芬太尼对瓣膜置换围术期患者细胞因子和丙二醛的影响

目的：探讨不同剂量芬太尼对心脏瓣膜置换围术期患者血浆细胞因子和丙二醛的影响。方法:择期行首次心脏瓣膜置换术患者30例，随机分为3组： A组(芬太尼总量30μg/kg)， B组(芬太尼总量60μg/kg)， C组(芬太尼总量100μg/kg)，分别于术前(T1)、CPB转流前(T2)、开主动脉后30min(T3)、开主动脉后2h(T4)及术后24 h(T5)各时间点测定动脉血中肿瘤坏死因子-α(TNF-α)，白细胞介素-6(IL-6)，白细胞介素-10 (IL-10)，血浆丙二醛(MDA)浓度，并记录3组患者在ICU的滞留时间和拔管时间。结果：与术前(T1)比较，3组TNF-α，IL-6，IL-10，MDA在体外循环后明显升高(P<0.01)，B,C组TNF-α， IL-6，MDA均明显低于A组(P<0.05)，B,C组IL-10在T4，T5时明显高于A组(P<0.05)，但B,C组比较无显著差别，C组患者ICU滞留和术后拔管时间明显比A组和B组延长(P<0.05)。结论：CPB可促发促炎和抗炎细胞因子及氧自由基的释放，较大剂量芬太尼可抑制心脏手术所致的全身性炎性反应,减少氧自由基的产生，从而减轻再灌注损伤，但达一定剂量后这种效应并不存在剂量依赖性，且延长患者在ICU的滞留时间。

Effects of fentanyl on cytokines and MDA during cardiopulmonary bypass in patients undergoing valve replacement

OBJECTIVE: To investigate the effect of fentanyl on cytokines and MDA in valve replacement surgery during cardiopulmonary bypass ( CPB). METHODS: Thirty ASA II approximately III adult patients scheduled for cardial valve replacement were randomly divided into 3 groups: Group A (fentanyl 30 microg/ kg), Group B (fentanyl 60 microg/kg), and Group C (fentanyl 100 microg/kg). Anesthesia was induced with medazalam 0.1 mg/kg, fentanyl 10 microg/kg and vecuronium 0.1 mg/kg Administered intravenously. After tracheal intubation the patients were mechanically ventilated with pure oxygen. P(ET)CO2 was maintained between 35 approximately 45 mmHg. Anesthesia were maintained with fentanyl infusion combined with intermittent intravenous bolus of midazolam and vecuronium. MAP, CVP, HR, P(ET)CO2, SPO2, nasal and rectal temperature were monitored continuously. Remained dose of fentanyl was infused before the CPB. Blood Samples were taken before the operation (T1 ), before the CPB ( T2 ), 30 min after aortic declamping (T3 ) , 2 h after aortic declamping (T4 ), and 24 h (T5 ) after the operation for determination of plasma levels of tumor necrosis factor (TNF-alpha), interteukin IL-6 and IL-10, MDA. RESULTS: There was no significant change in the age, body weight, aortic cross-clomp time, CPB time, and operation time. Levels of TNF-alpha, IL-6, IL-10 and MDA after the CPB in the 3 groups were significantly higher compared with T, (P <0.01 ), TNF-alpha, IL-6 and MDA levels at T3, T4 were significantly lower in Group B and C than those in Group A. IL-10 levels at T4, T5 were significantly higher in Group B and C than those in Group A, but levels of TNF-alpha, IL-6, IL-10 and MDA in Group B were not significantly different compared with those in Group C. The duration of stay in the ICU and time of endotracheal extubation were significantly longer in patients of Group C than those of Group A and B. CONCLUSION: CPB leads to a proinflammatory and antiinflammatory response, as well as oxygen free radicals release. Larger dose fentanyl seemed to be effective in reducing CPB-induced inflammatory response and ischemic reperfusion injury, but the effect was not dependent on dose while fentanyl dose reaching some value, at the same time the duration of stay in ICU and time of endotracheal extubation is longer.