摘要
目的 探索在围术期不同血糖的控制水平和瑞芬太尼心肌保护作用的相关性找出它们之间最适当的组合.方法 选择择期糖尿病合并冠心病在控制下、降压下行腹部大手术(肝脏、结直肠等)或妇科大手术(全子宫切除术、子宫内膜癌、宫颈癌根治术等)患者,ASAⅡ~Ⅲ级,随机分为6组:瑞芬太尼未处理+常规血糖控制组(D-C组,n=15);瑞芬太尼未处理+胰岛素严格控制血糖组(D-Ⅰ组,n=15);瑞芬太尼低剂量处理+常规血糖控制组(D-LR-C组,n=15);瑞芬太尼高剂量处理+常规血糖控制组(D-HR-C组,n=15);瑞芬太尼低剂量处理+胰岛素严格控制血糖组(D-LR-Ⅰ组,n=15);瑞芬太尼高剂量处理+胰岛素严格控制血糖组(D-HR-Ⅰ组,n=15).记录6组患者术中心肌缺血情况.分别于术前(T1)、手术开始2 h(T2),术后即刻(T3)、术后6 h(T4)、24 h(T5)抽取中心静脉血测定血清缺血修饰白蛋白(IMA)、心肌肌钙蛋白Ⅰ(cTnl)和肌酸激酶同工酶(CK-MB)浓度,以此来评价心肌损伤程度.结果 瑞芬太尼处理组比未处理组血清缺血修饰白蛋白(IMA)在T2、T3、T4的浓度低,血清心肌肌钙蛋白Ⅰ (cTnl)和肌酸激酶同工酶(CK-MB)在T3、T4、T5的浓度低;瑞芬太尼处理组中高处理组比低处理组IMA在T2、T3、T4的浓度低,cTnl和CK-MB在T3、T4、T5的浓度低;瑞芬太尼高处理组中胰岛素严格控制血糖组比常规血糖控制组(D-HR-Ⅰ组)IMA在T2、T3、T4的浓度低,cTnI和CK-MB在T3、T4、T5的浓度低;且D-HR-Ⅰ组的IMA、cTnI和CK-MB在T2、T3、T4、T5的浓度是各组中最低的,差异显著有统计学意义.结论 胰岛素控制血糖在5~7 mmol/L范围内,瑞芬太尼高剂量处理[(3~5 μg/(kg· min)]对糖尿病合并冠心病行非心脏手术的心肌保护作用是最佳的,值得临床推广.
Objective This study explored the correlation between the control level of different blood glucose during perioperative period and the protective effect of remifentanil on myocardial protection,to find the most appropriate combination about them. Methods Choose the patients with diabetes mellitus and coronary heart disease,who were experienced abdominal surgery( liver,colorectal,etc.) or major gynecologic surgery( general hysterectomy,endometrial cancer,radical resection of cervical cancer,etc.) under controlling Lowed blood pressure,ASA II ~ III. They were randomized into 6 groups:Remifentanil untreated + conventional glycemic control group( D-C group,n = 15);Remifentanil untreated + insulin strictly controlled blood glucose group( D-I group,n = 15);Remifentanil low-dose treatment + conventional glycemic control group( D-LR-C group,n = 15);Remifentanil high-dose treatment + conventional glycemic control group( D-HR-C group n = 15);Remifentanil low dose treatment + insulin strict control of blood glucose group( D-LR-I group,n = 15);Remifentanil high dose treatment + insulin strictly control blood sugar Group( D-HR-I group,n = 15). The situation about intraoperative myocardial ischemia of 6 groups was recorded. Ischemia modified albumin( IMA),cardiac troponin I( c Tnl) and creatine kinase isoenzyme( CK-MB) were measured at 5 moments: before operation( T1),2 hours after surgery( T2),immediately after surgery( T3),6 hours after surgery( T4),and 24 hours after surgery( T5),which were used to evaluate the damage of myocardial. Results The concentration of IMA in the remifentanil-treated group was lower than in the untreated group at the moment of T2,T3,T4. The concentrations of c Tnl and CK-MB were lower than in the untreated group at the moment of T3,T4,T5;The concentration of IMA in the high-treatment of the remifentanil-treated group was lower than the lower-treatment group at the moment of T2,T3,T4. The concentrations of c Tnl and CK-MB were lower at the moment of T3,T4,T5;The concentration of IMA in the remifentanil-treated of insulin controled group was lower than that of the conventional glycemic control group at the moment of T2,T3,T4. The concentrations of c Tn I and CK-MB were lower at the moment of T3,T4,T5;The concentrations of IMA,c Tn I and CK-MB in the D-HR-I group were the lowest in each group at the moment of T2,T3,T4,T5,and the difference was statistically significant. Conclusion The myocardial protection for non-cardiac surgery for diabetic patients with coronary heart disease was optimal when insulin control of blood glucose in the range of 5-7 mmol/L,and remifentanil high dose treatment 3-5 μg/( kg·min). That was more worthy of clinical promotion.
作者
卢钊楷
陈怀佳
陈丽斌
莫桂熙
刘永宏
谭彩姬
陈载鑫
陈醒霞
LU Zhaokai;CHEN Huaijia;CHEN Libin;MO Guixi;LIU Yonghong;TAN Caiji;CHEN Zaixin;CHENZaixin,CHEN Xingxi(Dongguan Houjie Hospital affiliated to Guangdong Medical University, Dongguan 523945, China)
出处
《现代医院》
2019年第9期1355-1359,共5页
Modern Hospitals
基金
东莞市社会科技发展一般项目(201750715023200)
关键词
瑞芬太尼
心肌保护
糖尿病
冠心病
Remifentanil
Myocardial Protection
Diabetes
Coronary Heart Disease
