Minami K, Körner M M, Vyska K, Kleesiek K, Knobl H, Körfer R
Department of Thoracic and Cardiovascular Surgery, Heart Center North Rhine-Westphalia, Bad Oeynhausen, Federal Republic of Germany.
J Thorac Cardiovasc Surg. 1990 Jan;99(1):82-91.
Thirty patients scheduled for elective coronary artery bypass grafting were studied in two groups. Group A had standard cardiopulmonary bypass with nonpulsatile perfusion and group B had pulsatile perfusion. Measurements of plasma epinephrine, norepinephrine, granulocyte elastase, and hemodynamic parameters including mean arterial pressure total peripheral resistance, cardiac index, and pulmonary capillary wedge pressure were made before and after anesthesia induction, after surgical incision, during cardiopulmonary bypass, and 2, 4, and 24 hours after the operation. The venous compliance of the total body venous bed was measured at the end of the operation. In all patients the total net fluid balance was determined during bypass and in the postoperative period. In both groups plasma catecholamine levels increased 5 minutes after institution of bypass (epinephrine 176 +/- 56 to 611 +/- 108 pg/ml and norepinephrine 231 +/- 48 to 518 +/- 100 pg/ml in group A; epinephrine 168 +/- 40 to 444 +/- 100 pg/ml and norepinephrine 162 +/- 44 to 267 +/- 52 pg/ml in group B). The maximum catecholamine level was measured between the end of bypass and 2 hours after the end of bypass (epinephrine 1489 +/- 169 pg/ml and norepinephrine 1542 +/- 108 pg/ml in group A; epinephrine 990 +/- 134 pg/ml and norepinephrine 934 +/- 197 pg/ml in group B). During the same period mean arterial pressure and total peripheral resistance were also significantly higher in group A than in group B mean arterial pressure, 61.4 +/- 3 versus 53.6 +/- 3, p less than 0.06; total peripheral resistance, 1055 +/- 60 versus 899 +/- 45, p less than 0.01). The venous compliance was significantly higher in group A than in group B (2.4 +/- 0.3 versus 1.2 +/- 0.3 ml/mm Hg/kg body weight). The intraoperative and perioperative net fluid balance were significantly higher in group A than in group B (p less than 0.005). The average postoperative tracheal intubation time was also significantly longer in group A than in group B (4.6 +/- 1.2 hours versus 2.7 +/- 0.8 hours, p less than 0.001). No significant difference was detected in either hemoglobin or plasma free hemoglobin content between the two groups postoperatively. The results suggest that pulsatile perfusion, when compared with nonpulsatile perfusion, can attenuate the catecholamine stress response to cardiopulmonary bypass, reduce the fluid overloading of patients, and improve the postoperative recovery period as evaluated by tracheal intubation time.
30例计划行择期冠状动脉搭桥术的患者被分为两组进行研究。A组采用标准的非搏动性灌注心肺转流，B组采用搏动性灌注。在麻醉诱导前、手术切口后、心肺转流期间以及术后2小时、4小时和24小时，分别测量血浆肾上腺素、去甲肾上腺素、粒细胞弹性蛋白酶以及包括平均动脉压、总外周阻力、心脏指数和肺毛细血管楔压在内的血流动力学参数。在手术结束时测量全身静脉床的静脉顺应性。在所有患者中，均测定了心肺转流期间和术后的总净液体平衡。两组患者在开始心肺转流5分钟后血浆儿茶酚胺水平均升高（A组肾上腺素从176±56 pg/ml升至611±108 pg/ml，去甲肾上腺素从231±48 pg/ml升至518±100 pg/ml；B组肾上腺素从168±40 pg/ml升至444±100 pg/ml，去甲肾上腺素从162±44 pg/ml升至267±52 pg/ml）。儿茶酚胺的最高水平在心肺转流结束至结束后2小时之间测得（A组肾上腺素为1489±169 pg/ml，去甲肾上腺素为1542±108 pg/ml；B组肾上腺素为990±134 pg/ml，去甲肾上腺素为934±197 pg/ml）。在同一时期，A组的平均动脉压和总外周阻力也显著高于B组（平均动脉压，61.4±3与53.6±3，p<=0.06；总外周阻力，1055±60与899±45，p<0.01）。A组的静脉顺应性显著高于B组（2.4±0.3与1.2±0.3 ml/mm Hg/kg体重）。A组术中及围手术期的净液体平衡显著高于B组（p<0.005）。A组术后平均气管插管时间也显著长于B组（4.6±1.2小时与2.7±0.8小时，p<0.001）。两组术后血红蛋白或血浆游离血红蛋白含量均未检测到显著差异。结果表明，与非搏动性灌注相比，搏动性灌注可减轻心肺转流时的儿茶酚胺应激反应，减少患者的液体超负荷，并通过气管插管时间评估改善术后恢复期。
