The role of different anesthetic techniques in altering the stress response during cardiac surgery in children: a prospective, double-blinded, and randomized study.
The role of different anesthetic techniques in altering the stress response during cardiac surgery in children: a prospective, double-blinded, and randomized study.
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DOI：
10.1097/pcc.0b013e31828a742c
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发表时间：
2013-06
期刊：
影响因子：
--
通讯作者：
Hoffman TM
中科院分区：
文献类型：
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作者：
Naguib AN;Tobias JD;Hall MW;Cismowski MJ;Miao Y;Barry N;Preston T;Galantowicz M;Hoffman TM
我们的目标是评估三种麻醉技术在快速追踪或早期拔管的情况下改变先天性心脏病手术患儿在体外循环下的应激反应的作用。此外，我们还想评估钝化应激反应与围手术期临床结果之间的相关性。前瞻性、随机、双盲研究。2008年12月至2011年5月的单中心。研究对象为48例(小剂量芬太尼+安慰剂，n=16；大剂量芬太尼+安慰剂，n=17；小剂量芬太尼+右美托咪定，n=15)，年龄在30天到3岁之间，计划行室间隔缺损、房室间隔缺损或法洛四联症修补术。先天性心脏病手术患儿随机分为小剂量芬太尼(10mcg/kg；小剂量芬太尼)、大剂量芬太尼(25mcg/kg；大剂量芬太尼)或小剂量芬太尼+右美托咪啶(负荷剂量为1mcg/kg)，然后以0.5mcg/kg/小时输注，直到脱离体外循环。此外，患者根据需要接受了一种挥发性麻醉剂，以维持血流动力学稳定。在基线、胸骨切开后、体外循环开始后、手术结束时和术后24小时检测血样中的代谢、激素和细胞因子标志物。48例受试者(小剂量芬太尼+安慰剂，n=16；大剂量芬太尼+安慰剂，n=17；小剂量芬太尼+右美托咪定，n=15)。在研究期间，小剂量芬太尼联合安慰剂组的受试者的促肾上腺皮质激素、皮质醇、葡萄糖、乳酸和肾上腺素水平显著高于对照组。无论是随着时间的推移(促肾上腺皮质激素，P=0.007；葡萄糖，P=0.007)和个别时间点(手术结束时皮质醇和乳酸，胸骨切开后肾上腺素；P<；0.05)，大剂量芬太尼加安慰剂组的应激标志物水平都是最低的。与小剂量芬太尼+安慰剂组相比，小剂量芬太尼+右美托咪丁组患者在手术结束时乳酸水平较低(p<；0.05)。虽然三组间血浆细胞因子水平无统计学差异，但小剂量芬太尼联合安慰剂组术后24小时IL-6/IL-10比值显著高于对照组(P<；0.0001)。此外，与小剂量芬太尼+安慰剂组相比，小剂量芬太尼+右美托咪丁组在胸骨切开后、体外循环开始后和手术结束时去甲肾上腺素水平低于基线(p≤005)。小剂量芬太尼联合安慰剂组的受试者术后麻醉用量更多(p=0.004)，凝血酶原时间更长(p≤0.03)，术后胸管输出量更多(p<；0.05)。两组间快速追踪成功率无显著差异(小剂量芬太尼+安慰剂75%，大剂量芬太尼+安慰剂82%，小剂量芬太尼+右美托咪定93%；p=0.39)。在我们的队列中，小剂量芬太尼的使用与最大的应激反应、最大的凝血障碍和最高的输血需求有关。更大剂量的芬太尼显示出更有利的钝化应激反应。与单独使用小剂量芬太尼相比，添加右美托咪定改善了应激反应的钝化，同时实现了更好的术后疼痛控制。
Our goal was to evaluate the role of three anesthetic techniques in altering the stress response in children undergoing surgery for repair of congenital heart diseases utilizing cardiopulmonary bypass in the setting of fast tracking or early tracheal extubation. Furthermore, we wanted to evaluate the correlation between blunting the stress response and the perioperative clinical outcomes. Prospective, randomized, double-blinded study. Single center from December 2008 to May of 2011. Forty-eight subjects (low-dose fentanyl plus placebo, n = 16; high-dose fentanyl plus placebo, n = 17; low-dose fentanyl plus dexmedetomidine, n = 15) were studied between ages 30 days to 3 years old who were scheduled to undergo repair for a ventricular septal defect, atrioventricular septal defect, or Tetralogy of Fallot. Children undergoing surgical repair of congenital heart disease were randomized to receive low-dose fentanyl (10 mcg/kg; low-dose fentanyl), high-dose fentanyl (25mcg/kg; high-dose fentanyl), or low-dose fentanyl plus dexmedetomidine (as a 1 mcg/kg loading dose followed by infusion at 0.5mcg/kg/hr until separation from cardiopulmonary bypass. In addition, patients received a volatile anesthetic agent as needed to maintain hemodynamic stability. Blood samples were tested for metabolic, hormonal and cytokine markers at baseline, after sternotomy, after the start of cardiopulmonary bypass, at the end of the procedure and at 24 hours postoperatively. Forty-eight subjects (low-dose fentanyl plus placebo, n = 16; high-dose fentanyl plus placebo, n = 17; low-dose fentanyl plus dexmedetomidine, n = 15) were studied. Subjects in the low-dose fentanyl plus placebo group had significantly higher levels of adrenocorticotropic hormone, cortisol, glucose, lactate, and epinephrine during the study period. The lowest levels of stress markers were seen in the high-dose fentanyl plus placebo group both over time (adrenocorticotropic hormone, p = 0.01; glucose, p = 0.007) and at individual time points (cortisol and lactate at the end of surgery, epinephrine poststernotomy; p < 0.05). Subjects in the low-dose fentanyl plus dexmedetomidine group had lower lactate levels at the end of surgery compared with the low-dose fentanyl plus placebo group (p < 0.05). Although there were no statistically significant differences in plasma cytokine levels between the three groups, the low-dose fentanyl plus placebo group had significantly higher interleukin-6:interleukin-10 ratio at 24 hours postoperatively (p < 0.0001). In addition, when compared with the low-dose fentanyl plus placebo group, the low-dose fentanyl plus dexmedetomidine group showed lower norepinephrine level from baseline at poststernotomy, after start of cardiopulmonary bypass, and end of surgery (p ≤ 0.05). Subjects in the low-dose fentanyl plus placebo group had more postoperative narcotic requirement (p = 0.004), higher prothrombin time (p ≤ 0.03), and more postoperative chest tube output (p < 0.05). Success of fast tracking was not significantly different between groups (low-dose fentanyl plus placebo 75%, high-dose fentanyl plus placebo 82%, low-dose fentanyl plus dexmedetomidine 93%; p = 0.39). The use of low-dose fentanyl was associated with the greatest stress response, most coagulopathy, and highest transfusion requirement among our cohorts. Higher dose fentanyl demonstrated more favorable blunting of the stress response. When compared with low-dose fentanyl alone, the addition of dexmedetomidine improved the blunting of the stress response, while achieving better postoperative pain control.