重组人脑利钠肽对非体外循环冠脉搭桥患者术后心功能的影响

发布时间：2018-06-03 14:40

本文选题：重组人脑利钠肽 + 非体外循环冠脉搭桥　；参考：《河北医科大学》2017年硕士论文

【摘要】：目的:观察重组人脑利钠肽(rhBNP)对非体外循环下冠脉搭桥患者术后心功能的影响;观察rhBNP对于非体外循环下冠脉搭桥术患者监护及住院总时间、心血管事件发生率的影响;观察rhBNP应用的安全性。方法:1将拟于我院接受非体外循环冠状动脉搭桥术(OPCABG)的103例患者利用随机数字表格法分为rhBNP组和对照组,其中rhBNP组52例、对照组51例。对照组:行OPCABG后带气管插管送ICU常规治疗;rhBNP组:在常规治疗基础上,术后返回ICU后静脉泵入rhBNP,先以1.5μg/kg的负荷量静注,后以0.0075μg·kg~（-1）·min~（-1）的维持量持续静脉泵入72小时;2两组病例均在静吸复合麻醉气管插管下完成手术;均常规于左侧桡动脉放置动脉留置针以直接监测血压,于右侧锁骨下静脉放置三腔Arrow静脉留置管以泵入药物,于右侧颈内静脉置入Swan-Ganz导管以检测相关指标,两组病例参与手术操作人员及过程均相同。过程如下:常规给予消毒铺单后行胸部正中切口,按照皮肤-皮下-肌肉-骨膜的顺序依次切开,胸骨锯纵行由上至下劈开胸骨,应用电刀及骨蜡充分止血后游离左侧胸廓内动脉(由第4或5肋开始游离,向上游离至第1肋,向下游离至剑突),同时取材大隐静脉(采取全开放方式),左侧胸廓内动脉远端离断后切开、悬吊心包并嘱麻醉师静脉应用肝素钠(1mg/kg),左侧胸廓内动脉远端结扎止血。使用北京航天卡迪HK系列心脏稳定器固定靶血管,常规冠状动脉腔内放置分流栓,以7-0或8-0 Prolence线连续缝合进行端侧、端端吻合,通常先行左侧胸廓内动脉与左前降支进行端侧吻合,然后根据造影结果判定靶血管,后行升主动脉-大隐静脉端侧吻合,再依次序贯吻合对角支、回旋系统及右冠系统;主动脉近端吻合均使用吻合辅助器械(Anastomosis Assist Device),以6-0 Prolence线连续缝合吻合口。3分别于术前、术后即刻(用药前)、术后24小时、术后48小时、术后7天抽取静脉血,检测B型脑钠肽(BNP)以及肌钙蛋白(c Tn I);分别于术前、术后即刻(用药前)、术后24小时、术后48小时、术后7天行心脏彩色多普勒超声心动图检查左心室射血分数(LVEF);分别于术前、术后即刻(用药前)、术后24小时、术后48小时、术后7天测定患者心排量(CO)及肺毛细血管楔压(PAWP)。4每次取血样3ml,抽血后30分钟内在4℃3000r/min离心机中离心10min,取上清液并于20min内进行检测并记录BNP以及c Tn I;由同一心脏超声科医生同一台机器行心脏彩色多普勒超声心动图检查并记录LVEF;由置入成功的Swan-Ganz导管监测并记录CO、PAWP。5术后观察心血管事件发生率。6计量资料采用均数±标准差(SX±)表示,组间比较采用t检验,两样本率的比较采用卡方检验或Fisher精确检验。结果:1两组各有1例术中中转体外循环而终止本项研究,实际参加本项研究例数:rhBNP组51例、对照组50例。2两组患者一般资料和桥血管情况比较:rhBNP组男性29人,女性21人,平均年龄62±7岁,吸烟者39人,血脂异常者29人,合并糖尿病者8人,合并高血压者24人,平均左心室射血分数51.24±3.26,平均血管桥数3.31±0.40,平均远端吻合口数3.20±0.40;对照组男性31人,女性19人,平均年龄64±9岁,吸烟者40人,血脂异常者30人,合并糖尿病者9人,合并高血压者27人,平均左心室射血分数50.34±2.79,平均血管桥数3.19±0.61,平均远端吻合口数3.30±0.31,两组间比较差别无统计学意义(P0.05)。3 rhBNP组和对照组术前BNP比较,差别无统计学意义(P0.05);术后即刻(用药前)BNP比较,差别无统计学意义(P0.05);术后24小时BNP比较,差别有统计学意义(P0.05);术后48小时BNP比较,差别有统计学意义(P0.01),术后7天BNP比较,差别有统计学意义(P0.05)。4 rhBNP组和对照组术前c Tn I比较,差别无统计学意义(P0.05);术后即刻(用药前)c Tn I比较,差别无统计学意义(P0.05);术后24小时c Tn I比较,差别有统计学意义(P0.05);术后48小时c Tn I比较,差别有统计学意义(P0.05),术后7天BNP比较,差别无统计学意义(P0.05)。5 rhBNP组和对照组术前LVEF比较,差别无统计学意义(P0.05);术后即刻(用药前)LVEF比较,差别无统计学意义(P0.05);术后24小时LVEF比较,差别有统计学意义(P0.05);术后48小时LVEF比较,差别有统计学意义(P0.01),术后7天LVEF比较,差别有统计学意义(P0.05)。6 rhBNP组和对照组术前CO比较,差别无统计学意义(P0.05);术后即刻(用药前)CO比较,差别无统计学意义(P0.05);术后24小时CO比较,差别有统计学意义(P0.05);术后48小时CO比较,差别有统计学意义(P0.01),术后7天CO比较,差别有统计学意义(P0.05)。7 rhBNP组和对照组术前PAWP比较,差别无统计学意义(P0.05);术后即刻(用药前)PAWP比较,差别无统计学意义(P0.05);术后24小时PAWP比较,差别有统计学意义(P0.05);术后48小时PAWP比较,差别有统计学意义(P0.01),术后7天PAWP比较,差别有统计学意义(P0.05)。8 rhBNP组发生心绞痛、室性心律失常、心肌梗死、低心排综合征分别为5例(9.8%)、7例(13.7%)、2例(3.9%)及0例,对照组发生心绞痛、室性心律失常、心肌梗死、低心排综合征分别为5例(10%)、8例(16%)、2例(4%)及1例(2%),两组均未出现死亡病例。两组患者住院期间心血管事件和死亡的发生情况差异无统计学意义(χ2=0.117,P=0.7320.05)。9 rhBNP组和对照组ICU平均时间分别为54±14小时、61±16小时,两者比较t=2.33,P0.05,差别有统计学意义;两组住院总时间分别为9±2.4天、10±1.3天,两者比较t=2.59,P0.05,差别有统计学意义。结论:OPCABG术后应用rhBNP可明显改善患者的心功能;OPCABG术后应用rhBNP可缩短术后监护及住院总时间;应用rhBNP安全、可靠;rhBNP对心血管事件发生率没有明显的升高或降低的作用。
[Abstract]:Objective: To observe the effect of recombinant human brain natriuretic peptide (rhBNP) on cardiac function after off-pump coronary artery bypass grafting (CPB), to observe the effect of rhBNP on the monitoring of patients with coronary artery bypass grafting under extracorporeal circulation and the total time of hospitalization, the incidence of cardiovascular events, and to observe the safety of the rhBNP application. Methods: 1 we will receive non extracorporeal circulation crowns in our hospital. 