非体外循环冠脉搭桥术后病人静脉自控镇痛对血液动力学和氧代谢的影响  

Effects of postoperative patient-controlled intravenous analgesia on hemodynamics and balance between oxygen delivery and consumption after off-pump coronary artery bypass grafting

作　　者：陆益斌[1] 彭章龙[1] 于布为[1] 

机构地区：[1]上海第二医科大学附属瑞金医院麻醉科,200025

出　　处：《中华麻醉学杂志》2004年第5期335-338,共4页Chinese Journal of Anesthesiology

摘　　要：目的 评价病人静脉自控镇痛(PCIA)对不停跳冠脉搭桥术后血液动力学和氧代谢的影响。方法 40例不停跳冠脉搭桥术后病人随机分为PCIA组和肌注镇痛组(IM组),每组20例。PCIA组镇痛药配方为吗啡100mg、咪唑安定0.03～0.06mg/kg和胃复安20mg,用生理盐水稀释至100ml。手术结束后开始镇痛,背景剂量1ml/h,PCA量1ml,锁定时间15min。IM组病人诉疼痛时,肌肉注射哌替啶50mg/次,间隔时间不少于6h。术后进行VAS评分,保留Swan-Ganz导管,以BaxterCCO监测仪监测血液动力学及混合静脉血氧饱和度(SvO_2),并计算全身氧代谢指标。结果 (1)术后16、24和40h,PCIA组VAS明显低于IM组(P<0.05)。(2)术后随时间延长,CO和CI均渐增加,两组间差异无显著性。术后24h和40h,PCIA组HR、MAP和SVR均明显低于IM组(P<0.05)。(3)两组间DO_2无差异。而PCIA组的VO_2和O_2ER明显低于IM组(P<0.01),SvO_2明显高于IM组(P<0.05)。结论病人静脉自控镇痛能为冠脉搭桥术后病人提供有效镇痛,减少血液动力学波动,同时改善全身氧供需平衡。Objective To compare the effects of patient-controlled intravenous analgesia (PCIA) and old- fashioned intramuscular dose of 50 mg pethidine every 6h for postoperative analgesia on hemodynamics and the balance between oxygen delivery (DO_2 ) and oxygen consumption (VO_2 ) after off-pump coronary artery bypass grafting (CABG). Methods Forty patients (27 male, 13 female) aged 52-79 yr weighing 54-86 kg undergoing off- pump CABG were enrolled in this study. Their preoperative cardiac functions were classified as New York Heart Association (NYHA) grade Ⅱ -Ⅳ and ejection fractions between 46%-57%. Anesthesia was induced with midazolam 3-5 mg, fentanyl 5-10μg·kg^(-1), propofol 0.5-1 .0 mg·kg^(-1) and vecuronium 0. 1 mg·kg^(-1) and maintained with isoflurane inhalation, continuous infusion of propofol (2-4 mg·kg^(-1)·h^(-1)) and intermittent i. v. boluses of fentanyl and vecuronium. A six-lumen Swan-Ganz catheter was inserted via right internal jugular vein and attached to a continuous cardiac output (CCO) monitor (Baxter Vigilance). The patients were randomly divided into 2 groups: PCIA group received a PCA solution containing morphine 100 mg, midazolam 0.03-0 .06 mg ·kg^(-1) and metoclopramide 20mg in 100 ml of normal saline with background infusion of 1 ml·h^(-1) and a bolus of 1ml with a 15 min lock-out interval (n = 20); IM group received pethidine 50 mg i. m. whenever VAS>5. The interval between two i. m. injections was>6 h (n = 20). Swan-Ganz catheter was left in place after surgry for 40 h. MAP, HR, ECG, cardiac output (CO), cardiac index (CI), PAP, PCWP, CVP, SVR, PVR and DO_2, VO_2, O_2-extraction rate (O_2 ER) were measured and/or calculated immediately after operation (T_1), 16 h (T_2 ), 24 h (T_3 ) and 40 h (T_4 ) after operation. Results VAS scores were significantly lower in PCIA group than those in IM group at T_(2, 3, 4) (P<0.05 ). CO and CI

关 键 词：非体外循环冠脉搭桥术 静脉自控镇痛 血液动力学 氧代谢 PCIA 氧消耗 

分 类 号：R614[医药卫生—麻醉学]