Effects And Mechanisms Of Ultrasound-Guided Left SGB On The Outcome In Patients Undergoing Cardiac Surgery With CPB

Part 1 The effect of left SGB on the outcome in patients undergoing cardiac surgery with CPBObjectives:The present study was undertaken to evaluate the effect of left stellate ganglion block on hemodynamics changes;pulmonary artery pressure and incidence of arrhythmia after CPB;complications,time of distubation,ICU stay time,hospitalization time,total expense,30-day mortality in patients underwent cardiac surgery with CPB.And the severity of complications was classified and the risk factors of serious complications of Clavien Dindo III-IV after cardiac surgery were analyzed.Methods:From May 2016 to June 2017,52 paitens who underwent valve replacement with cardiopulmonary bypass in one Universory Affiated Hospital were enrolled.Patients were randomly divided into SGB group(0.5% ropivacaine 8 ml ultrasound-guided left stellate ganglion block)and control group(0.9% saline 8 ml left stellate ganglion block).Patients with local anesthetic allergy,fever,preoperative hormone use and other inflammatory diseases were excluded.Excluding one failure of SGB and one re-doing,a total of 50 patients were enrolled in the prospective randomized controlled study.All cases were operated by fixed members of the same treatment group.The same general anesthesia scheme was used to collect patients’ characteristics(age,gengder,body mass index,ASA grade,preoperative cardiac function,exercise tolerance,preoperative cardiac ejection fraction,MAP,CVP,arterial pressure,cetral venous pressure,pulmonary artery pressure),intraoperative and auto-rebeating conditions(cardiopulmonary bypass time,aortic occlusion time,blood transfusion,pulmonary arterial pressure,ventricular and atrial fibrillation incidence);Postoperative conditions(intubation time,complications,ICU stay time,hospital stay time,total cost of hospitalization,30 day mortality).All postoperative complications(incision infection,oxygenation damage,lung infection,renal insufficiency,malignant arrhythmia,bleeding,cognitive function,etc.)were recorded and graded by Clavien Dindo classofication.Risk factors for serious complications of Dindo III-IV of cardiac surgery were analyzed.Results:1.A total of 50 patients were analyzed in the present study,25 in each group.There was no significant difference in basic characteristics(age,gender,BMI,ASA classification,cardiac function,disease type and surgical option)(P > 0.05).Systolic blood pressure decreased briefly after being blocked in SGB group(142.96±15.16 vs128.48±18.29,P<0.05).2.Compared with the control group,the pulmonary artery pressure(4.32 ±7.71 mmhg vs 1.80 ± 5.87 mmhg,P < 0.05)and the incidence of ventricular fibrillation decreased significantly(12% vs 36%,P < 0.01)in the SGB group after CPB.3.The complications(mild oxygenation damage,postoperative delirium and malignant arrhythmia)in SBG group were less than those in control group(P < 0.01).The time of vasoactive drug support and intubation duration in SBG group were less than those in control group,but there was no statistical significance between the two groups.Cardiac ejection fraction and Troponin I change on the first day after operation and 30-day mortality were comparable between the two groups.ICU stay,hospital stay and total hospitalization cost in SBG group were slightly less than those in control group,but there was no statistical significance between the two groups.There was no significant difference in incision infection,hemorrhage and renal insufficiency between the two groups(P > 0.05),but severe complication score of Clavien Dindo III-IV in the control group was significantly higher than that in the SBG group(24% vs 4%,P <0.01).4.Clavien Dindo III-IV severe complication score significantly increased ICU stay;postoperative hospital stay and total cost of hospitalization(P<0.01).Gender,age,smoking history,SGB,intubation duration and exercise tolerance were the possible influencing factors,while exercise tolerance < 3 was the independent risk factors for Clavien Dindo III-IV severe complication.Conclusions:Compared with the control group,the left SGB can reduce the pulmonary artery pressure and the incidence of ventricular fibrillation during auto-rebeating period,it could also reduce the incidence of mild oxygenation damage,postoperative delirium,malignant arrhythmia and the occurrence of severe complications of Clavien Dindo III-IV after cardiac surgery.Statistical analysis showed that gender,elder,smoking history,SGB,intubation duration and exercise tolerance were the risk factors and exercise tolerance < 3 was the independent risk factor of Clavien Dindo III-IV severe complications.The ultrasound-guided SGB is safe and none of the patients suffered hematoma,recurrent laryngeal nerve palsy,peripheral tissue injury and other complications and can be widely used in clinical,but it needs more further study on the mechanism of SGB.Part 2 The menchanisms of left SGB improving outcome in patients undergoing cardiac surgery with CPBObjectives:Cardiac surgery with CPB would induce systemic inflammatory response syndrome(SIRS),immunosuppression for the surgical trauma,hypothermia,ischemia-reperfusion injury.How to effectively prevent and improve the outcome especially the complicaitons of cardiac surgery has always been a research hotspot.Neuroendocrine immune network is an important regulatory system.The sympathetic nervous system plays an important role in maintaining the steady state of neuroendocrine immune network.Stellate ganglion block(SGB)has been proved to regulate inflammation and immune system through sympathetic block in animals and human body.In the first sub topic of clinical research,we have found that SBG can effectively improve the outcome in patients of cardiac surgery,especially decrease the incidence and severity of perioperative complicaions.In this part,we mainly focus on inflammation and the dynamic changes of inflammarory factores to explore the possible molecular mechanisms of SGB to improve perioperative outcome.We aim to provide a new strategy and theoretical basics for improving the outcome in patients undergoing cardiac surgery.Methods:50 patients who underwent valve replacement surgery from May 2016 to June2017 were finally prospectively enrolled in the present study.The details of groups,anesthesia and surgergy were seen in the Part 1.The WBC count,body temperature,heart rate and respiratory index were recorded within 24 hours after operation,and the incidence of SIRS was compared between the two groups.The dynamic changes of neutrophils,lymphocytes,TNF-α,IL-1 β,IL-10 in plasma were measured at four time points before(T1)and after block 6h(T2),1D(T3)and 5D(T4).We aim to explore the possible molecular mechanism of SGB to improve the perioperative prognosis and reduce severe complications in patients undergoing cardiac surgery.Results:1.Compared with the control group,patients with WBC > 12 × 109 / L or HR >90 BMP within 24 h after CPB was lower in SGB group,but the difference was not statistically significant.There was also no difference in body temperature and respiratory index between the two groups(P > 0.05).Compared with the control group,SGB significantly decreased the up-regulated neutrophils 6 hours after CPB(92.26 + 2.60 vs 89.5 + 3.42,P < 0.01),but significantly increased down-regulated lymphocytes 5 days after CPB(10.94 + 6.15 vs 15.76 + 4.99,P < 0.05)After all,the incidence of SIRS in SGB group and control group was 40% and72% respectively,SGB significantly reduced the incidence of SIRS in 24 hours(P <0.05).2.Compared with the control group,SBG effectively inhibited the increase of TNF-α 6 hours {50.7(27.1,72.4)vs 28.2(24.6,39.3)} and {42.6(25.8,72.8)vs 25.7(24.1,44.4)} one day after block(P < 0.05).But there was no significant difference in IL-1 βand IL-10 between the two group at each time point(P > 0.05).Conclusions:SBG can effectively inhibit the increase of plasma TNF-α,promote the recovery of up-regulated neutrophil and down-regulated lymphocytes,and effectively reduce the incidence of SIRS 24 hrs after heart operation.But as to IL-1 β and IL-10,there is no difference between the two groups.