103 patients with artery bypass grafting (OPCABG) were divided into rhBNP group and control group by random digital table method, of which 52 cases in group rhBNP and 51 cases in control group. The control group was given ICU routine treatment with tracheal intubation after OPCABG; rhBNP group: on the basis of routine treatment, after the return of ICU, the venous pump entered rhBNP after the operation, and then was injected with a load of 1.5 u g/kg, then 0 The maintenance of 075 mu g. Kg~ (-1). Min~ (-1) was maintained for 72 hours, and 2 two cases were performed under the combined anesthesia and endotracheal intubation. All the cases were routinely placed on the left radial artery to monitor the blood pressure directly. The three cavity Arrow vein catheter was placed in the right subclavian vein to pump the drug and the right internal jugular vein was placed in S. The wan-Ganz catheter was used to detect the related indexes. The two groups of cases participated in the operation and the process were the same. The process was as follows: the routine was given after the sterilizing sheet was given in the middle incision, the skin subcutaneous muscle - periosteum was cut in order, the sternum saw the sternum from top to bottom, and the left left chest was free after the electroknife and bone wax were fully hemostat. The internal artery (from fourth or 5 ribs began to dissociate, free to first ribs, down to the sword process), and the large saphenous vein (all open mode), the left side of the distal thoracic artery was removed from the distal end, the pericardium was suspended and the anesthesiologist used heparin sodium (1mg/kg), and the left thoracic internal artery was ligated to the distal end of the thoracic artery. The use of Beijing space Cardy H The K series of cardiac stabilizers fixed the target vessels in the conventional coronary artery. The end to side and end to end anastomosis was performed continuously with 7-0 or 8-0 Prolence lines. Usually the left anterior thoracic artery and the left anterior descending branch were anastomosed to the end to side, and then the target tube was determined according to the results of the angiography, then the ascending aorta and the end to side anastomosis of the great saphenous vein were followed. Sequential anastomosis of diagonal branches, gyrations and right coronal systems; anastomosis auxiliary instruments (Anastomosis Assist Device) were used in the proximal anastomosis of the aorta, and the anastomotic.3 was sutured continuously with 6-0 Prolence lines before operation, immediately after the operation (before use), 24 hours after operation, 48 hours after operation, and 7 days after the operation to detect B type natriuretic peptide (BNP) and muscle. Calcium protein (C Tn I); before operation, immediately after operation (before use), 24 hours after operation, 48 hours after operation, and 7 days after operation, the left ventricular ejection fraction (LVEF) was examined by color Doppler echocardiography; the cardiac output (CO) and pulmonary capillary wedges were measured at 48 hours after operation, 24 hours after operation and 48 hours after operation. Pressure (PAWP).4 was taken every time 3ml of blood sample, 30 minutes after blood was pumped, 10min was centrifuged in 3000r/min centrifuge at 4 C, the supernatant was detected in 20min and BNP and C Tn I were recorded and C Tn I was recorded by the same heart ultrasound doctor with a color Doppler echocardiography of the same machine. Records CO, PAWP.5 after the observation of the incidence of cardiovascular events.6 measurement data using mean standard deviation (SX +), compared with t test, two sample rate compared to Chi square test or Fisher accurate test. Results: 1 two groups of 1 cases in the operation of cardiopulmonary bypass and end of the final study, the actual participation in the number of cases: rhBNP group 51 In the control group, the general data and the bridge vessel condition of the 50.2 two groups were compared: the rhBNP group was 29 men and 21 women, the average age 62 + 7 years old, 39 smokers, 29 dyslipidemia, 8 with diabetes, 24 with hypertension, average left ventricular ejection fraction 51.24 3.26, average vascular bridge number 3.31 + 0.40, average distal anastomosis number 20 + 0.40, 31 men and 19 women in