Effect Of Sevoflurane With Propofol On Stress Response During One Lung-ventilation

Background and ObjectiveOne-lung ventilation,OLV is widely used in thoracic surgery from providing the ideal surgical field to the operation to a serious accident and emergency treatment of pulmonary hemorrhage.However,one-lung ventilation can result in intrapulmonary shunt,Qs/Qt ventilation than blood(V/Q)disorders,high airway pressure and ischemia-reperfusion in lung and other physiological disorders,the body should have a strong stress response,leading to a variety of stress hormones and a variety of cytokines(CK) to release and causes the systemic inflammatory response syndrome(SIRS) caused a further series of pulmonary complications.Sevoflurane for its low blood gas partition coefficient(0.63) so that the depth of anesthesia can be controlled and predictable recovery time,and the insoluble so that people can more easily manage the depth of anesthesia and to maintain hemodynamic stability,althoug sevoflurane on the cardiovascular system have a certain degree of inhibition,and have the trend of a dose-dependent manner.of myocardial ischemia-reperfusion injury and protective effect on cerebral blood vessels are weak expansion of the role of its the advantage of clinical application.Related studies have shown that inhalation of halogen-type anesthetic agents have inhibited hypoxic pulmonary vasoconstriction(HPV).In the application on one-lung ventilation,the impact compared with propofol to(HPV) is no significant difference.Sevoflurane at the same time can reduced to generate oxygen free radicals on the antioxidant free radical damage,reduce the myocardial ischemia-reperfusion injury,but also by reducing the lactate dehydrogenase(LDH) activity and inhibition of tumor necrosis factor-α(TNF-α) release reduce nitric oxide(NO) metabolites reduce the lung ischemia-reperfusion-induced acute lung injury(ALI).Sevoflurane can also affect the metabolism of oxygen free radicals and NO reduce endotoxin(LPS)-induced ALI;sevoflurane can inhibit TNF-αexpression or release in a certain extent in the lungs to reduce the inflammatory response.And propofol is a new intravenous anesthetic,is widely used in clinical anesthesia and Intensive Care Unit,ICU of sedation in critical patients,the study shows that propofol inhibited adrenocortical hormone secretion by the cortex can reduce cortisol and catecholamines,but,after stopping,the density rapidly return to preoperative levels The results showed that routine doses of propofol inhibited to some extent the hypoxic pulmonary vasoconstriction(HPV),increase in Qs/Qt,so that decline in PaO2,but it is still the normal range,no significant hypoxia acidosis and carbon dioxide retention,Qs/Qt is also less 30%stable hemodynamics.At the same time,propofol can affect the TNF-αproduction and release,and at low concentrations have a strong inhibitory effect,can reduces significantly IL-6,TNF-αresponse.Propofol reduced LPS stimulated the release of polymorphonuclear cell IL-8.Effectively inhibited IL-8 synthesis and release,may be a slight increase in the release of IL-4 to enhance IL-10 and IL-1ra content,reduces the toxicity of endotoxin,intravenous maintain promotes anti-inflammatory cytokine production.The results from existing research that propofol and sevoflurane on lung injury induced by the one-lung ventilation have a protective effect,but,between propofol and sevoflurane,the direct comparative study has not been reported,the aim of this experiment is to compare the effecs of sevoflurane inhalation compound remifentanil general anesthesia and intravenous propofol continuous infusion composite of remifentanil in general anesthesia on perioperative cortisol,TNF-α,IL-10 and hemodynamics,evaluate of which drugs is more conducive to injury caused by thoracic surgery on one-lung ventilation,to provide reasonable anesthesia.Materials and Methods30 patients in