Effects of preoperative dexmedetomidine on preoperative hemodynamics and myocardial injury in Stanford type A aortic dissection
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摘要: 目的探讨右美托咪定对急性Stanford A型主动脉夹层患者血流动力学以及围术期心肌损伤的影响。方法选择2018年3月-2022年3月期间于我院行手术治疗的120例Stanford A型主动脉夹层患者，随机数字表法将患者分为4组，每组30例。A组术前不使用右美托咪定；B、C、D组在A组的基础上增加右美托咪定，于入院1 h内分别给予1.0、1.5、2.0 μg/kg负荷剂量右美托咪定(10 min泵注完毕)，然后3组均持续给予0.1~0.7 μg/(kg·h)右美托咪定静脉泵入直至术毕，其它处理同A组。观察4组患者入院时(T0)、入院1 h(T1)、入院3 h(T2)、入院12 h(T3)、入院24 h(T4)、麻醉诱导前(T5)、插管完成时(T6)、劈开胸骨时(T7)、缝合胸骨时(T8)、手术完成时(T9)各时间点的心率、收缩压、脉搏血氧饱和度、呼吸频率以及麻醉诱导前(M0)、术后12 h(M1)、术后24 h(M2)、术后48 h(M3)、术后72 h(M4)患者血浆心肌损伤、炎症因子指标的变化和差异。结果4组患者的心率、收缩压于T1-4降低，T5-8升高，后于T9降低；呼吸频率T1-5逐渐降低；脉搏血氧饱和度逐渐增加并保持稳定，差异有统计学意义(P < 0.05)。D组T1-9心率、收缩压均低于A、B、C组(P < 0.05)，指脉氧饱和度、呼吸频率比较均差异无统计学意义(P>0.05)。4组围术期肌酸激酶同工酶(CK-MB)、肌钙蛋白Ⅰ(cTnI)、脑利钠肽前体(BNP)、C反应蛋白(CRP)、肿瘤坏死因子-α(TNF-α)于M1-2增高，M3-4降低，差异有统计学意义(P < 0.05)。C、D组患者M1-4CRP、TNF-α、CK-MB、cTnI、BNP均低于A、B组，差异有统计学意义(P < 0.05)。结论术前应用1.5 μg/kg负荷剂量右美托咪定可有效控制Stanford A型主动脉夹层心率和血压，稳定血流动力学，降低炎症反应，减轻围术期心肌损伤。Abstract: ObjectiveTo investigate the effects of preoperative dexmedetomidine on preoperative hemodynamics and perioperative myocardial injury in Stanford type A aortic dissection.MethodsOne hundred and twenty patients with Stanford type A aortic dissection who underwent surgical treatment in our hospital from March 2018 to March 2022 were selected. The patients were divided into four groups by random number table method, with 30 patients in each group. Group A was not given dexmedetomidine before surgery, while group B, C and D were given loading doses of Dexmedetomidine at 1.0 μg/kg, 1.5 μg/kg and 2.0 μg/kg, respectively, within 1 h after admission, and then continued intravenous pumping of Dexmedetomidine at 0.1~0.7 μg/(kg·h) until end of the surgery. Heart rate, systolic blood pressure, finger pulse oxygen saturation and respiration were observed at admission(T0), admission 1 h(T1), admission 3 h(T2), admission 12 h(T3) and admission 24 h(T4), and plasma myocardial injury, inflammatory factors and oxidative stress indexes at before induction of anesthesia(M0), 12 h after operation(M1), 24 h after operation(M2), 48 h after operation(M3) and 72 h after operation(M4) were detected.ResultsHeart rate and systolic blood pressure in the four groups decreased from T1-4, increased from T5-8and then decreased again from T9. From T1-5respiration gradually decreased, and pulse oxygen saturation gradually increased and remained stable, the difference was statistically significant(P < 0.05). The heart rate and systolic blood pressure of T1-9in group D were lower than those in groups A, B and C, the difference was statistically significant(P < 0.05), and there was no statistical difference in oxygen saturation of digital pulse and respiration among groups(P>0.05). Creatine kinase isoenzyme(CK-MB), troponin I(cTnI), brain natriuretic peptide precursor(BNP), C-reactive protein(CRP), tumor necrosis factor-α(TNF-α), malondialdehyde(MDA) increased in M1-2 and decreased in M3-4 in four groups. Total antioxidant capacity(TAC) was decreased in M1-2 and increased in M3-4(P < 0.05). CRP, TNF-α, CK-MB, cTnI and BNP at M1-4in groups D and C were lower than those in groups A and B, the difference was statistically significant(P < 0.05).ConclusionDexmedetomidine at 1.5 μg/kg load dose before surgery can effectively control heart rate and blood pressure of Stanford type A aortic dissection, thus stabilize hemodynamics, reduce inflammation response, and alleviate perioperative myocardial injury.
