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硝普钠复合美托洛尔控制性降压期间血液动力学的变化

时间:2010-08-24 11:31:09  来源:  作者:

Hemodynamic Changes during Controlled Hypotension Induced by Sodium Nitroprusside Alone or Combined with Metoprolol in Neurosurgical Patients

焦希平
邢 燕
王保国
中国医学科学院首都医科大学附属北京天坛医院麻醉科,北京100050
Xiping Jiao, MDYan Xing, MD,Baoguo Wang,MD
Department of Anesthesiology, Beijing Tian Tan Hospital, Capital University of Medical Sciences, Chinese Academy of Medical Sciences, Beijing 100050, China

              ABSTRACT
  Objective
: To compare the hemodynamic changes during controlled hypotension induced by sodium nitroprusside (SNP) alone or SNP combined with metoprolol (MET) in neurosurgical patients.
  Methods: Thirty ASA I-II patients scheduled for elective neurosurgery, were randomly allocated into group A (n=15) and group B (n=15). Anesthesia was maintained with 1.0 MAC isoflurane. Controlled hypotension was performed after opening of dura and the MAP was reduced and maintained between 7.33-8.0 kPa (55-60 mmHg) with continuous infusion of SNP at 1.0-2 μg•kg-1•min-1 in group A. In group B metoprolol 0.04 mg•kg-1 were given 3-5 minutes before controlled hypotention. MAP, HR, CO, SV, PV, ACC, LVET and TSVR were monitored using HEMOSONICTM 100. Hymodynamic parameter were recorded before hypotension, reach aim, 5min, 15min and 30min during hypotension, 5min and 10min after discontinuing hypotension, respectively.
  Results: During controlled hypotension, HR, CO, SV, PV and ACC were increased (P<0.05) in group A. In group B, CO and SV were increased, but HR, PV and ACC did no change sugnificantly. The dose of  SNP in group B was significant less than that in group A.
  Conclusion: Metoprolol could potentiate the hypotensive effect of  SNP, decrease the doses of SNP and maintain a stable hemodynamics during controlled hypotension.
  Key words: Sodium nitroprusside; Metoprolol; Controlled hypotention; Hemodynamics
  

      硝普钠(SNP)控制性降压起效快,作用强,复压迅速,不降低心输出量,但增快心率,甚至引起相对性心肌缺血[1]。美托洛尔(MET)为β1受体阻滞剂,可选择性抑制心脏β1受体,减慢心率。理论上两药合用可起到互补的作用。本研究采用经食道超声多普勒技术对比观察硝普钠或硝普钠复合美托洛尔控制性降压对血流动力学的影响,旨在为临床合理用药提供参考依据。
             资料和方法
   病例选择
:30例ASAⅠ~Ⅱ级无心肺疾患的择期颅脑手术病人,随机分为硝普钠组(A组)和硝普钠复合美托洛尔组(B组)。A组15例(男5例,女10例),年龄(40±8.9)岁,体重(63.8±10.5)kg, 身高(166.1±7.04)cm。B组15例(男8例,女7例),年龄 (40.1±9.8)岁,体重(67.1±11.5)kg, 身高(167.4±8.4)cm。所有病人均未用术前药及影响植物神经功能的药物。排除标准包括
ASA分级超过Ⅲ级;肝功能障碍(ALT/AST>40 unit /litre);肾功能不全(肌酐>1.mg/dl); 血红蛋白浓度小于12g/dl;高血压(收缩压>180mmHg 或舒张压>100mmHg,正在接受药物治疗;有心绞痛、心肌梗死的病史。<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" />

  麻醉方法: 依次静脉注射芬太尼2μg•kg-1维库溴铵0.1mg•kg-1异丙酚 2mg•kg-1 进行麻醉诱导。口咽和气管内表面麻醉后,暴露声门,先行气管插管,再放置食道超声多普勒探头。气管插管后接Ohmeda Excel 10型麻醉机和Ohmeda-7000呼吸机纯氧间隙正压控制通气。吸入异氟醚维持麻醉,控制性降压期间维持吸入1MAC异氟醚。调整通气参数使PetCO2保持在4.0-4.67kpa(30-35mmHg)。
  监测方法: 用多功能监测仪(SPACE LAB,USA)连续监测足背平均动脉压(MAP)、心率(HR)、心电图(ECG)、脉搏血氧饱和度(SpO2)。将无创血液动力监测仪(HEMOSONICTM 100,USA)与食道超声多普勒传感器连接,调节其深度(35-45cm)和角度,以便探测到最大的降主动脉直径和血流速度,连续监测血流峰速度(PV)、血流加速度(ACC)、左室射血时间(LVET)、每搏量(SV)、心输出量(CO),计算全身血管阻力(TSVR)。用气体浓度监测仪(Datex Ultima,芬兰)连续监测PetCO2、SpO2、呼气末异氟醚浓度。
  降压方法: 降压前配制0.02%硝普钠溶液(北京制药工业研究所实验药厂批号981222),避光,在剪开硬膜后,需行控制性降压时,A组用微量泵(英国产
Grasby)输注SNP B组先静注美托洛尔(山东鲁抗辰欣药业有限公司)0.04mg•kg-1 3-5分钟后再泵注SNP,初始量1.0-2μg•kg-1•min-1, 然后调节SNP泵入速度,将平均动脉压(MAP)降至并维持于7.33-8.0kPa (50-60mmHg)。不需降压时,停用降压药,使血压回升。降压期间根据出血量和尿量适当输液。分别于降压前、降压达目标时、维持降压5、15、30分钟、停降压5、10分钟、血压恢复时记录各参数。<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" />

  统计学处理: 所得数据用SPSS软件包进行统计学处理。组内比较用方差分析和配对t检验,组间比较以各参数与降压前的差值行t检验,P<0.05认为有显著性差异。
             结  果     
  两组年龄、身高、体重、维持降压时间、降压中输液速度(表1)均无统计学差异(p>0.05)。A、B组于开始输注SNP 3.7±1.7分钟和2.4±1.1分钟达到降压目标(表2),SNP的诱导用药量B组较A组减少50%,持续降压时间分别为55.3±40.3分钟和52.0±25.7分钟,SNP总用量分别为5.6±3.2mg和2.2±1.2mg,B组较A组减少60.7%。两组维持降压期间CO增加(A组20.8%-27.1%, B组3.4%-14.6%)、SV增加(A组2.9%-7.6%,B组11.4%-13.3%)、PV增加(A组18.1%-26.3%, B组5.2%-7.5%);A组ACC增加20.5%-41.0%, B组轻度下降8.7%-13.5%(P>0.05);两组LVET无显著性变化。A组HR增加20.5%-25.0%, B组维持稳定(-5.5%-2.1%);A和B组TSVR分别下降35%-39%和30%-36%。停降压后血压恢复时间平均3.9±3.9分钟和3.3±2.1分钟(表3)。 
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