摘要：
Objective To investigate the effects of remifentanil combined with propofol on hemodynamics,inflammatory stress response and immune function in patients with acute abdomen complicated with septic shock.Methods From June 2017 to August 2018,112 patients with acute abdomen complicated with septic shock who admitted to the First Affiliated Hospital of Xiamen University were enrolled in the study.They were randomly divided into observation group and control group according to the digital table,with 56 cases in each group.The control group was anesthetized with sevoflurane combined with propofol.The observation group was anesthetized with remifentanil combined with propofol.The hemodynamic parameters of the patients entering the operating room(T0),0.5h(T1),1h (T2) and awake (T3) after anesthesia were recorded.The intraoperative norepinephrine dosage was recorded.The inflammatory response,stress response and immune function indicators at T0,T2 and T3 were recorded.Results Compared with T0,T1 and T2,the MAP of the two groups was higher at T3,and the differences were statistically significant(tcontrol group =4.834,4.484,5.378,tobservation group =6.420,7.006,6.152,all P ＜0.05).Compared with T0,the HR of the two groups was higher at T3,and the differences were statistically significant (tcontrol group =5.943,tobservation group =7.722,all P ＜ 0.05).Compared with T1 and T2,CO of the two groups was higher at T3,and the differences were statistically significant (tcontrol group =4.276,2.262,tobservation group =6.318,5.132,all P ＜ 0.05).There were no statistically significant differences in MAP,HR and CO between the two groups at T0,T1,T2 and T3 (all P ＞0.05).The doses of norepinephrine in the observation group and the control group were (1 587.7 ± 287.5) μg and (1 937.9 ±397.6) μg,respectively,and the difference was statistically significant(t =5.341,P ＜0.05).The serum levels of C reactive protein(CRP),tumor necrosis factor alpha(TNF-α) and interleukin 6 (IL-6) increased with time in the two groups,and the differences were statistically significant(tcontrol group =17.06,36.13,19.07,3.822,9.466,2.874,14.18,26.87,16.21,tobservation group =11.72,20.79,11.01,2.810,6.559,3.716,10.52,24.56,17.64,all P ＜ 0.05).At T2 and T3,the serum levels of CRP,TNF-α and IL-6 in the observation group [T2:CRP (89.63 ±17.65) mg/L,TNF-α (51.16 ± 10.16) ng/L,IL-6 (34.26 ± 6.25) ng/L,T3:CRP (136.15 ±26.25) mg/L,TNF-α (58.64 ± 11.12)ng/L,IL-6 (67.56 ± 12.67)ng/L] were lower than those in the control group[T2:CRP (112.15 ±22.34) mg/L,TNF-α (59.56 ± 11.58) ng/L,IL-6 (42.65 ± 8.37) ng/L,T3:CRP (175.16 ±34.75) mg/L,TNF-α (65.79 ± 11.35) ng/L,IL-6 (79.02 ± 14.56) ng/L],the differences were statistically significant (t =5.919,6.703,4.080,3.367,6.010,4.443,all P ＜ 0.05).Compared with T0,serum levels of epinephrine(E),cortisol(Cor) increased in two groups