情況。于痳醉後切皮前（T0）、主動脈開放後10min（T1）、CPB停機即刻（T2）、CPB停機後6h（T3）和CPB停機後24h（T4）5箇時間點抽取橈動脈血，檢測血漿肌痠燐痠激酶同工酶（ creatine phosphokinase isoenzyme，CK-MB）、心肌肌鈣蛋白I（ cardiac troponin I，cTnI）、丙二醛（ malondialdehyde，MDA）水平和超氧化物歧化酶（ superoXide dismutase，SOD）活性。結果2組CPB時間、主動脈阻斷時間以及射血分數差異均無統計學意義（ p＞0.05）。2組cTnI、CK-MB、MDA水平均于T1時升高，T3時達到峰值，T4時齣現下降。組內比較，在T1~4時cTnI、MDA水平均高于T0（p＜0.01）；各時點cTnI、MDA水平組間比較，T0時差異無統計學意義（p＞0.05），T1~4時S組cTnI、MDA水平低于C組（p＜0.01）。各時點CK-MB水平組間比較，T0~3時差異無統計學意義（p＞0.05），T4時S組CK-MB水平低于C組（p＜0.01）。C組SOD活性于T1時開始降低，T2時達最低值，T3時齣現迴升，T4時恢複T0水平；T1、T2及T3時SOD活性均低于T0（ p＜0.01），S組T1~4時SOD活性與T0比較差異無統計學意義（ p＞0.05）；各時點SOD活性組間比較，T0、T4時差異無統計學意義（p＞0.05），T1~3時S組SOD活性高于C組（p＜0.01）。結論七氟醚預處理對先心病患兒心內直視手術的心肌具有保護作用，能減輕MI/RI後心肌細胞的損傷。
목적：탐토칠불미예처리대선천성심장병（선심병）환인위술기심기결혈/재관주손상（ myocardial ischemia/reperfuison injury，MI/RI）적영향급기궤제。방법택기의행선심병수술환자40례，ASAⅠ혹Ⅱ급，수궤분위2조：대조조（ C조，n=20），불급여흡입성마취약；칠불미예처리조（ S조，n=20），우벽개흉골후지속흡입2MAC （2×1.71%）농도적칠불미，지체외순배（ cardiopulmonary bypass，CPB）개시전결속。2조균채용미서안정0.08~0.12mg/kg、분태니5~10μg/kg、유고추안0.1mg/kg행전신마취유도，3min후기관내삽관。술중안수추가미서안정、분태니급유고추안。분별기록주동맥조단시간、체외순배시간、자동복도급전제전정황。우마취후절피전（T0）、주동맥개방후10min（T1）、CPB정궤즉각（T2）、CPB정궤후6h（T3）화CPB정궤후24h（T4）5개시간점추취뇨동맥혈，검측혈장기산린산격매동공매（ creatine phosphokinase isoenzyme，CK-MB）、심기기개단백I（ cardiac troponin I，cTnI）、병이철（ malondialdehyde，MDA）수평화초양화물기화매（ superoXide dismutase，SOD）활성。결과2조CPB시간、주동맥조단시간이급사혈분수차이균무통계학의의（ p＞0.05）。2조cTnI、CK-MB、MDA수평균우T1시승고，T3시체도봉치，T4시출현하강。조내비교，재T1~4시cTnI、MDA수평균고우T0（p＜0.01）；각시점cTnI、MDA수평조간비교，T0시차이무통계학의의（p＞0.05），T1~4시S조cTnI、MDA수평저우C조（p＜0.01）。각시점CK-MB수평조간비교，T0~3시차이무통계학의의（p＞0.05），T4시S조CK-MB수평저우C조（p＜0.01）。C조SOD활성우T1시개시강저，T2시체최저치，T3시출현회승，T4시회복T0수평；T1、T2급T3시SOD활성균저우T0（ p＜0.01），S조T1~4시SOD활성여T0비교차이무통계학의의（ p＞0.05）；각시점SOD활성조간비교，T0、T4시차이무통계학의의（p＞0.05），T1~3시S조SOD활성고우C조（p＜0.01）。결론칠불미예처리대선심병환인심내직시수술적심기구유보호작용，능감경MI/RI후심기세포적손상。
OcjectiVe To interpret the perioperative myocardial protection of sevoflurane preconditioning during myocardial ischemia/reperfuison injury( MI/RI)caused by open-heart surgery in congenital heart disease children. Methods Forty patients of scheduled for repair to ventricular septal defect(VSD)and to atrial septal defect(ASD)were randomly divided into two groups,control group (group C,n =20)and sevoflurane preconditioning group(group S,n =20). In group S,2MAC of sevoflurane was continuously inhaled from the beginning of operation to the beginning of cardiopulmonary bypass( CPB),and no anesthetic used sevoflurane in group C. Patients of anesthesia were injected with intravenous midazolam(0. 08-0. 12mg/kg),fentanyl(5-10μg/kg)and vecuronium(0. 1mg/kg)and anesthesia was maintained with midazolam,fentanyl and vecuronium in intermittent iv boluses was induced. The time of clamping aorta,cardiopulmonary bypass and operating,the rate of spontaneously rebeating of heart and the situation of electrocution defibrillation were recorded. The plasma levels of creatine phosphokinase isoenzyme( CK-MB),cardiac troponin I( cTnI),malondialdehyde( MDA)and the activity of superoXide dismutase(SOD)were measured after induction of anesthesia(T0),10minutes after aorta unclamping(T1),immediately after CPB(T2),6h(T3)and 24h(T4)after CPB. Results All patients were similar with regard to demographic data between two groups(p >0. 05). cTnI,CK-MB, MDA in both group increased at T1 ,reached peak at T3 and declined at T4 . The cTnI,MDA level at T1-4 were higher than that at T0( p <0 . 01 ). There were no significant difference at T0 between two groups (p>0. 05),the cTnI,MDA level at T1-4 in group S was lower than that in group C(p<0. 01). The CK-MB level at T1-4 was higher than that at T0( p <0. 01 ). There was no significant difference at T0-3 between two groups( p>0. 05 ),the CK-MB level at T4 in group S was lower than that in group C( p<0. 01). The SOD activity at T1-3 was higher than that at T0( p <0. 01 ). In group S,there was no significant difference at T1-4 when compared with T0 . There was no significant difference at T0 between two groups( p>0 . 05 ),the SOD activity at T1-3 in group S was higher than that in group C( p<0 . 01 ). Conclusion Sevoflurane preconditioning will be a novel therapeutic strategy to reduce the risk of myocardial MI/RI during open-heart surgery with CPB in children.