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Key words:
- dexmedetomidine /
- aortic dissection /
- heart rate /
- blood pressure /
- hemodynamics /
- myocardial injury
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表 1 基线资料比较
例(%)，X±S 项目 A组(30例) B组(30例) C组(30例) D组(30例) F/Z/χ2 P 年龄/岁 46.35±6.59 45.97±6.08 46.02±6.59 46.11±6.34 0.021 0.996 性别 1.207 0.751 男 17(56.67) 12(40.00) 10(33.33) 16(53.33) 女 13(43.33) 18(60.00) 20(66.67) 14(46.67) 吸烟 11(36.67) 12(40.00) 13(43.33) 10(33.33) 0.705 0.872 入院至手术时间/h 25.75(24，48) 25.01(25，46) 25.60(24，47) 25.25(24，46) 0.329 0.804 基础疾病 高血压 15(50.00) 16(53.33) 12(40.00) 17(56.67) 1.867 0.601 糖尿病 12(40.00) 10(33.33) 11(36.67) 9(30.00) 0.733 0.866 高脂血症 8(26.67) 10(33.33) 6(20.00) 12(40.00) 3.175 0.365 缺血性心脏病 2(6.67) 1(3.33) 3(10.00) 2(6.67) 1.071 0.784 脑血管疾病 3(10.00) 4(13.33) 2(6.67) 3(10.00) 0.741 0.864 手术时间/min 445.02±52.65 448.02±53.06 446.09±51.95 447.49±50.49 0.021 0.996 体外循环时间/min 224.35±36.35 225.03±37.09 226.03±36.59 225.12±35.49 0.011 0.999 主动脉阻断时间/min 134.02(101，165) 136.05(103，160) 135.02(103，158) 134.92(103，161) 0.029 0.993 基线LVEF/% 56.16±6.09 58.09±5.97 57.16±5.39 59.42±5.73 1.716 0.168 基线BNP/(pg·mL-1) 105.35±13.26 116.35±12.44 113.47±13.05 109.08±14.13 0.176 0.906 基线心率/(次·mim-1) 98.53±9.08 97.08±9.13 96.35±10.35 99.02±11.41 0.459 0.711 基线收缩压/mmHg 163.35±13.26 165.05±13.48 166.32±13.68 165.42±13.58 0.255 0.858 
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表 2 4组血流动力学变化和差异
X±S 组别 时间 心率/(次·mim-1) 收缩压/mmHg 指脉搏氧饱和度/% 呼吸频率/(次·mim-1) A组(30例) T0 98.53±9.08 163.35±13.26 96.23±3.26 26.35±3.59 T1 96.89±9.02 162.03±12.49 98.15±1.03 24.15±3.02 T2 85.02±7.27 150.02±11.72 99.02±0.65 21.05±2.85 T3 80.03±6.12 139.42±10.08 99.11±0.53 18.35±3.05 T4 75.02±5.83 120.35±8.13 99.13±0.55 18.01±3.46 T5 74.01±5.11 121.42±6.35 99.02±0.53 18.02±3.24 T6 80.12±6.59 130.02±8.45 99.11±0.43 - T7 89.12±7.68 136.02±9.35 99.05±0.35 - T8 91.52±8.46 137.04±10.41 99.35±0.32 - T9 88.01±6.35 130.42±8.70 99.41±0.36 - B组(30例) T0 97.08±9.13 165.05±13.48 95.77±3.51 27.12±3.47 T1 90.02±8.031) 136.21±12.091) 98.02±1.5 23.95±3.11 T2 85.04±6.371) 125.02±10.381) 99.06±0.53 21.65±2.75 T3 80.13±5.471) 119.35±9.071) 99.15±0.52 17.45±3.01 T4 70.01±4.091) 113.42±7.091) 99.24±0.31 17.10±3.26 T5 70.05±4.321) 113.68±7.15 99.35±0.42 17.02±3.42 T6 75.22±5.651) 125.02±8.01 99.50±0.36 - T7 80.35±6.351) 129.26±8.49 99.51±0.42 - T8 85.02±7.851) 131.32±9.35 99.62±0.30 - T9 83.02±6351) 125.02±8.32 99.81±0.13 - C组(30例) T0 96.35±10.35 166.32±13.68 95.03±3.43 27.71±3.42 T1 81.35±8.021)2) 127.35±11.471)2) 98.21±1.01 23.75±3.17 T2 74.16±5.351)2) 116.35±9.481)2) 99.05±0.32 20.75±2.28 T3 63.42±7.491)2) 113.25±8.151)2) 99.21±0.63 17.25±2.75 T4 60.35±7.111)2) 107.52±6.981)2) 99.33±0.41 17.11±2.82 T5 61.02±7.351)2) 107.35±6.49 99.40±0.40 17.05±2.06 T6 66.02±8.571)2) 119.02±7.46 99.43±0.42 - T7 73.05±8.351)2) 124.35±7.85 99.53±0.31 - T8 