硬膜外超前镇痛对老年高血压患者围术期心肌损伤的影响

摘要

Objective To compare the effects of pre-emptive epidural analgesia and postoperative epidural analgesia on perioperative myocardial injury in elderly hypertensive patients. Methods Sixty ASA Ⅱor Ⅲ patients with hypertension of Ⅱ degree aged >64 yr undergoing elective upper abdominal surgery were randomly divided into 2 groups (n=30 each): Ⅰpre-emptive epidural analgesia group (group P) and Ⅱpostoperative epidural analgesia group (group C).A mixture of 0.5 μg/ml sufentanil and 0.15% ropivacaine 250 ml was used for epidural analgesia in both group. The epidural catheter was placed at T7-8 interspace. The epidural regimen included a loading dose of 15 ml fol owed after 30 min by continuous epidural influsion at 5 ml/h for 50 h .In group P the epidural analgesia was started at 20 min before skin incision ,while in group C after operation when the patients emerged from general anesthesia and were extubated. BIS was maintained at 40-60.The changes in ST segment were recorded before anesthesia,after intubation and surgical exploration and immediately after extubation. Myocardial ischemia was defined as ST segment depression≥0.1mV for more than 1 min.Blood samples were obtained from peripheral vein of upper limb,before anesthesia (T0),1 h after skin incision (T1),at the end of operation (T2) and 6,24 h after operation (T3-4) for determination of plasma CK-MB activity and plasma concentrations of cTnI and CRP. Results The ST segment depression was singnificantly deeper after extubation in group C than in group P. The plasma CK-MB activity and concentrations of cTnI and CRP were singnificantly increased after operation as compared with the baseline values at T0. The plasma levels of cTnI and CRP were singnificantly higher in group C than in group P at 6,24 h after operation. Conclusion Pre-emptive epidural analgesia can more effectively inhibit stress response than postoperative epidural analgesia to upper abdominal surgery in elderly hypertensive patients,and may have a protection on myocardium.%目的：比较硬膜外超前镇痛与术后硬膜外镇痛对老年高血压患者围术期心肌损伤的影响。方法择期全麻下拟行上腹部手术的老年患者60例，随机分为术后硬膜外镇痛组（C组）和硬膜外超前镇痛组（P组）。于T7，8椎间隙行硬膜外穿刺并置管。 P组于切皮前硬膜外注射0.5μg/mL舒芬太尼＋0.15%罗哌卡因混合液15 mL，30 min后接镇痛泵，以5 mL/h的速率硬膜外输注250 mL。C组患者术后硬膜外注射混合液15 mL，30 min后接镇痛泵，以5 mL/h的速率硬膜外输注250 mL。分别记录不同时段心电图ST段水平和血浆心肌肌酸激酶同工酶（CK-MB）、心肌肌钙蛋白（cTnI）和C反应蛋白（CRP）的浓度。结果术毕拔出气管导管后C组ST段水平明显低于P组(P＜0.05)，与麻醉前比较，术后6 h、24 h各组血浆CRP及术毕至术后24 h血浆cTnI浓度、CK-MB活性明显升高(P＜0.05)；P组术后6 h、24 h血浆cTnI和CRP浓度明显低于C组(P＜0.05)。结论与术后硬膜外镇痛相比，硬膜外超前镇痛可更好地抑制上腹部手术后应激反应，对老年高血压患者围术期心肌损伤有一定的保护作用。