1、    不同術前藥的冠心病病人術中冠脈搭橋前 入液量對血流動力學的影響        摘要將80例冠脈搭橋病人隨機雙盲分為：A組(對照組，n=40)；B組(試驗組，n=40)。A組術前1 h口服安定10 mg、術前30 min肌注嗎啡0.150.2 mg/kg和東莨菪堿0.3 mg。B組術前藥增加口服氨酰心安6.2512.5 mg及硫氮唑酮30 mg。分別觀察體外循環(CPB)前2組病人在不同入液量下的各項血流動力學指標。A組與B組病人誘導后靜脈入液量分別為652.

2、5 ml及657.5 ml；開胸前分別為1116.3 ml及1070.0 ml，明顯高于誘導后靜脈入液量(P0.01)；CPB前分別為1711.3 ml及1715.0 ml，顯著高于誘導后和開胸前的靜脈入液量(P0.01)。與麻醉誘導后比較，開胸前A組與B組病人的各項血流動力學參數均無顯著差異(P0.05)。與麻醉誘導后和開胸前比較，CPB前A組病人SBP明顯下降(P0.05和P0.01)；DBP明顯降低(P0.01)；MAP明顯低于開胸前(P0.01)；HR明顯高于誘導后(P0.05)；CO及CI明顯增高(P0.05)；SVR及SVRI明顯降低(P0.01)。CPB前B組病人SBP明顯低于開

3、胸前(P0.01)；DBP明顯降低(P0.05和P0.01)；MAP明顯下降(P0.05和P0.01)；HR明顯高于誘導后(P0.01)；SVR及SVRI明顯降低(P0.05)。當入液量增加到一定量時，SVR及SVRI明顯降低、血壓下降、HR增快、CO及CI增高(A組明顯)，2組病人變化趨勢相同。麻醉誘導前用氨酰心安和硫氮唑酮不影響體循環和肺循環對入液量改變的反應，不抑制心功能對增加入液量的反應。關鍵詞入液量術前藥氨酰心安硫氮唑酮血流動力學心功能 The Influence of Liquid Intake via Intravenous on the Hemodynamics of Pati

4、ents Undergoing Coronary Artery Graft with Different PremedicantsZhao Xiaoqin,Zhang JieDe(partment of Anesthesiology,Cardiovascular Institute and Fuwai Hospital,CAMS and PUMC,Beijing 100037)AbstractTo study the influence of liquid intake via intravenous before coronary artery graft on the hemodynami

5、cs of patients with different premedicants.Eighty patients undergoing coronary artery graft were randomly divided into two groups:In group A,oral diazepam 10 mg,morphine 0.150.2 mg/kg IM and scopolamine 0.3 mg IM as premedicants.In group B,oral diazepam 10 mg,atenolol 6.2512.5 mg and diltiazem 30 mg

6、,morphine 0.150.2 mg/kg IM and scopolamine 0.3 mg IM as premedicants.The hemodynamics were measured after intubation,before opening chest and before cardiopulmonary bypass(CPB) in group A and group B.The liquid intake via IV were 652.5 ml and 657.5 ml after intubation respectively in group A and gro

7、up B.Before opening chest,the liquid intake via IV were 1116.3 ml and 1070.0 ml respectively in group A and group B,It were significantly different from the liquid intake via IV after intubation (P0.01).Before CPB,the liquid intake via IV were significant higher in group A(1711.3 ml,P0.01)and in gro

8、up B(1715.0 ml,P0.01)than the liquid intake of after intubation.Before opening chest,there were no significant different on hemodynamics from after intubation in group A and group B(P0.05).In group A,before CPB the SBP was lower than after intubation(P0.05)and before opening chest (P0.01).Compared w

9、ith after intubation and before opening chest the DPB,SVR and SVRI were significant low(P0.01).The MAP were significant lower than before opening chest(P0.01).The HR was higher than after intubation(P0.05).The CO and CI were significant higher than after intubation and before opening chest(P0.05).In

10、 group B,before CPB the SBP was significant lower than before opening chest(P0.01).The DBP and MAP were lower compared with after intubation(P0.05) and before opening chest(P0.01).The HR was significant higher than after intubation (P0.01).Compared with after intubation and before opening chest,the