77.02±9.051)2) 125.52±8.02 99.42±0.35 - T9 75.02±8.461)2) 119.35±6.35 99.48±0.29 - D组(30例) T0 99.02±11.41 165.42±13.58 95.13±3.42 26.91±3.47 T1 73.26±9.351)2)3) 120.05±10.391)2)3) 99.21±0.41 23.05±3.52 T2 62.35±7.161)2)3) 110.35±8.061)2)3) 99.32±0.35 21.05±2.15 T3 54.35±6.081)2)3) 106.35±6.981)2)3) 99.41±0.23 17.15±2.65 T4 53.26±6.351)2)3) 101.32±6.351)2)3) 99.53±0.15 17.01±2.06 T5 53.62±6.191)2)3) 101.45±6.19 99.41±0.39 17.01±2.03 T6 56.32±6.951)2)3) 108.35±6.89 99.50±0.40 - T7 60.32±7.151)2)3) 117.05±7.49 99.43±0.32 - T8 65.12±8.051)2)3) 120.51±8.32 99.50±0.47 - T9 63.02±7.031)2)3) 115.02±6.35 99.15±0.42 - 与A组同时间点比较，1)P < 0.05；与B组同时间点比, 2)P < 0.05；与C组同时间点比较，3)P < 0.05；“-”表示机械通气。
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表 3 4组心肌损伤指标变化和差异
X±S 组别 时间 CK-MB/(U·L-1) cTnI/(μg·L-1) BNP/(pg·mL-1) A组(30例) M0 2.35±0.63 0.05±0.01 105.35±13.26 M1 4.52±1.02 0.09±0.03 153.02±203.46 M2 12.11±2.69 0.16±0.04 250.35±241.77 M3 10.05±2.05 0.12±0.03 235.23±209.35 M4 8.11±1.73 0.10±0.02 205.35±182.47 B组(30例) M0 2.40±0.59 0.05±0.02 116.35±12.44 M1 3.35±0.771) 0.07±0.021) 133.52±16.491) M2 6.23±1.471) 0.12±0.031) 215.16±21.351) M3 5.02±1.321) 0.10±0.021) 195.35±13.711) M4 4.77±1.151) 0.08±0.021) 152.12±13.481) C组(30例) M0 2.39±0.59 0.05±0.01 113.47±13.05 M1 2.95±0.601)2) 0.06±0.021)2) 124.12±15.471)2) M2 4.01±1.051)2) 0.11±0.031)2) 162.05±16.351)2) M3 3.55±0.681)2) 0.09±0.021)2) 143.31±11.521)2) M4 3.02±0.521)2) 0.07±0.021)2) 126.35±10.151)2) D组(30例) M0 2.41±0.63 0.06±0.01 109.08±14.13 M1 2.91±0.551)2) 0.06±0.011)2) 122.73±13.611)2) M2 3.98±1.031)2) 0.11±0.021)2) 160.42±11.811)2) M3 3.50±0.621)2) 0.09±0.011)2) 142.75±10.521)2) M4 2.96±0.501)2) 0.07±0.011)2) 125.44±9.451)2) 与A组同时间点比较，1)P < 0.05；与B组同时间点比较，2)P < 0.05。
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表 4 4组围术期炎症因指标变化和差异
X±S 组别 时间 CRP/(mg·L-1) TNF-α/(ng·L-1) A组(30例) M0 6.23±1.57 21.24±6.32 M1 12.05±2.52 36.35±8.16 M2 19.35±3.26 43.26±12.45 M3 15.02±3.02 38.05±7.49 M4 13.11±2.69 32.15±6.43 B组(30例) M0 6.29±1.60 21.30±5.85 M1 10.05±2.13 32.05±7.46 M2 16.35±3.47 37.39±9.51 M3 12.05±2.35 32.05±6.47 M4 10.05±2.09 27.05±5.32 C组(30例) M0 6.41±1.62 20.96±6.14 M1 8.12±1.68 26.05±7.89 M2 10.05±2.69 31.35±6.13 M3 9.21±2.51 25.05±5.84 M4 7.02±1.69 21.23±3.35 D组(30例) M0 6.61±1.62 22.01±6.74 M1 8.02±1.52 25.97±7.29 M2 9.68±2.41 31.05±6.07 M3 9.12±2.33 24.95±5.12 M4 6.92±1.53 20.93±3.05
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[1] Kuang J, Yang J, Wang Q, Et Al. A preoperative mortality risk assessment model for stanford type a acute aortic dissection[J]. Bmc Cardiovasc Disord, 2020, 20(1): 508. doi: 10.1186/s12872-020-01802-9
[2] Weerink M, Struys M, Hannivoort Ln, et al. Clinical Pharmacokinetics And Pharmacodynamics Of Dexmedetomidine[J]. Clin Pharmacokinet, 2017, 56(8): 893-913. doi: 10.1007/s40262-017-0507-7