routine lobectomy with lung cancer were randomly divided into two groups:group sevoflurane(S),group propofol(P);15 cases of each group.Inclusion criteria:one-week history of non-infected;lung function and normal or only mild dysfunction of ventilation,do not pre-operative immunotherapy and chemotherapy;not immune,endocrine system complications;not taking hormone drugs.Operation time of less than three hours,during non-blood transfusion,the importation of normal saline,Ringer's solution and the colloidal liquid.Exclusion criteria:(1) double-lumen intubation difficulties and poor positioning; (2) intraoperative application of corticosteroids,aprotinin or other drugs the patient cell membrane stability,and those who can not complete the test.(3) blood loss greater than 400 ml or more.Preoperative preparation:Patients included in trials in 30 minutes before anesthesia injected with atropine 0.5mg,phenobarbital sodium 0.1 g.After entering the operating room and opening up channels of peripheral intravenous infusion with a Philips multi-function monitor vital signs of patients continuous monitoring of blood pressure(BP),heart rate(HR),electrocardiogram(ECG),pulse oxygen saturation (S_pO₂);the Board Ma under the ipsilateral upper extremity radial artery puncture directly measured arterial pressure and the right subclavian vein puncture,placement of central venous catheter,single cavity to obtain blood samples,induction of anesthesia and intraoperative transfusion connecting bispectral index(BIS) monitor A-2000.Anesthesia induction is practiced in two groups by intravenous injection: midazolam 0.1mg/kg,fentanyl 4μg/kg,etomidate 0.3mg/kg,succinylcholine 1 mg/kg, then inserted a double-lumen bronchial tube.anesthesia maintain were done: continuous intravenous propofol infusion 4-8mg/kg with micro-pump(Group P) and inhaled 1%-3%sevoflurane(Group S),Remifentanil 0.2μg/kg·min was continuous intravenous injected with micro-pump and Atracurium 0.1-0.5mg/ml was injected intermittently in two groups.The propofol infusion speed and the concentration of sevoflurane inhalation was adjusted in accordance to the intraoperative BIS value and hemodynamic changes.Continuous monitoring of systolic blood pressure(SBP), diastolic blood pressure(DBP),heart rate(HR),electrocardiogram(ECG),pulse oxygen saturation(S_pO₂)and end-tidal carbon dioxide partial pressure(P_ETCO₂) and respectively at 5 minutes before induction(T₀),lateral position TLV 10 minutes(T₁), one-lung ventilation OLV 40 minutes(T₂),OLV 90 minutes(T₃),re-TLV 30 minutes (T₄),the serum cortisol,tumor necrosis factor-α(TNF-α),interleukin-10(IL-10) concentration were determined in the serum come from centrifugal center vein blood.Measured data for statistical treatment were carryed out by SPSS11.5 statistical analysis software.Measurement data were demonstrated by mean±standard deviation((?)±s).Comparison of groups by independence sample test analysis.Monofactorial analysis of variance,ANOVA is applied on comparison in group,the comparison of rate by X² test,criterion standard:P＜0.05 is condidered as statistically significant.Rsults1.The general situation of patients in two groupsTwo groups of patients with gender(Group P M 10/F5,Group S M 9/F6), age(Group P 54.5±11.9years,Group S 52.13±12.35 years),body mass(Group P 65.8±4.6 kg,Group S 62.6±5.7 kg),height(Group P 167±12.6cm,Group S 165±13.2cm),the proportion of lung lateral thoracotomy(Group P left 9 / right 6,Group S left8 / right 7) no significant difference(P＞0.05)(see Table 1).Maintain anesthesia time of two groups patients(group P 158±28.6 min, group S 156±27.3 min),operative time(group P 146.7±25.6 min,group S 144±22.8min),one-lung ventilation time(Group P 158±28.6 min,Group S 156±27.3 min),the volume of intraoperative transfusion(Group P of 1850±242 ml,Group S 1788±321 ml),blood volume(Group P 346±47 ml,Group S 351±43 ml), Intraoperative urine output(group P 445±120ml,group S 437±118 ml) groups compared to no statistically significant difference(P＞0.05),the amount of atracurium (Group P 104.8±18.7 mg,Group S 81.3±16.9 mg) groups compared to the differences were significant(P＜0.05),group S is less than the amount of group P. Sevoflurane and propofol,respectively,for the amount of 41.8±5.2ml and 78.3±4.3mg.