| Part1 effect of sufentanil combined with dexmedetomidine on perioperative organ protection in patients undergoing hert valve replancement under cardiopulmonarybypassObjective To observe the effect of sufentanil combined with dexmedetomidine on perioperative organ protection in patients undergoing heart valve replacement,so as to provide clinical guidance for the rational application of anesthetic drugs.Methods A total of 120 patients undergoing heart valve replacement with cardiopulmonary bypass were selected during the period from May 2016 to March 2018 in the People's Hospital of Guangxi Zhuang Autonomous Region.All patients were divided into sufentanil group(S group),fentanyl group(F group),dexmedetomidine + sufentanil group(SD group)and dexmedetomidine+ fentanyl group(FD group)used by random number table method,with 30 cases in each group.In the S group and the SD group,sufentanil was used for analgesia throughout the operation.The F group and FD group used fentanyl for analgesia throughout the operation.SD and FD groups were continuously intravenously pumped with 0.4 ?g/kg/h dexmedetomidine 10 min before induction of anesthesia until the end of surgery.Observe and analyze the following indicators:(1)The aortic crossclamp time,cardiopulmonary bypass time(CPB),anesthesia time,surgery time,intraoperative blood loss,amount of crystals delivered,amount of colloids delivered,intraoperative urine volume,spontaneous relapse and defibrillation recurrent conditions,intraoperative installation of pacemakers,and the use of anesthetic analgesics and intraoperative vasoactive drugs were recorded.(2)At the time before surgery(T0),at the beginning of surgery(T1),at the end of extracorporeal circulation(T2),and at the end of the surgery(T3),the changes of intraoperative MAP,HR,lactic acid and blood glucose were recorded.(3)Venous blood was collected at preoperatively(T0),postoperative day 1(T4),postoperative 3 days(T5),and postoperative 7 days(T6),to detection the expression of inflammatory factors such as WBC,N%,hs-CRP,the expression of alanine aminotransferase(ALT),aspartate transferase(AST),urea(UREA),creatinine(CREA),cystatin C(Cys C),creatine kinase MB(CK-MB),troponin(c Tnl)and hemoglobin(HBG),And calculate the oxygenation index(OI)and alveolar-arterial oxygen pressure difference P(A-a DO2).Results(1)There was no significant difference in the intraoperative aortic blockade time,CPB time,anesthesia time,time required for surgery,blood loss during surgery,intraoperative crystal volume,spontaneous relapse and defibrillation recurrent conditions,intraoperative installation of pacemakers,and isoproterenol dosage,norepinephrine dosage between the 4 groups(P>0.05).(2)To compared the use of anesthetic drugs in 4 groups,the dose of sufentanil in the SD group was lower than that in the S group,the dose of sufentanil in the FD group was lower than that in the F group(P<0.05),and the dose of propofol and midazolam were lower than other 3 groups.(3)To compared the use of vasoactive drugs in 4 groups,the amount of dopamine in the SD group was lower than that of the other three groups.The amount of nitroglycerin in the SD group and FD group was lower than that in group S and F,and the amount of epinephrine in the SD group was lower than that in group F(P<0.05).(4)To compared the intraoperative MAP,at T1,T2,T3 time point,the MAP levels in the SD group and the FD group were lower than those in the S group and the F group respectively(P<0.05),but there was no significant difference between the SD group and the FD group(P>0.05).Compared with intraoperative HR of the4 groups,the HR levels in SD was lower than those in S and F groups and FD groups at T1(P<0.05),and FD group was lower than S group and F group(P<0.05).The HR level of patients at T1 and T3 was higher than T0(P<0.05).(5)To compared the levels of lactic acid and blood glucose in 4 groups,at T2,T3 time point,the levels of lactic acid and blood glucose in the SD group and the FD group were lower than those in the S group and the F group respectively(P<0.05).The levels of lactic acid and blood glucose in 4 groups at T1,T2,T3 were higher than those in T0(P<0.05).(6)The blood WBC,N%,CRP,and hs-CRP levels were lower in the SD group and the FD group than in the S group and the F group at the time of T4,T5 and T6(P<0.05).At the time of T4,the CRP and hs-CRP levels in the SD group were lower than those in the FD group(P<0.05).The blood WBC,blood N%,CRP,and hs-CRP levels in the SD group were lower than those in the FD group at T5 and T6(P<0.05).The above indexes of T4,T5 and T6 were higher than those of T0 before surgery(P<0.05).