冠状动脉旁路移植术（CABG）手术期间的内分泌应激反应和炎症激活。一项比较瑞芬太尼输注与间断芬太尼的随机试验。

Endocrine stress response and inflammatory activation during CABG surgery. A randomized trial comparing remifentanil infusion to intermittent fentanyl.

作者信息

Winterhalter M, Brandl K, Rahe-Meyer N, Osthaus A, Hecker H, Hagl C, Adams H A, Piepenbrock S

机构信息

Hannover Medical School, Department of Anaesthesiology, Hannover, Germany.

出版信息

Eur J Anaesthesiol. 2008 Apr;25(4):326-35. doi: 10.1017/S0265021507003043. Epub 2007 Nov 16.

DOI:10.1017/S0265021507003043

PMID:18005471

Abstract

BACKGROUND AND OBJECTIVE

Our aim was to compare a continuous infusion of remifentanil with intermittent boluses of fentanyl as regards the perioperative hormonal stress response and inflammatory activation in coronary artery bypass graft patients under sevoflurane-based anaesthesia.

METHODS

In all, 42 patients undergoing coronary artery bypass grafting with cardiopulmonary bypass were prospectively randomized to a fentanyl group (n = 21, total fentanyl dose 2.6 +/- 0.3 mg), or a remifentanil group (n = 21, infusion rate 0.25 microg kg(-1) min(-1)). Haemodynamics, plasma levels of epinephrine, norepinephrine, antidiuretic hormone, adrenocorticotropic hormone, cortisol, complement activation (C3a, C5b-9), interleukin (IL)-6, IL-8 and tumour necrosis factor-alpha were measured at T1: baseline, T2: intubation, T3: sternotomy, T4: 30 min on cardiopulmonary bypass, T5: end of surgery and T6: 8 h postoperatively. Troponin T and creatine kinase-MB were measured postoperatively.

RESULTS

Patients in the remifentanil group were extubated significantly earlier than fentanyl patients (240 +/- 182 min vs. 418 +/- 212 min, P = 0.006). Stress hormones 30 min after start of cardiopulmonary bypass showed higher values in the fentanyl group compared to the remifentanil group (antidiuretic hormone (ADH): 39.94 +/- 30.98 vs. 11.7 +/- 22.8 pg mL(-1), P = 0.002; adrenocorticotropic hormone: 111.5 +/- 116.8 vs. 21.81 +/- 24.71 pg mL(-1), P = 0.01; cortisol 185 +/- 86 vs. 131 +/- 82 ng mL(-1), P = 0.04). The interleukins were significantly higher at some perioperative time points in the fentanyl group compared to the remifentanil group (tumour necrosis factor: T5: 3.57 vs. 2.37; IL-6: T5: 4.62 vs. 3.73; and IL-8: T5: 4.43 vs. 2.65 and T6: 2.61 vs. 1.13). However, cardiopulmonary bypass times and aortic cross-clamp times were longer in the fentanyl group, which may to some extent account for the differences.

CONCLUSIONS

The perioperative endocrine stress response was attenuated in patients supplemented with continuous remifentanil infusion as compared to intermittent fentanyl.

摘要

背景与目的

我们的目的是比较在基于七氟醚的麻醉下，持续输注瑞芬太尼与间断推注芬太尼对冠状动脉搭桥手术患者围手术期激素应激反应和炎症激活的影响。

方法

总共42例接受体外循环冠状动脉搭桥手术的患者被前瞻性随机分为芬太尼组（n = 21，芬太尼总剂量2.6±0.3 mg）或瑞芬太尼组（n = 21，输注速率0.25μg·kg⁻¹·min⁻¹）。在T1：基线、T2：插管、T3：胸骨切开、T4：体外循环30分钟、T5：手术结束和T6：术后8小时测量血流动力学、血浆肾上腺素、去甲肾上腺素、抗利尿激素、促肾上腺皮质激素、皮质醇、补体激活（C3a、C5b - 9）、白细胞介素（IL）-6、IL - 8和肿瘤坏死因子-α水平。术后测量肌钙蛋白T和肌酸激酶-MB。

结果

瑞芬太尼组患者拔管时间明显早于芬太尼组患者（240±182分钟对418±212分钟，P = 0.006）。体外循环开始30分钟后，芬太尼组的应激激素水平高于瑞芬太尼组（抗利尿激素（ADH）：39.94±30.98对11.7±22.8 pg·mL⁻¹，P = 0.002；促肾上腺皮质激素：111.5±116.8对21.81±24.71 pg·mL⁻¹，P = 0.01；皮质醇185±86对131±82 ng·mL⁻¹，P = 0.04）。在围手术期的一些时间点，芬太尼组的白细胞介素水平明显高于瑞芬太尼组（肿瘤坏死因子：T5：3.57对2.37；IL - 6：T5：4.62对3.73；IL - 8：T5：4.43对2.65和T6：2.61对1.13）。然而，芬太尼组的体外循环时间和主动脉阻断时间更长，这在一定程度上可能解释了这些差异。