11、SVR and SVRI decreased significantly at before CPB(P0.05).When the liquid intake was enough,the BP,SVR and SVRI decreased significantly.The HR,CO and CI increased significantly.The change of hemodynamics at different liquid intake was no different in group A and group B.Key words：Liquid intake;Preme

12、dicant;Atenolol;Diltiazem;Hemodynamics;Cardiac function氨酰心安為選擇性1-受體阻滯劑，而硫氮唑酮為鈣通道阻滯劑。將氨酰心安和硫氮唑酮作為術前依賴該類藥物進行調節的冠脈搭橋患者的術前藥，雖可避免麻醉誘導前的心絞痛發作，但是否會對靜脈入液量改變引起的心功能和血流動力學反應產生明顯影響?本文對80例冠脈搭橋患者進行了研究，了解不同術前用藥的冠心病病人，術中靜脈入液量改變對心功能和血流動力學的影響。資料與方法80例行冠脈搭橋手術患者隨機雙盲法分為A組(對照組)及B組(試驗組)。A組麻醉誘導前1 h常規口服安定10 mg，誘導前30 min肌注嗎啡

13、0.150.2 mg/kg和東莨菪堿0.3 mg。B組除常規術前用藥外，誘導前1 h還增加口服氨酰心安6.2512.5 mg及硫氮唑酮30 mg。2組病人入室后均面罩吸氧，監測心電(ECG)、脈搏血氧飽和度(SpO2)，局麻下開放上肢靜脈及行橈動脈穿刺置管監測動脈壓。靜脈注射咪唑安定0.1 mg/kg或依托咪酯0.2 mg/kg、芬太尼20 ug/kg、哌庫溴胺0.10.15 mg/kg行麻醉誘導插管。穿刺頸內靜脈放置7.5F特制漂浮導管(Baxter CCO-SvO2)，用Space Lab多功能監測儀監測病人ECG、動脈壓、中心靜脈壓(CVP)、肺動脈壓(PAP)、肺毛細血管嵌頓壓(PCW

14、P)。用連續心排血量監測儀(CCO-Baxter Vigilance)連續動態監測心排血量(CO)及混合靜脈血氧飽和度。于麻醉誘導后、開胸前、體外循環(CPB)前三個階段分別記錄A組及B組病人的靜脈入液量和記錄及計算各項血流動力學參數。采用方差分析和t檢驗分別統計處理2組病人的入液量和各項血流動力學指標的動態改變。P0.05為統計學上有顯著差異，P0.01為差異非常顯著。結果2組病人的一般情況見表1。組間無顯著差異。表1病人一般情況A組B組例數(n)4040年齡(歲)55.6±7.554.7±8.5體重(kg)69.8±6.971.7±6.7A組與B組病

15、人誘導后靜脈入液量分別為652.5 ml及657.5 ml(均<10 ml/kg)；開胸前分別為1116.3 ml及1070.0 ml(約為15 ml/kg)，明顯高于誘導后靜脈入液量(P0.01)；CPB前分別為1711.3 ml及1715.0 ml(約24 ml/kg)，顯著高于誘導后和開胸前的靜脈入液量(P0.01)。與麻醉誘導后比較，A組與B組病人開胸后的血流動力學參數，包括體循環(SBP、DBP、HR、CUP、SVR、SVRI)、肺循環(MPAP、PVR、PVRI、PCWP)和心臟作功(CO、CI、SV、SVI、LVSWI、RVSWI)均無顯著差異(P0.05)。A組病人CPB

16、前SBP明顯低于誘導后，(P0.05)和開胸前(P0.01)；DBP明顯低于誘導后(P0.01)和開胸前(P0.01)；MAP明顯低于開胸前(P0.01)；HR明顯高于誘導后(P0.05)；CO及CI(P0.01)明顯高于誘導后(P0.05)和開胸前(P0.05)；SVR及SVRI明顯低于誘導后(P0.01)和開胸前(P0.01)。其他血流動力學參數動態變化不顯著。表2A組病人血流動力學參數誘導后開胸前CPB前入液量(ml)652.5±271.5*#1116.3±310.6#1711.3±512.0SBP(mmHg)116.9±18.2#118.6

