Clinical Research On The Effect Of The Creatine Phosphate Sodium Preconditioning On The Tourniquet Reaction In Orthopedic Operations During General Anesthesia

Objective:Through monitor the changes of the hemo-dynamics during the tourniquet application and the arterial plasma lactate after tourniquet deflation, to investigate on the effect of the creatine phosphate sodium preconditioning on the tourniquet-induced hyper-dynamic response in limbs orthopedics operation during general anesthesia.Methods:In this experiment, 42 patients undergoing limbs operations were selected from the Department of orthopedics of the First Affiliated Hospital of Dalian Medical University, between 2014 October and 2015 February. All cases were divided randomly into control group(group Co,n=17) and creatine phosphate sodium preconditioning group(group CP,n=25). Inclusion criteria were: adult patients(18-55 year old), with American Society of Anesthesiologists physical status I or II, who were scheduled for selective orthopedic limbs operations and required pneumatic tourniquet application during the operations. We excluded patients with American Society of Anesthesiologists physical status III or IV. We excluded patients with obesity(body mass index > 30kg/m2),anemia(hematocrit< 20%), fever(>38℃),or leucocytosis(white blood cells >10,000 /ml), too. Moreover, we excluded patients with a history of heart disease,diabetes, hypertension, lung disease, cerebrovascular disease, renal dysfunction, hepaticdysfunction, or allergy to creatine phosphate sodium. As well,We excluded patients with tourniquet time of >150 min or <60 min.Anesthesia induction: The blood concentration of remifentanil and propofol of target-controlled infusions was respectively set to 2ng/ml and 2.5μg/ml; and set the time of reaching the blood concentration 3 minutes. After target controlled infusion pump worked, midazolam(0.03mg/kg), cis-atracurium(0.2mg/kg), etomidate(0.2mg/kg) and sufentanil(0.5ug/kg) were given successively by intravenous injection. After successful induction of anesthesia and 10 min before the tourniquet inflation, the 2g of Creatine Phosphate Sodium dissolved in 20 ml normal saline(bolus time >4min), was injected slowly through the intravenous infusion channel in the group CP. In Co group, an equal amount of the normal saline was given instead of creatine phosphate sodium.Anesthesia maintenance: Remifentanil and propofol was respectively according to the blood concentration of 3ng/ml and 3μg/ml by target-controlled infusion after tracheal intubation. Cisatracurium besilate was given according to the dose of 0.1mg/kg by intravenous injection to maintain muscle relaxation per 45 min. During the maintenance of anesthesia, liquid only included the normal saline and hydroxyethyl starch(according to the normal saline: hydroxyethyl starch =2:1 standard infusion),which the infusion rate was 120-180ml/h, used only for maintaining venous access.During the anesthesia, patients who experienced hypertension(i.e. DAP > 90 mm Hg and/or SAP > 160 mm Hg for more than 5 min) were treated with urapidil injection((0.2-0.5)mg/kg, IV). Patients who experienced hypotension(i.e. MAP < 70 mm Hg and/or SAP < 90 mm Hg for more than 5 min) were treated with ephedrine injection(6mg, IV). Tachycardia(i.e. HR > 100 bpm for more than 5 min) was treated with esmolol injection(20-30 mg, IV), whereas bradycardia(i.e., HR < 50 bpm for more than 5 min)was treated with atropine injection(0.5mg, IV).During the anesthesia,we measured and recorded HR、SBP、MAP、DBP、BIS、P ET CO2 and RPP at the following time points : after the patients entered into the operation room(T0), immediately intubation during the anesthesia induction(T induction),immediately before tourniquet inflation(T inflation), every 15 min during tourniquetinflation(T15、T30、T45、T60、T75 and T90, respectively), immediately before tourniquet deflation(T bef-deflat), and 5 min after tourniquet deflation(T deflation). We extracted the blood samples from the radial arterial at T inflation and T deflation to measure:Lactate、 p H value、 glucose、P CO2. Moreover, we recorded the uses of and the total doses of various vasoactive drugs.The percentages of patients who developed tourniquet-induced hypertension(TIH), defined as more than a 30% increase in SAP during tourniquet application, were compared between groups.Results :1、The comparison of HR between patients in two groups(1)The HR values in the CP group measured at T30、T45、T60、T75、T90、T bef-deflat and T deflation were significantly lower than those in the Co group(all P < 0.05), the differences was statistically significant.(2)In the Co group, the HR values measured at T30、T45、T60、T75、T90 and T bef-deflat were significantly higher than that measured at T inflation(all P <0.05), the difference was statistically significant. While in the CP group, the HR values measured at T60、T75、T90and T bef-deflat were significantly higher than that measured at T inflation(all P < 0.05), the difference was statistically significant.2、The comparison of SBP、DBP、MAP between patients in two groups(1)There were no significant differences in SBP between two groups throughout the experiment(all P > 0.05).(2)In both groups, the SBP values measured at T15、T30、T45、T60、T75、T90 and T bef-deflat were significantly higher than that in the some group measured at T inflation(all P < 0.05), the difference was statistically significant.(3)The changes in MAP and DAP paralleled those of SAP.3、The comparison of RPP between patients in two groups(1)The RPP values in the CP group measured at T30、T45、T60、T75、T90、T bef-deflat and T deflation were significantly lower than those in the Co group(all P < 0.05), the difference was statistically significant.(2)In both groups, the RPP values measured at T15、T30、T45、T60、T75、T90 and T bef-deflat were significantly higher than that in the some group measured at T inflation(all P < 0.05), the difference was statistically significant.(1)There were no significant differences in BIS between two groups throughout the experiment(all P > 0.05).(2)In both group, there were no significant differences in BIS between in the some group throughout the experiment(all P > 0.05).5、The comparison of P ET CO2 between patients in two groups(1)The P ET CO2 value in the CP group measured at T deflation was significantly lower than that in the Co group( P < 0.05), the difference was statistically significant.(2)In both groups, the P ET CO2 value measured at T deflation was significantly higher than that in the some group measured at T inflation( P < 0.05), the difference was statistically significant.6、The comparison of the incidence of TIH、 the uses of various vasoactive drugs and the difference value of lactate between patients in two groups(1)The difference value of lactate in the CP group was significantly lower than that in the Co group( P < 0.05), the difference was statistically significant. In both groups, the lactate value measured at T deflation was significantly higher than that in the some group measured at T inflation( P < 0.05), the difference was statistically significant.(2)However, the incidence of TIH, the total doses of urapidil、esmolol and atropine consumption in these two groups were comparable(all P > 0.05). In addition, none of the cases included in this study received ephedrine.4、The comparison of BIS between patients in two groupsConclusion:Creatine phosphate sodium preconditioning can alleviate the increase of HR and reduce the myocardial oxygen consumption caused by tourniquet application; can reduce the accumulation of lactate and the generation of CO2 during tourniquet application. But whether creatine phosphate preconditioning can attenuate tourniquet-induced hyper-dynamic response, it remains to be further explored.