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Inflammatory response and changes in pulmonary function after myocardial revascularizafion with or without cardiopulmonaryt bypass

宋琳琳 王东信 吴新民 赵国立

SONG Lin－lin，WANG Dong－xin，Wu Xin－min，et al. Department of Anesthesiology，First Hospital，Peking University，Beijing 100034，China

Abstract

　　Objective：To compare the degree of inflammatory response and changes in pulmonary function in patients undergoing coronary artery bypass grafting （CABG） with or without cardiopulmonary bypass（CPB）

　　Methods：Elective CABG was performed in twenty－two patients with CPB（n＝11）or off－pump（n＝11）.The patients were premedicated with oral midazolamb 7.5mg and intramuscular morphine 10 mg.Anesthesia was induced with fentanyl 5－10μg/kg^－1， midazolam 0.05mg/kg^－1 etomidate 0.15 mg/kg^－1 and rocuroniunl 0.6 mg/kg^－1 and maintained with intermittentiv boluses of fentanyl and rocuronium. All patients had pulmonary artery catheter and arterial line placed. ECG，SpO₂，PεΤ C0₂，body temperature and urine output were monitored.In CPB group aprotinin was ven. The patients were transferred to ICU after operation and mechanically ventilated. Extubation was performed when standard extubation criteria were met. The length of ICU stay and hospitalization were recorded.CI，PVRI，SVRI，PA－α0₂，Pa0₂/Fi0₂ and Qs/QT were measured and calculated before and at the end of operation and 4，12，24，36h after operation. Blood samples were taken from radial artery and pulmonary artery（mixed venous blood）before and ate end of operation and 4，12，36h after operation for determination of plasma levels of IL－6，IL－8 and neutrophil elastance，the numbers of WBC and neutrophil，the numbers of WBC and neutrophil segregated in the lungs（the number of WBC/neutrophil in mixed venous blood－the number of WBC/neutrophil in arterial blood）.

　　Results：The two groups were comparable with respect to age，sex，duration of anesthesia and surgery and the num be r of grafts.CI was significantly increased while SVRI significantly decreased after operation as compared to the baseline values before operation. There was no significant diference in CI and SVRI after operation between the two groups. The postoperative PVRI and P_A­－αO₂ were significantly lower while postoperative PaO₂/FiO₂ was significantly higher in the off－pump group than in the CPB group（P<0.05 or 0.01）The postoperative plasma levels of IL－6 and neutrophil elastance were significantly lower in the off－pump group than in the CPB group. The numbers of WBC and neutrophil segregated in the lungs were significantly increased after operation compared to the baseline numbers before operation in the CPB group but not in the off－pump group. The duration ofmechan ical ventilation and endotracheal intubation were significantly longer in CPB group than in pump group.

　　Conclusion：Off－pump CABG is superirt CABG with CPB in terms finnarm at 0ry resp.I1se，postoperative pulmonary function and the length of ICU stay.<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" />

　　Key words：Cardiopulmonary nary bypass；Coronary artery bypass；Innarmatin mediatrs；Pulmonary exchange.

　　在体外循环（CPB）下进行心脏手术的病人常发生术后肺功能障碍，这可导致术后恢复延迟、住院时间延长、医疗费用增加，严重时甚至引起病人死亡^[1]。一般认为，CPB可触发炎性反应而引起术后肺功能障碍^[1，2]。为了避免CPB引起的不良影响，近年来在非CPB下进行冠脉搭桥术逐渐普及^[3]。最近的研究显示，与常规CPB下冠脉搭桥术相比，在非CPB下手术可减轻全身炎性反应，但并不能减轻术后肺功能损害的程度^[2，4～6]。对此，本研究拟比较在CPB或非CPB下冠脉搭桥术后炎性反应和肺功能变化。

资料和方法

　　病例选择与分组拟行冠脉搭桥术的病人22例，随机分为2组，分别在CPB(CPB组，n＝11)或非CPB(非CPB组/t＝11)下进行手术。病人入选标准：既往无慢性呼吸系统疾病、免疫系统疾病、糖尿病、急慢性肾功能衰竭、血液系统疾病和胸部手术史，术前6个月内无全身炎性疾病和心肌梗塞病史，术前左室射血分数>40％。

