The Protection Of Fentanil、Sufentanil And Remifentanil Against Myocardial Injury In Patients Undergoing Cardiac Valve Replacement

Objective:To compare the degrees of fentanil, sufentanil and remifentanil of equivalent dose on myocardial protection during perioperation in patients undergoing cardiac valve replacement under cardiopulmonary bypass.Methods:Thirty-six patients, ASA Ⅱ-Ⅲ undergoing cardiac valve replacement under cardiopulmonary bypass were randomly divided into three groups(n=12):fentanil group(group F); sufentanil group(group S); remifentanil group(group R). All the patients were induced with intravenous injection of midazolam、opioid agonists、vecuronim、 propofol, and intubated when BIS value was under60.Opioid drug and propofol were used by intravenous injection during operation.But different opioid drug were used in each group for induction, maintenance and postoperative analgesia. Group F was induced with fentanyl5-10μg/kg and maintained at a rate of5-15μg/kg/h, fentanyl0.5mg and midazolam5mg were diluted to50ml for postoperative analgesia at a rate of2ml/h by intravenous injection. Group S was induced with sufentanyl0.5-1μg/kg and maintained at a rate of0.5-1.5μg/kg/h, sufentanyl50μg and midazolam5mg were diluted to50ml for postoperative analgesia at a rate of2ml/h by intravenous injection.Group R was induced with remifentanyl0.5-1μg/kg and maintained at a rate of0.2-0.7μg/kg/min, remifentanyl3mg and midazolam5mg were diluted to50ml for postoperative analgesia at a rate of2-4ml/h by intravenous injection. Blood samples were taken before anesthesia(T1), thirty minites after aortic declamping(T2), the end of operation(T3),6h(T4) and24h(T5) after CPB for determination of plasma concentration of creatine kinase-MB(CK-MB),troponinI(cTnI),interleakin-10(IL-10),interleakin-6(IL-6) and solube intercellular adhesion molecule-1(sICAM-1).Results:1. Three groups patients in age, weight, sex ratio, AS A grade, distribution of surgical approach, aortic cross-clamp time and cardio pulmonary bypass time were not signifieantly different(P>0.05).2. The change of plasma markers of cardiomyocyte injury Intra-group comparisons:cTnl and CK-MB in three group at T1were in normal range (compared to the normal healthy volunteers),T2’s were significantly higher than T1(P<0.01), T3’s and T4’s were higher than Tl’s (P<0.05). CK-MB reached the hightest level at T4and cTnI reached the hightest level at T5. Among-group comparison:cTnI in three group at T1was in normal range and was not signifieantly different in among-group comparisons (P>0.05); Compared to group F, cTnI in group S and group R at T2,T3,T4,T5decreased significantly(P<0.01). Compared to group R, cTnl of Group S at T2,T3,T4,T5was not signifieantly different(P>0.01); At T1,T2,T5CK-MB in three group was not signifieantly different among-group comparisons (P>0.05). But,CK-MB in three group S and group R at T3,T4were significantly lower than group F (P<0.05).3. The change of plasma markers of inflammatory response Intra-group comparisons:IL-6, IL-10and sICAM-1in three group at T1were in normal range (compared to the normal healthy volunteers),at T2were significantly higher than T1(P<0.05)-at T1were lower than that at T3and T4(P<0.05), reached the peak level at T4. Only IL-6in group F was significantly higher than T1in three group at T5(P<0.05). IL-10in three group at T5was significantly higher than T1’s(P<0.05),but IL-10of group S at T2was not significantly higher than T1’s (P>0.05).SICAM-1of group F at T5was significantly higher than T1in three group(P<0.05). Among-group comparison:IL-6in three group at T1was not signifieantly different in among-group comparisons (P>0.05).Compared to group F, IL-6of group S and group R at T2,T,3,T4and T5was significantly lower (P<0.05); IL-10in three group at T1was not signifieantly different in among-group comparisons (P>0.05).Compared to group F, IL-10in group S and group R at T3and T4was significantly higher (P<0.05); sICAM-1in three group at T1and T2was not signifieantly different in between-group comparisons(P>0.05), compared to group F, sICAM-1in group S and group R at T3was significantly lower (P<0.05); sICAM-1in group R at T4and T5was significantly lower (P<0.05). Conclusion:Compared with equivalent doses of fentanil, sufentanil and remifentanil have better effect on lessening myocardial injury than fentanil for patients who undergoing cardiac valve replacement under cardiopulmonary bypass,and remifentanil maybe has a little more contribution to myocardial injury than sufentanil.