at T2 and T3,and the differences were statistically significant(tcontrol group =10.03,8.096,8.679,7.029,tobservation group =6.473,4.728,6.330,4.727,all P ＜ 0.05).Compared with T2,serum levels of E and Cor in two groups at T3 were decreased,and the differences were statistically significant (tcontrol group =2.400,2.638,tobservation group =2.260,2.162,all P ＜ 0.05).At T2 and T3,the serum levels of E,Cor in the observation group [T2:E (286.36 ± 41.02) ng/L,Cor (262.52 ± 29.89) μg/L,T3:E (270.35 ±33.59)ng/L,Cor (253.23 ±30.28)μg/L]were lower than those in the control group[T2:E (312.56 ±38.75)ng/L,Cor (287.56 ± 38.76) μg/L,T3:E (295.79 ± 35.12) ng/L,Cor (270.25 ± 30.15) μg/L],the differences were statistically significant (t =3.457,3.917,3.828,2.981,all P ＜ 0.05).At To,T2 and T3,there were no statistically significant differences in CD3+,CD4+,CD8+ and CD4+/CD8+ between the two groups (all P ＞ 0.05).Conclusion Remifentanil combined with propefol anesthesia can make hemodynamics more stable in patients with acute abdomen complicated with septic shock,and can alleviate inflammation and stress response.%目的 探讨瑞芬太尼复合丙泊酚对急腹症并发感染性休克患者血流动力学、炎症应激反应和免疫功能的影响.方法 选取厦门大学附属第一医院2017年6月至2018年8月收治的急腹症并发感染性休克患者112例为观察对象,采用随机数字表法分为观察组和对照组,每组56例.对照组以七氟烷复合丙泊酚麻醉,观察组以瑞芬太尼复合丙泊酚麻醉.记录患者入手术室(T0)、麻醉后0.5 h(T1)、1 h(T2)和清醒后(T3)的血流动力学指标;记录术中去甲肾上腺素用量;记录T0、T2和T3的炎性反应指标、应激反应指标、免疫功能指标.结果 与T0、T1和T2比较,两组患者在T3时的平均动脉压(MAP)较高且差异均有统计学意义(t对照组=4.834、4.484、5.378,t观察组=6.420、7.006、6.152,均P＜0.05).与T0比较,两组患者在T3时的心率较高且差异有统计学意义(t对照组=5.943,t观察组=7.722,均P＜0.05).与T1和T2比较,两组患者在T3时的心输出量(CO)较高且差异均有统计学意义(t对照组=4.276、2.262,t观察组=6.318、5.132,均P＜0.05).在T0、T1、T2和T3两组患者同期MAP、HR和CO差异均无统计学意义(均P＞0.05).观察组、对照组术中去甲肾上腺素用量分别为(1 587.7±287.5)μg、(1 937.9±397.6) μg,差异有统计学意义(t=5.341,P＜0.05).两组血清C反应蛋白(CRP)、肿瘤坏死因子α(TNF-α)和白细胞介素6(IL-6)随时间延长增高且差异均有统计学意义(t对照组=17.06、36.13、19.07、3.822、9.466、2.874、14.18、26.87、16.21,t观察组=11.72、20.79、11.01、2.810、6.559、3.716、10.52、24.56、17.64,均P＜0.05).在T2和T3,观察组血清CRP、TNF-α和IL-6[T2:CRP(89.63±17.65) mg/L、TNF-α(51.16±10.16) ng/L、IL-6(34.26±6.25) ng/L,T3:CRP(136.15±26.25) mg/L、TNF-α(58.64±11.12) ng/L、IL-6(67.56±12.67) ng/L]均低于同期对照组[T2:CRP(112.15±22.34) mg/L、TNF-α(59.56±11.58) ng/L、IL-6 (42.65±8.37) ng/L,T3:CRP(175.16±34.75) mg/L、TNF-α(65.79±11.35) ng/L、IL-6(79.02±14.56) ng/L],差异均有统计学意义(t=5.919、6.703、4.080,3.367、6.010、4.443,均P＜0.05).T2、T3与T0比较,两组血清肾上腺素(E)、皮质醇(Cor)上升且差异均有统计学意义(t对照组=10.03、8.096、8.679、7.029,t观察组=6.473、4.728、6.330、4.727,均P＜0.05).T3与T2比较,两组血清E、Cor降低且差异均有统计学意义(t对照组=2.400、2.638,t观察组=2.260、2.162,均P＜0.05).在T2和T3,观察组血清E、Cor[T2:E(286.36±41.02)ng/L、Cor(262.52±29.89) μg/L,T3:E(270.35±33.59)ng/L、Cor(253.23±30.28)μg/L]均低于同期对照组[T2:E(312.56±38.75) ng/L、Cor(287.56±38.76) μg,/L,T3:E(295.79±35.12) ng/L、Cor(270.25±30.15) μg/L],差异均有统计学意义(t=3.457、3.917,3.828、2.981,均P＜0.05).在T0、T2和T3,两组CD3+、CD4+、CD8+及CD4+/CD8+差异均无统计学意义(均P＞0.05).结论 瑞芬太尼复合丙泊酚能使急腹症并发感染性休克患者的血流动力学更稳定,减轻炎性反应和应激反应.