the control group, the average age of 64 + 9 years, 40 smokers and 30 people with dyslipidemia, 9 people with diabetes, 27 people with hypertension, average left ventricular ejection fraction 50.34 + 2.79, average vascular bridge number 3.19 + 31, average distal anastomosis number, and the difference was not statistically significant (P0.05).3 R There was no statistical difference between group hBNP and control group before operation BNP (P0.05); there was no significant difference in BNP comparison (P0.05) after the operation (P0.05). The difference was statistically significant (P0.05) after 48 hours after operation (P0.05), and the difference was statistically significant (P0.01), and BNP comparison of 7 days after the operation, and the difference was statistically significant (P0.05).4 There was no statistical difference between group hBNP and control group before operation C Tn I (P0.05), and there was no statistical difference (P0.05) in C Tn I immediately after operation (P0.05), and the difference was statistically significant after 24 hours C Tn I. The difference was statistically significant 48 hours after the operation, and there was no statistical difference between the 7 days after the operation. There was no statistically significant difference between the P0.05.5 rhBNP group and the control group before operation (P0.05), and there was no statistically significant difference (P0.05) compared with LVEF before operation (P0.05). The difference was statistically significant (P0.05) at 24 hours after operation (P0.05), and the difference was statistically significant (P0.01) at 48 hours after operation (P0.01), and 7 days after the operation, the difference was statistically significant. There was no statistical difference between the P0.05.6 rhBNP group and the control group before operation (P0.05), and there was no statistically significant difference (P0.05) compared with CO before operation (P0.05). The difference was statistically significant (P0.05) at 24 hours after operation (P0.05); the difference was statistically significant (P0.01) at 48 hours after operation (P0.01), and 7 days after the operation, the difference was statistically significant. There was no statistical difference between group P0.05.7 rhBNP and control group before operation PAWP (P0.05), and there was no statistical significance (P0.05) compared with PAWP before operation (P0.05). The difference was statistically significant (P0.05) at 24 hours after operation, and the difference was statistically significant (P0.01) at 48 hours after operation (P0.01), and 7 days after operation, there was a difference. There were 5 cases (9.8%), 7 cases (13.7%), 2 cases (3.9%) and 0 cases in group.8 rhBNP, 7 cases (13.7%), 2 cases (3.9%), 5 cases (10%), 8 cases (16%), 8 cases (4%) and 7 patients in the control group. There was no significant difference in the incidence of cardiovascular events and deaths in the two groups (x 2=0.117, P=0.7320.05).9 rhBNP and the control group, the average time of ICU was 54 + 14 hours, 61 + 16 hours respectively, and the difference was t=2.33, P0.05, and the difference was statistically significant; the total hospital time in the two group was 9 + 2.4 days, 10 + 1.3 days, the two were compared. Compared with t=2.59, P0.05, the difference was statistically significant. Conclusion: the use of rhBNP after OPCABG can obviously improve the cardiac function of the patients; after OPCABG, the application of rhBNP can shorten the postoperative monitoring and the total time of hospitalization; the application of rhBNP is safe and reliable; rhBNP does not significantly increase or decrease the incidence of cardiovascular events.
【学位授予单位】：河北医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R654.2

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