(7)To compare the protective effects of organ injury in 4 groups,at the time of T4,T5 and T6,SD and FD group had higher level of OI than S and F group,and the level of ALT,AST,UREA,CREA,Cys C,CK-MB,c Tn I and P(A-a DO2)were lower than group S and F group(P<0.05).At the time of T4,the c Tn I level in the SD group was lower than that in the FD group(P<0.05).The levels of Cys C,CK-MB,c Tn I,and P(A-a DO2)in the SD group were better than those in the FD group at the T5 time point(P<0.05).At the time of T6,the levels of CK-MB and P(A-a DO2)in the SD group were lower than those in the FD group(P<0.05).The levels of ALT,AST,UREA,CREA,Cys C,CK-MB and c Tn I at time of T4,T5,T6 were higher than those at T0(P<0.05),and the level of OI was lower than T0(P<0.05).The level of P(A-a DO2)at T4 in 4 groups were higher than T0,while the level of P(A-a DO2)at T5 and T6 in 4 groups were higher than T0(P<0.05).Conclusion Sufentanil combined with dexmedetomidine has a certain protective effect on heart,lung,liver,kidney and other organs of patients undergoing CPB heart valve replacement surgery,and the effect of combined protection was better than that of other single drug groups and combination group,which may be associated with reduced hemodynamic fluctuation and inflammatory stress response.Part2 effect of sufentanil combined with dexmedetomidine on postoperative cognitive function in patients undergoing heart valve replacement under cardiopulmonarybypassObjective To explore the effect of sufentanil combined with dexmedetomidine on postoperative cognitive function in patients undergoing heart valve replacement,and evaluate the brain protective effects of different anesthetic drugs.Methods(1)The study subjects,randomized grouping,experimental scheme and anesthetic methods included in this part were the same as the first part.(2)At the patient before entering the operating room(T0),when the operation begins to saw the sternum(T1),at the end of the extracorporeal circulation(T2),and at the end of the surgery(T3),patients' postoperative cognitive function was assessed by MMSE and Mo CA.(3)The occurrence of hemorrhoids within 3 and 7 days postoperatively was assessed using the revised rating scale(CAM)-98.(4)Adverse reactions in 48 hours after operation were recorded in each group.(5)Record the incidence of pulmonary infection at 7days after surgery.(6)Visual analogue scale(VAS)scale was used to evaluate the pain in each group on the 1st and 3rd days after surgery.(7)The patient's preoperative and postoperative 5 days left ventricular ejection fraction(LVEF)were recorded.(8)Postoperative recovery quality scale QOR-15 was used to understand the patient's health and recovery before and after surgery before surgery(T0),3 days after surgery(T5),7 days after operation(T6).Results(1)To compare the scores of MMSE and Mo CA in 4 groups,the scores of MMSE and Mo CA in SD and FD patients at T5 and T6 were higher than those in S and F groups(P<0.05).The MMSE and Mo CA,scores of patients in 4 groups at T5 and T6 were lower than T0(P<0.05).(2)To compare the incidence of delirium in 4 groups,The incidence of delirium in SD group was lower than that in S group and F group on postoperative day 3 and postoperative 7 days(P<0.05),the FD group was lower than the F group(P<0.05).The incidence of cognitive impairment in SD group and FD group was lower than that in S group and F group at 3 days after operation(P<0.05),the SD group was lower than S group and F group(P<0.05),and FD group was lower than F group(P<0.05)at 7 days after operation.At 3 days after operation,the incidence of POCD in SD group was lower than that in S group and F group(P<0.05),the FD group was lower than F group(P<0.05).At 7 days after operation,there was no significant difference in the incidence of POCD between the 4 groups(P>0.05),but the incidence of POCD in the SD group was the lowest.(3)The incidence of hypertension at 48 hours after surgery in SD group was lower than in S group,F group(P<0.05).The incidence of arrhythmia in SD group and FD group were lower than in F group(P<0.05).The incidence of agitation in the SD group was lower than that in the F group(P<0.05).(4)To compare the score of VAS in 4 groups,on the 1st day after surgery,the VAS score of SD group was lower than that of S group,F group,and FD group(P<0.05).The FD group was lower than S group and F group(P<0.05).On the3 th days after surgery,the VAS score of SD group was lower than the S group and the F group(P<0.05),the FD group was lower than the F group(P<0.05),there was no significant difference between the SD group and the FD group(P>0.05).At 3 days after surgery,the VAS scores in all groups were lower than those after 1 day(P<0.05).(5)To compare the level of LVEF in 4 groups,at 5days after surgery,the LVEF level in the SD group was higher than that in other 3 groups(P<0.05).Postoperative 5d LVEF of each group was higher than before surgery,and the difference was statistically significant(P<0.05).(6)There were no statistical significant in incidence of lung infection at postoperative 5d between 4 groups.(7)To compare the postoperative score of QOR-15 in 4groups,at T5,T6 time point,the score of QOR-15 in SD and FD group were higher than that in S and F group,but the score of QOR-15 in SD group were higher than that in FD group(P<0.05).The score of QOR-15 in 4 groups were lower than T0(P<0.05).Conclusion Sufentanil and dexmedetomidine can reduce postoperative cognitive dysfunction and delirium incidence rate in patients undergoing cardiopulmonary bypass,and have a certain cerebral protective effect.It also can improve the prognosis of patients,reduce the risk of postoperative adverse events,help patients recover after surgery. |
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