文章摘要
艾司氯胺酮对心肺转流心脏手术患者心室功能及颈内动脉血流的影响
Effects of esketamine on ventricular function and internal carotid artery blood flow in patients undergoing cardiac surgery under cardiopulmonary bypass
  
DOI：10.12089/jca.2024.10.006
中文关键词: 艾司氯胺酮  心室功能  超声斑点追踪显像  经食管超声心动图
英文关键词: Esketamine  Ventricular function  Speckle tracking imaging  Transesophageal echocardiography
基金项目:
作者单位E-mail
李宛霖 210006,南京医科大学附属南京医院（南京市第一医院）麻醉疼痛与围术期医学科  
孟洁琼 210006,南京医科大学附属南京医院（南京市第一医院）麻醉疼痛与围术期医学科（现在上海市第六人民医院麻醉科）  
韩瑛 210006,南京医科大学附属南京医院（南京市第一医院）麻醉疼痛与围术期医学科  
赵雅梅 210006,南京医科大学附属南京医院（南京市第一医院）麻醉疼痛与围术期医学科  
尹加林 210006,南京医科大学附属南京医院（南京市第一医院）麻醉疼痛与围术期医学科  
魏海燕 210006,南京医科大学附属南京医院（南京市第一医院）麻醉疼痛与围术期医学科  
苏中宏 210006,南京医科大学附属南京医院（南京市第一医院）麻醉疼痛与围术期医学科  
施韬 210006,南京医科大学附属南京医院（南京市第一医院）麻醉疼痛与围术期医学科  
葛亚力 210006,南京医科大学附属南京医院（南京市第一医院）麻醉疼痛与围术期医学科  
史宏伟 210006,南京医科大学附属南京医院（南京市第一医院）麻醉疼痛与围术期医学科 mdshw@163.com 
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中文摘要:
      
目的：评价心肺转流（CPB）开始时静脉输注艾司氯胺酮对心脏瓣膜置换术患者心室功能和颈内动脉血流的影响。
方法：选择择期行CPB心脏瓣膜置换术的患者60例，男38例，女22例，年龄18～75岁，BMI 18.5～30.0 kg/m2，ASA Ⅱ或Ⅲ级，NYHA心功能分级Ⅰ—Ⅲ级，左心室射血分数（LVEF）≥45%。采用随机数字表法将患者分为两组：艾司氯胺酮组（E组）和生理盐水组（C组），每组30例，术中均采用全凭静脉麻醉。CPB开始后，E组静脉输注艾司氯胺酮0.5 mg·kg-1·h-1至手术结束，C组以相同速度输注等容量生理盐水。记录麻醉诱导前、切皮时、CPB停机后60 min内HR、MAP、CVP、心脏指数（CI）；切皮时、CPB 40 min内、CPB停机后60 min内LVEF、左心室整体纵向应变（GLS）、整体纵向达峰时间应变标准差（GLTSD）、整体环向应变（GCS）、整体环向达峰时间应变标准差（GCTSD）以及右心室射血分数（RVEF）、右心室GLS、GLTSD；麻醉诱导前、切皮时、CPB 40 min内、CPB停机后60 min内rScO2、BIS、Hb和乳酸（Lac）浓度以及颈内动脉血流收缩期峰值流速（SPV）、颈内动脉血流量（Q-ICA）、血流阻力指数（RI）；麻醉诱导前、术后6 h心肌肌钙蛋白I（cTnI）、谷丙转氨酶（ALT）、肌酐（Cr）、神经元特异性烯醇化酶（NSE）浓度。记录停机后自动复跳例数、术后拔管时间、ICU停留时间、总住院时间、心脏不良事件以及术后30 d死亡例数。
结果：与C组比较，E组CPB停机后60 min内CI明显升高（P＜0.05）；CPB停机后60 min内LVEF、RVEF及右心室GLS明显升高（P＜0.05）；CPB停机后30 min左心室GLS、GCS及右心室GLS明显升高（P＜0.05）；CPB 40 min内RI明显升高（P＜0.05）。两组cTnI、ALT、Cr、NSE浓度、停机后自动复跳比例、术后拔管时间、ICU停留时间、总住院时间、心脏不良事件发生率以及术后30 d死亡率差异均无统计学意义。
结论：心脏手术患者在CPB开始后使用艾司氯胺酮能明显增加CPB停机后的CI，并可能通过增加心室纵向和环向应变力来增强心肌收缩，提高术后心室射血分数，维持血流动力学稳定。
英文摘要:
      
Objective: To assess the impact of intravenous esketamine administered prior to cardiopulmonary bypass (CPB) initiation on ventricular function and internal carotid artery blood flow in patients undergoing heart valve replacement surgery.
Methods: Sixty patients underwent elective CPB heart valve replacement, 38 males and 22 females, aged 18-75 years, BMI 18.5-30.0 kg/m2, ASA physical status Ⅱ or Ⅲ, NYHA cardiac function classificationⅠ-Ⅲ, and a left ventricular ejection fraction (LVEF) of ≥ 45%, were selected. The patients were randomly divided into two groups: esketamine group (group E) and normal saline group (group C), 30 patients in each group. Total intravenous anesthesia was used during the operation. Following the initiation of CPB, group E received an intravenous infusion of esketamine at a rate of 0.5 mg·kg-1·h-1 until the conclusion of the procedure, while group C received an equivalent volume of normal saline concurrently at the same rate. HR, MAP, CVP, and cardiac output index (CI) were recorded before anesthesia induction, during skin resection, and within 60 minutes after stopping CPB. LVEF, left ventricular global longitudinal strain (GLS), global longitudinal time-to-peak strain standard deviation (GLTSD), global circumferential strain (GCS), global circumferential time-to-peak strain standard deviation (GCTSD), right ventricular ejection fraction (RVEF), right ventricular GLS, and GLTSD were obtained during skin resection, within 40 minutes of CPB, and 60 minutes after stopping CPB. rScO2, BIS, concentrations of Hb and lactic acid (Lac), peak systolic flow velocity (SPV), quantity of flow-internal carotid artery (Q-ICA), and blood flow resistance index (RI) were recorded before anesthesia induction, during skin resection, within 40 minutes of CPB, and within 60 minutes after stopping CPB. Concentrations of cardiac troponin I (cTnI), alanine aminotransferase (ALT), creatinine (Cr), and neuron-specific enolase (NSE) were recorded before anesthesia induction and 6 hours after operation. Spontaneous resuscitation after CPB, postoperative extubation time, duration of ICU stay, total hospital stay, incidence of adverse cardiac events, and 30-day postoperative mortality were recorded.
Results: Compared with group C, group E exhibited a significant increase in CI within 60 minutes after stopping CPB (P < 0.05). The LVEF, RVEF, and right ventricular GLS demonstrated significant increases within 60 minutes after stopping CPB in group E compared with group C (P < 0.05). The left ventricular GLS and left ventricular GCTSD displayed significant increases 30 minutes after stopping CPB in group E compared with group C. The RI exhibited a significant increase within 40 minutes of CPB in group E compared with group C (P < 0.05). There were no significant differences in cTnI, ALT, Cr, NSE, spontaneous resuscitation affter CPB, postoperative extubation time, duration of ICU stay, total hospital stay, incidence of cardiac adverse events, and 30-day postoperative mortality between the two groups.
Conclusion: Administration of esketamine following the onset of CPB in patients undergoing cardiac surgery demonstrates a significant elevation in CI post-CPB cessation. Furthermore, it may augment ventricular longitudinal strain, thereby enhancing myocardial contraction, leading to increased postoperative ventricular ejection fraction, and sustaining hemodynamic stability.
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