[3] Ren J, Li C, Ma S, et al. Impact of dexmedetomidine on hemodynamics in rabbits[J]. Acta Cir Bras, 2018, 33(4): 314-323. doi: 10.1590/s0102-865020180040000003
[4] 中华心血管病杂志编辑委员会, 胸痛规范化评估与诊断共识专家组. 胸痛规范化评估与诊断中国专家共识[J]. 中华心血管病杂志, 2014, 42(8): 627-632. doi: 10.3760/cma.j.issn.0253-3758.2014.08.002
[5] 张陈光, 张向阳, 王琰, 等. 急诊就诊Standford A型和B型主动脉夹层的临床差异性研究[J]. 临床急诊杂志, 2021, 22(11): 747-751. https://www.cnki.com.cn/Article/CJFDTOTAL-ZZLC202111009.htm
[6] 雍莉, 赵立志. 中性粒细胞计数对Standford B型急性主动脉夹层患者短期预后的影响[J]. 临床急诊杂志, 2020, 21(9): 731-738. https://www.cnki.com.cn/Article/CJFDTOTAL-ZZLC202009012.htm
[7] 刘皇军, 金立军, 刘雪银, 等. 主动脉夹层62例患者的血压特征及临床转归分析[J]. 实用医学杂志, 2011, 27(17): 3178-3180. doi: 10.3969/j.issn.1006-5725.2011.17.035
[8] 毛生元, 查斌山, 仇鹏, 等. 术前心率对急性B型主动脉夹层患者围术期发生主动脉相关不良事件的影响[J]. 中华血管外科杂志, 2020, 5(3): 169-174. doi: 10.3760/cma.j.cn101411-20191204-00079
[9] Lee S. Dexmedetomidine: present and future directions[J]. Korean J Anesthesiol, 2019, 72(4): 323-330. doi: 10.4097/kja.19259
[10] Chamadia S, Pedemonte JC, Hobbs LE, et al. A Pharmacokinetic and Pharmacodynamic Study of Oral Dexmedetomidine[J]. Anesthesiology, 2020, 133(6): 1223-1233. doi: 10.1097/ALN.0000000000003568
[11] Kang D, Lim C, Shim DJ, et al. The correlation of heart rate between natural sleep and dexmedetomidine sedation[J]. Korean J Anesthesiol, 2019, 72(2): 164-168. doi: 10.4097/kja.d.18.00208
[12] Wang C, Yuan W, Hu A, et al. Dexmedetomidine alleviated sepsis-induced myocardial ferroptosis and septic heart injury[J]. Mol Med Rep, 2020, 22(1): 175-184. doi: 10.3892/mmr.2020.11114
[13] 项冰倩, 罗梓垠, 高慧, 等. 右美托咪定对肺缺血再灌注小鼠的心肌保护作用: 与内质网应激的关系[J]. 中华麻醉学杂志, 2017, 37(1): 61-65. https://www.cnki.com.cn/Article/CJFDTOTAL-ZSFX202020011.htm
[14] Cifani N, Proietta M, Tritapepe L, et al. Stanford-A acute aortic dissection, inflammation, and metalloproteinases: a review[J]. Ann Med, 2015, 47(6): 441-446. doi: 10.3109/07853890.2015.1073346
[15] Lu HY, Hsu HL, Li CH, et al. Hydrogen Sulfide Attenuates Aortic Remodeling in Aortic Dissection Associating with Moderated Inflammation and Oxidative Stress through a NO-Dependent Pathway[J]. Antioxidants(Basel), 2021, 10(5): 682.
[16] Feng X, Guan W, Zhao Y, et al. Dexmedetomidine ameliorates lipopolysaccharide-induced acute kidney injury in rats by inhibiting inflammation and oxidative stress via the GSK-3β/Nrf2 signaling pathway[J]. J Cell Physiol, 2019, 234(10): 18994-19009. doi: 10.1002/jcp.28539
[17] Wang G, Zhong Q, Xu D. Comment on "Protective effect of dexmedetomidine on perioperative myocardial injury in patients with Stanford type-A aortic dissection"[J]. Rev Assoc Med Bras, 2021, 67(7): 1067. doi: 10.1590/1806-9282.20210375
[18] Pan S, Chen Y, Zhang X, et al. The JAK2/STAT3 pathway is involved in dexmedetomidine-induced myocardial protection in rats undergoing cardiopulmonary bypass[J]. Ann Transl Med, 2020, 8(7): 483. doi: 10.21037/atm.2020.03.67
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