　　麻醉和手术 麻醉前1.5h口服咪唑安定7.5mg、0.5h肌肉注射吗啡10mg。两组病人均静脉注射芬太尼5～10kg、咪唑安定0.05mg/kg、依托咪酯0.15mg/kg和罗库溴铵0.6ms/kg行麻醉诱导；术中自主循环期间以异氟醚吸入和芬太尼、罗库溴铵间断静脉注射维持麻醉，CPB期间以异丙酚2～4mg/kg/h^-1持续输注和芬太尼、罗库溴铵间断静脉注射维持麻醉。常规监测心电图、脉搏血氧饱和度、桡动脉压、中心静脉压、肺动脉压、呼气末二氧化碳分压、体温、尿量等生理指标。术中自主循环期间以纯氧机械通气，维持动脉血二氧化碳分压35～45mmHg(1 mm Hg＝0.133kPa)；CPB期间以纯氧5cm H₂0(1cm H₂0＝0.098kPa)正压持续膨肺。

　　CPB组术中给予抑肽酶500万KIU(切皮前负荷量200万KIU静脉注射，CPB预充液中加入200万KIU，维持量100万KIU静脉输注)；乳内动脉分离完毕静脉注射肝素3mg/kg，CPB预冲液中加入肝素50mg，维持激活凝血时间>750S；CPB采用滚轴泵(Stockerr公司，德国)和一次性膜肺(Dideco公司，意大利)，流量2.5L/min^-1m^－2，维持体温>36^oC、平均动脉压60～80mmHg；主动脉阻断期间间断灌注冷血停跳液保护心肌。非CPB组术中不给予抑肽酶；静脉注射肝素1mg/kg，维持激活凝血时间>250S；维持体温>36^oC。两组术毕均静脉给予等量鱼精蛋白拮抗肝素使激活凝血时间恢复至术前水平。

　　术后监测 术毕病人带气管插管入监护室，PB7200呼吸机(Tyco公司，美国)辅助呼吸，呼气末正压为5cmH₂O，根据动脉血气结果调整吸入氧浓度和呼吸参数；维持动脉血氧分压80～100mmHg、动脉血二氧化碳分压35～45mm Hg。待病人神志清醒，体温恢复正常，循环稳定，自主呼吸潮气量>5ml/kg、呼吸频率<25次/min，暂停机械通气30min，动脉血气维持正常后拔除气管导管。由监护室医生决定病人转出监护室的时间，由病房医生决定病人的出院时间。

　　血液动力学和氧合指标测定分别于术前(诱导后，下同)、术毕和术后4、12、24、36h采用热稀释法测定心输出量(CMS 2002多功能监测仪，Agilent公司，美国)，抽取动脉血和混合静脉血行血气分析(OMNI 6血气分析仪，AVL公司，奥地利)，计算心脏指数(CI)、肺循环阻力指数(PVRI)、体循环阻力指数(SVRI)、肺泡－动脉血氧分压差(P_A－ａO₂：)、氧合指数(PaO₂/FiO₂)和肺内分流率(Q_s/Q_T)。

　　血浆炎性介质浓度测定 分别于术前、术毕和术后4、12h抽取动脉血4 ml置于EDTA真空采血管，即刻4℃ 2000r/min离心10min分离出血浆，移入EP管，(20℃低温保存。酶联免疫吸附法测定白介素(IL)－6、IL－8(试剂盒来自北京晶美生物工程有限公司)和中性粒细胞弹性蛋白酶(试剂盒来自Milenia Biotec公司，德国)浓度。测定数值以红细胞比容校正。

　　白细胞、中性粒细胞计数测定和肺隔离白细胞、中性粒细胞数量计算分别于术前、术毕和术后4、12、36h抽取动脉血和混合静脉血各2 ml置入EDTA真空采血管，测定白细胞和中性粒细胞计数(KX－21血细胞分析仪，Sysmex公司，日本)，计算肺隔离白细胞数(混合静脉血白细胞数一动脉血白细胞数)和肺隔离中性粒细胞数(混合静脉血中性粒细胞数一动脉血中性粒细胞数)。

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