17、77;13.6#108.8±13.5DBP(mmHg)66.5±8.9#65.1±8.4#59.8±8.2MAP(mmHg)83.0±12.884.9±9.7#78.2±9.3HR(bpm)49.8±6.8#51.8±7.953.9±8.8CVP(mmHg)4.8±2.55.9±2.54.9±2.3CO(L/min)3.4±0.8 #3.4±0.6#3.8±0.7CI(L/min/m2)1.9±0.5#1.9±0.4

18、#2.1±0.4SVR(dn-s/cm51899.1±483.8#1911.2±407.3#1616.4±375.0SVRI(dn-s-m2/cm5)3425.2±908.2#3424.2±722.9#2914.3±697.1PVR(dn-s/cm5)119.3±46.5130.6±69.8124.3±54.3PVRI(dn-s-m2/cm5)212.5±85.0217.7±86.9221.8±97.4SV(ml/b)70.8±17.968.6±

19、16.670.5±13.1SVI(ml/b/m2)39.4±9.538.2±8.239.6±7.3LVSWI(g-m/m2/b)39.4±12.238.7±9.336.8±7.9RVSWI(g-m/m2/b)5.0±2.75.0±2.45.7±2.6MPAP(mmHg)13.9±4.215.2±4.815.3±4.8PCWP(mmHg)9.3±3.610.2±3.79.7±3.3(%)77.0±5.479.4±5.8

20、80.4±5.7注：SBP收縮壓DBP舒張壓MAP平均動脈壓HR心率CVP中心靜脈壓CO心輸出量CI心臟指數SVR外周血管阻力SVRI外周血管阻力指數PVR肺血管阻力PVRI肺血管阻力指數SV心臟每搏量SVI心臟每搏量指數LVSWI左室作功指數RVSWI右室作功指數MPAP平均肺動脈壓PCWP肺毛細血管嵌頓壓混合靜脈血氧飽和度與開胸前比較*P0.01與CPB前比較#P0.05#P0.01 表3B組病人血流動力學參數誘導后開胸前CPB前入液量(ml)657.5±254.3*#1070.0±338.0#1715.0±464.1SBP(mmHg)116.2&#

21、177;16.8119.4±12.4#110.9±11.4DBP(mmHg)65.5±8.6#67.4±7.4#61.7±6.8MAP(mmHg)84.0±10.8#85.6±9.1#79.2±7.8HR(bpm)48.8±5.4#50.0±7.352.4±6.3CVP(mmHg)5.7±2.46.4±2.16.0±2.4CO(L/min)3.4±0.8 3.4±0.73.7±0.8CI(L/min/m2)1.9±0

22、.41.9±0.42.1±0.4SVR(dn-s/cm5)1905.5±530.2#1895.0±504.8#1628.5±423.1SVRI(dn-s-m2/cm5)3394.0±943.9#3405.6±900.1#2943.9±744.6PVR(dn-s/cm5)121.4±47.4124.2±50.0129.0±51.9PVRI(dn-s-m2/cm5)217.3±86.6222.5±91.1228.2±93.0SV(ml/b)70.9±

23、18.170.1±15.071.4±13.9SVI(ml/b/m2)38.5±8.338.9±8.640.1±8.0LVSWI(g-m/m2/b)39.6±11.939.0±8.437.9±8.7RVSWI(g-m/m2/b)4.7±2.54.6±1.85.1±1.9MPAP(mmHg)14.2±3.415.1±3.015.4±2.8PCWP(mmHg)9.3±2.910.0±2.59.8±2.2(%)76.0±4.

24、976.9±6.879.2±6.6注：與開胸前比較*P0.01，與CPB前比較#P0.05，#P0.01 B組病人CPB前SBP明顯低于開胸前(P0.01)；DBP明顯低于誘導后(P0.05)和開胸前(P0.01)；MAP明顯低于誘導后(P0.05)和開胸前(P0.01)；HR明顯高于誘導后(P0.01)；SVR及SVRI明顯低于誘導后(P0.05)和開胸前(P0.05)。其他血流動力學參數動態變化不顯著。討論A組和B組病人入液量從<10 ml/kg增至15 ml/kg，各項血流動力學參數并未改變。2組病人當靜脈入液量達到24 ml/kg時，使由于因血容量不足引起的外周血管收縮(SVR及SVRI明顯高于正常)解除，外周血管阻力明顯下降(A組P0.01，B組P0.05)以接近正常。此時血壓(包括SBP、DBP和MAP)明顯下降(P0