Kirov M Y, Lenkin A I, Kuzkov V V, Suborov E V, Slastilin V Y, Borodin V V, Chernov I I, Shonbin A N, Bjertnaes L J
Department of Anaesthesiology and Intensive Care Medicine, Northern State Medical University, Arkhangelsk, Russian Federation.
Acta Anaesthesiol Scand. 2007 Apr;51(4):426-33. doi: 10.1111/j.1399-6576.2006.01247.x.
Off-pump coronary artery bypass grafting (OPCAB) can be associated with severe cardiovascular changes, thus requiring advanced haemodynamic monitoring. Our aim was to investigate the feasibility of transpulmonary single thermodilution (STD) combined with pulse-contour analysis, a newly introduced method for cardiovascular monitoring, for assessment of changes in haemodynamics during different anaesthetic techniques in OPCAB.
Thirty-six patients scheduled for elective OPCAB were randomized to receive anaesthesia either with midazolam, propofol or isoflurane, in addition to fentanyl and pipecuronium. After catheterization of the femoral artery, haemodynamic parameters were assessed using STD and pulse-contour analysis. The measurements were performed after induction of anaesthesia, during surgery and at 2, 4 and 6 h post-operatively.
At the end of surgery, the global ejection fraction decreased by 29% and 19% in the midazolam and the propofol groups, respectively, (P < 0.05) but remained unchanged in the isoflurane group. Moreover, in the isoflurane group, the left ventricular contractility index was higher and the mean arterial pressure (MAP) and the systemic vascular resistance index (SVRI) decreased in comparison with pre-operative values. Post-operatively, the cardiac index (CI) and the cardiac function index (CFI) increased in all groups (P < 0.05). The peri-operative requirement for ephedrine and nitroglycerin increased in the propofol and the midazolam groups, respectively (P < 0.05).
During OPCAB, STD and pulse-contour analysis displayed changes in preload, myocardial function and afterload that gave valuable guidance for the conduct of anaesthesia, fluid management, and the administration of vasoactive agents. As assessed using STD, isoflurane within the present dose range appears to maintain myocardial performance and vascular tone better than midazolam or propofol.
非体外循环冠状动脉旁路移植术（OPCAB）可能伴有严重的心血管变化，因此需要先进的血流动力学监测。我们的目的是研究经肺单次热稀释法（STD）联合脉搏轮廓分析（一种新引入的心血管监测方法）在评估OPCAB中不同麻醉技术期间血流动力学变化方面的可行性。
36例计划行择期OPCAB的患者被随机分为接受咪达唑仑、丙泊酚或异氟醚麻醉，同时给予芬太尼和哌库溴铵。股动脉插管后，使用STD和脉搏轮廓分析评估血流动力学参数。测量在麻醉诱导后、手术期间以及术后2、4和6小时进行。
手术结束时，咪达唑仑组和丙泊酚组的整体射血分数分别下降了29%和19%（P<0.05），而异氟醚组保持不变。此外，与术前值相比，异氟醚组的左心室收缩指数更高，平均动脉压（MAP）和全身血管阻力指数（SVRI）降低。术后，所有组的心脏指数（CI）和心功能指数（CFI）均升高（P<0.05）。丙泊酚组和咪达唑仑组围手术期麻黄碱和硝酸甘油的需求量分别增加（P<0.05）。
在OPCAB期间，STD和脉搏轮廓分析显示了前负荷、心肌功能和后负荷的变化，为麻醉实施、液体管理和血管活性药物的给药提供了有价值的指导。使用STD评估，在当前剂量范围内，异氟醚似乎比咪达唑仑或丙泊酚能更好地维持心肌性能和血管张力。
