异丙酚-瑞芬太尼和异氟烷-芬太尼麻醉下肝切除术患者肝缺血再灌注损伤的比较

目的 通过比较异丙酚-瑞芬太尼与异氟烷-芬太尼麻醉下肝切除术患者肝脏缺血再灌注损伤的程度,探讨肝切除术适宜的麻醉方法 .方法 择期行肝部分切除术患者30例,年龄41～64岁,体重58～86 kg,ASA Ⅰ或Ⅱ级,肝功能Child A级,随机分为异丙酚-瑞芬太尼组(PR组)和异氟烷-芬太尼组(IF组),每组15例.静脉注射咪达唑仑、芬太尼、依托咪酯和维库溴铵行麻醉诱导,气管插管后行机械通气.麻醉维持:PR组靶控输注异丙酚(血浆靶浓度3.5 μg/ml)和瑞芬太尼(血浆靶浓度4.2ng/ml);IF组吸入1.5%～2.5%异氟烷,问断静脉注射芬太尼2 μg/kg;2组均间断静脉注射维库溴铵维持肌松.于肝门阻断前(T1)、肝门开放后即刻(T2)、30 min(T3)、60 min(T4)和术后1 d(T5)时取右颈内静脉血样,测定血清谷丙转氨酶(ALT)、谷草转氨酶(AST)、γ-谷氨酰转肽酶(γ-GGT)、乳酸脱氢酶(LDH)、总胆红素(TBIL)、总超氧化物歧化酶(T-SOD)和丙二醛(MDA)的水平.结果 与IF组比较,PR组T5时ALT活性降低,L3、T4时γ-GGT活性降低,T5时T-SOD活性升高,T4、T5时MDA浓度降低(P<0.05).结论 与异氟烷-芬太尼麻醉相比,异丙酚-瑞芬太尼麻醉可减轻患者肝脏缺血再灌注损伤的程度,更适用于肝切除术.

Comparison of hepatic ischemia/reperfusion injury caused by partial hepatectomy performed under isoflurane-fentanyl and propofol-remifentanil anesthesia

Objective To compare the severity of hepatic ischemidreperfusion(I/R)injury caused by partial hepatectomy performed under propofol-remifentanil and isoflurane-fentanyl anesthesia.Methods Thirty ASA Ⅰ or Ⅱ patients aged 41-64 yr weighing 58-86 kg undergoing elective partial hepatectomy were randomly divided into 2 groups(n=15 each):propefol-remifentanil group(PR)and isoflurane-fentanyl group(IF).Anesthesia was induced with midazolam,fentanyl,etomidate and vecuronium.The patients were mechanically ventilated after tracheal intubation.Anesthesia was maintained with TCI of propofol(Cp=3.5μg/ml)and remifentanil(Cp=4.2 ng/ml)in group PR or 1.5%-2.5% isoflurane and intermittent iv boluses of fentanyl in group IF.Muscle relaxation was maintained with intermittent iv boluses of vecuronium in both groups.Blood samples were taken before occlusion of hepatic portal(T1)immediately(T2)and 30,60 min after release of portal occlusion(T3,4)and 1 d after operation(T5),for determination of sernm levels of ALT,AST,γ-GGT,LDH,TBIL,T-SOD and MDA.Specimens were obtained from the liver left intact after partial hepatectomy for ultrastructural examination with electron microscope.ResultsSerum levels of ALT at T5,γ-GGT at T3,4,and MDA at T4,5 were significandy lower while T-SOD at T5 were significantly higher in group PR than in group IF.Electron microscopic examination showed that tissue damages were significantly aRenuated in PR group as compared with IF group.Conclusion Propofol-remifentanil anesthesia can to some extent pmtect the liver against I/R injury during partial hepatectomy by reducing oxygen free radicals.