Effects Of Different Intraoperative Hemodynamic Management Goals On Postoperative Myocardial Injury In Elderly Patients

Objective:To compare the effects of goal-directed hemodynamic management and conventional blood flow management on myocardial injury in elderly patients undergoing resection of the prostate.Methods:Seventy elderly patients who planned to undergo elective resection of the prostate under general anesthesia were randomly divided into two groups according to different hemodynamic management:routine management group（n=32）and goal-oriented management group（n=38）.Anesthesia method:General anesthesia was induced by intravenous injection of propofol 1.5 mg/kg,sufentanil 0.3μg/kg and rocuronium bromide 0.8mg/kg,and then endotracheal intubation and ventilator connection.For maintenance of anesthesia,sevoflurane was continuously inhaled with a minimum alveolar effective concentration of 0.7-0.8,and 0.4μg/（kg·min）of dexmedetomidine and 5-15μg/（kg·h）of remifentanil were continuously pumped.After intubation,the radial artery was punctured to measure cardiac output[cardiac output（CO）,stroke volume（SV）and stroke variability（SVV）],heart rate（HR）and invasive arterial pressure[systolic blood pressure（SBP）,diastolic blood pressure（DBP）,mean arterial pressure（MAP）].The routine management group was maintained as follows:（1）HR>60 beats/min.If HR≤60 times/min,inject atropine 0.01mg/kg intravenously until HR>60 times/min;（2）Maintain systolic blood pressure>90mm Hg.If the systolic blood pressure≤90mm Hg persists for more than 1 min,norepinephrine 0.1μg/kg will be injected intravenously until the systolic blood pressure>90mm Hg.The goal-oriented management group was maintained as follows:（1）Maintain HR at 60-80times/min.If HR≤60 times/min,inject atropine 0.01mg/kg intravenously until HR>60times/min.If HR≥80 times/min,increase remifentanil pump volume or intravenously inject esmolol 0.02mg/kg each time until HR<80 times/min;（2）maintain diastolic blood pressure>60mm Hg and mean arterial pressure>65mm Hg.If systolic and diastolic blood pressure≤60mm Hg or mean arterial pressure≤65mm Hg lasted for more than1min,intravenous injection of norepinephrine 0.1μg/kg each time until diastolic blood pressure>60mm Hg and mean arterial pressure>65mm Hg.Observation indicators:（1）Record the time when the two groups of patients entered the room（T0）,immediately after anesthesia induction（T₁）,after intubation（T₂）,the beginning of the operation（T₃）,the end of the operation（T₄）,and when the tracheal tube was pulled out（T₅）.Systolic blood pressure（SBP）,diastolic blood pressure（DBP）,mean arterial pressure（MAP）,heart rate（HR）,cardiac output（CO）,stroke volume（SV）and stroke variability（SVV）;The amount of norepinephrine used was recorded;（3）blood was drawn at 6 hours and30 hours after operation to measure myocardial injury markers:myoglobin（MYO）,creatine kinase isoenzyme（CK-MB）and high-sensitivity troponin T（hs-TNT）;（4）Blood was drawn at 6 hours and 30 hours after operation to measure N-terminal pro-brain natriuretic peptide（NT-pro BNP）;（5）Record blood loss,infusion volume and intraoperative lavage volume after operation;（6）Use dynamic electrocardiogram to record the average heart rate,number of atrial premature beats and premature ventricular beats 48 hours after operation;（7）Record the changes of dynamic electrocardiogram（ST segment changes,T wave inversion and pathological Q wave）48 hours after surgery,and record 48 hours after surgery Whether there are symptoms of myocardial ischemia（paroxysmal chest pain,chest tightness,and dyspnea）;（8）The incidence of acute cardiovascular events（myocardial infarction,pulmonary infarction,stroke）after surgery,and record the postoperative mortality rate;（9）After surgery 30-day follow-up（the specific follow-up content should be described）patients.The preoperative special conditions,New York Heart Association（NYHA）score,and energy metabolic equivalent（MET）score were recorded.Results:（1）The heart rate of the goal-oriented group was slower than that of the routine management group at the beginning of the operation（T₃）,at the end of the operation（T₄）,and at the time of extubation（T₅）（P<0.05）.The diastolic blood pressure,systolic blood pressure,mean arterial pressure and stroke volume in the goal-directed group were higher than those in the routine management group at the beginning of the operation（T₃）,at the end of the operation（T₄）,and at the time of extubation（T₅）（P<0.05）.（2）The consumption of norepinephrine in the goal-oriented group was more than that in the routine management group（P<0.05）.（3）Myoglobin（MYO）,creatine kinase isoenzyme（CK-MB）and high-sensitivity troponin T（hs-TNT）in the goal-oriented group were lower than those in the routine management group at 6 hours and30 hours after operation（P<0.05）.（4）The N-terminal N-terminal natriuretic peptide precursor in the goal-directed group was lower than that in the routine management group at 6 hours and 30 hours after operation（P<0.05）.（5）There was no significant difference in blood loss,infusion volume,and lavage volume between the two groups（P>0.05）;（6）The number of atrial premature beats and premature ventricular beats in the goal-oriented group 48 hours after operation was less than that of the routine management group（P<0.05）,there was no significant difference in the average heart rate at 48 hours after operation between the two groups（P>0.05）;（7）The number of patients with myocardial ischemia at 48 hours after operation in the goal-oriented group was more than that in the routine management group（P<0.05）.Conclusion:The implementation of goal-oriented hemodynamic management can reduce myocardial injury in elderly patients undergoing resection of the prostate.