Loick H M, Schmidt C, Van Aken H, Junker R, Erren M, Berendes E, Rolf N, Meissner A, Schmid C, Scheld H H, Möllhoff T
Klinik und Poliklinik für Anästhesiologie und operative Intensivmedizin, Westfälische Wilhelms-Universität Münster, Germany.
Anesth Analg. 1999 Apr;88(4):701-9. doi: 10.1097/00000539-199904000-00001.
In this prospective study, we evaluated whether high thoracic epidural anesthesia (TEA) or i.v. clonidine, in addition to general anesthesia, affects the cardiopulmonary bypass- and surgery-associated stress response and incidence of myocardial ischemia by their sympatholytic properties. Seventy patients scheduled for elective coronary artery bypass graft (CABG) received general anesthesia with sufentanil and propofol. TEA was randomly induced before general anesthesia and continued during the study period in 25 (anesthetized dermatomes C6-T10). Another 24 patients received i.v. clonidine as a bolus of 4 microg/kg before the induction of general anesthesia. Clonidine was then infused at a rate of 1 microg x kg(-1) x h(-1) during surgery and at 0.2-0.5 microg x kg(-1) x h(-1) postoperatively. The remaining 21 patients underwent general anesthesia as performed routinely (control). Hemodynamics, plasma epinephrine and norepinephrine, cortisol, the myocardial-specific contractile protein troponin T, and other cardiac enzymes were measured pre- and postoperatively. During the preoperative night and a follow-up of 48 h after surgery, five-lead electrocardiogram monitoring was used for ischemia detection. Both TEA and clonidine reduced the postoperative heart rate compared with the control group without jeopardizing cardiac output or perfusion pressure. Plasma epinephrine increased perioperatively in all groups but was significantly lower in the TEA group. Neither TEA nor clonidine affected the increase in plasma cortisol. The release of troponin T was attenuated by TEA. New ST elevations > or = 0.2 mV or new ST depression > or = 0.1 mV occurred in > 70% of the control patients but only in 40% of the clonidine group and in 50% of the TEA group. We conclude that TEA (but not i.v. clonidine) combined with general anesthesia for CABG demonstrates a beneficial effect on the perioperative stress response and postoperative myocardial ischemia.
Thoracic epidural anesthesia combined with general anesthesia attenuates the myocardial sympathetic response to cardiopulmonary bypass and cardiac surgery. This is associated with decreased myocardial ischemia as determined by less release of troponin T. These findings may have an impact on the anesthetic management for coronary artery bypass grafting.
在这项前瞻性研究中，我们评估了除全身麻醉外，高位胸段硬膜外麻醉（TEA）或静脉注射可乐定是否因其抗交感神经特性而影响体外循环和手术相关的应激反应以及心肌缺血的发生率。70例计划行择期冠状动脉搭桥术（CABG）的患者接受了舒芬太尼和丙泊酚全身麻醉。25例患者（麻醉皮节为C6 - T10）在全身麻醉前随机诱导TEA并在研究期间持续使用。另外24例患者在全身麻醉诱导前静脉注射4μg/kg的可乐定推注剂量。然后在手术期间以1μg·kg⁻¹·h⁻¹的速率输注可乐定，术后以0.2 - 0.5μg·kg⁻¹·h⁻¹的速率输注。其余21例患者按常规进行全身麻醉（对照组）。术前和术后测量血流动力学、血浆肾上腺素和去甲肾上腺素、皮质醇、心肌特异性收缩蛋白肌钙蛋白T以及其他心脏酶。在术前一晚和术后48小时的随访期间，使用五导联心电图监测检测缺血情况。与对照组相比，TEA和可乐定都降低了术后心率，且不影响心输出量或灌注压。所有组围手术期血浆肾上腺素均升高，但TEA组显著较低。TEA和可乐定都不影响血浆皮质醇的升高。TEA减轻了肌钙蛋白T的释放。对照组超过70%的患者出现新的ST段抬高≥0.2 mV或新的ST段压低≥0.1 mV，而可乐定组仅40%，TEA组为50%。我们得出结论，TEA（而非静脉注射可乐定）联合全身麻醉用于CABG对围手术期应激反应和术后心肌缺血具有有益作用。
胸段硬膜外麻醉联合全身麻醉可减轻心肌对体外循环和心脏手术的交感神经反应。这与肌钙蛋白T释放减少所确定的心肌缺血减少有关。这些发现可能会对冠状动脉搭桥术的麻醉管理产生影响。