(See Table 1)The two groups were not awareness to occur during operation;recovery time group S(9.1±3.6 min) than the group P(12.6±3.7 min) is shorter;postoperative nausea and vomiting(Group P 1 case,Group S 1 case) the occurrence of rate was no significant difference(P＞0.05).(See Table 2)Application of vasoactive drugs in the two groups:(Group P 2 cases group S 1 patient of ephedrine,group P 1 case,group S 1 patient of urapidil,group P 0 case group S 1 case of metoprolol,group P 1 case,group S 0 case of atropine) compared the difference was not significant(P＞0.05).(See Table 3)2.S_PO₂ and P_ETCO₂ of patients in two groups S_PO₂ of patients in two groups were more than 95%,P_ETCO₂ were maintained at between 30 and 40mmHg in the operation,inter-group comparison was no significant difference(P＞0.05).(See Table 4 and Table 5)3.The changes of MAP and HR of patients in two groupsGroup comparison:Blood pressure and heart rate of two groups at each time point were in the normal range.SBP,DBP in the group and inter-group wre no significant difference between(P＞0.05);The HR of group P at T2(65.2±6.6 times / min),T3(69.4±6.2 times / min) is lower than that in group S at T2(72.9±7.8 times / min),T3(78.1±7.8 times / min)(P＜0.05);Comparison in the group:The HR of group P at T₁(68.5±6.8 times / min),T₂ (65.2±6.6 times / min) were lower than that at To(75.4±10.8 times / min)(P＜0.05). The HR at other time points in compared with To were no significant difference(P＞0.05).(See Table 6 and Figure 1,2)4.The changes of serum cortisol concentration in two groupsGroup comparison:The serum cortisol concentration in group S at T₂,T₃,T₄(T₂ 218.6±12.3 ng/ ml,T₃ 224.7±10.4 ng / ml T₄ 229.5±0.7 ng / ml) were significantly lower than that in the group P at T₂,T₃,T₄(T₂ 227.7±10.3 ng / ml,T₃ 243.2±11.5 ng/ ml T₄ 250.1±0.8 ng / ml)(P＜0.05)Comparison in the group:The concentration of serum cortisol in group P at T₂,T₃, T₄(T₂ 227.7±10.3 ng/ ml,T₃ 243.2±11.5 ng / ml,T₄ 250.1±0.8 ng/ ml) and in group S at T₃,T₄(T₃ 224.7±10.4 ng/ ml,T₄ 229.5±0.7 ng / ml) were higher than that at T₀(group P 212.1±12.5 ng / ml,group S 209.3±9.2 ng / ml)(P＜0.05).(See Table 7 and Figure 3)5.The changes of TNF-αof patients in two groupsGroup comparison:Between the two groups,the serum TNF-αconcentration at the T₃,T₄ time point(group P T₃ 0.78±0.41μg/ml,T₄ 0.89±0.35μg/ml;) were higher than that at T₃(0.62±0.72μg / ml),T₄(0.74±0.54μg/ml) in group S(P＜0.05).Comparison in the group:The concentration of serum TNF-αin group P at T₃,T₄ (T30.78±0.41μg/ml,T40.89±0.35μg/ml) and the concentration of serum TNF-αin group S at T₄(0.74±0.54μg/ml) were higher than that at T₀(group P 0.48±0.32μg/ml, group S 0.46±0.13μg/ml)(P＜0.05).(See Table 8 and Figure 4)6.The changes of IL-10 of patients in two groupsGroup comparison:There was no significant difference in the two groups for the serum concentrations of IL-10 at every timepoints(P＞0.05).Comparison in the group:In group P at T₃,T₄(T₃ 75.9±22.1 pg / ml,T₄ 83.5±17.4 pg / ml) and in group S at T₃,T₄(T₃ 82.5±17.9 pg / ml,T₄ 88.4±12.8 pg / ml),the serum concentrations of IL-10 were higher than that at T₀(P group 61.7±23.2 pg / ml,S group 63.1±25.4 pg / ml),the difference was statistically significant (P＜0.05).(See Table 9 and Figure 5)Conclusion1.The hemodynamics is stabler in sevoflurane group than that in propofol group;2.Sevoflurane has more strong ability to inhibit cortisol secretion than propofol;3.Sevoflurane has more strong ability to inhibit TNF-αsecretion than propofol,the effects of sevoflurane and propofol on the IL-10 were no significant difference.