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1、麻醉与创伤患者的器官麻醉与创伤患者的器官 保护保护 中国医科大学附属第一医院中国医科大学附属第一医院 麻醉科麻醉科 王王 俊俊 麻醉对于器官功能的影响麻醉对于器官功能的影响 时间时间 器 官 功 能器 官 功 能肝、肾、消化道功能肝、肾、消化道功能 血管阻力血管阻力 心肌收缩力心肌收缩力 呼吸功能呼吸功能 意识状态意识状态 不同程度的下降不同程度的下降 这些影响能否完全逆转？这些影响能否完全逆转？ 时间时间 大 脑 功 能大 脑 功 能睁眼睁眼 认知认知 情感情感 定向定向 这些影响能否完全逆转？这些影响能否完全逆转？ 时间时间 其 他 器 官 功 能其 他 器 官 功 能呼吸呼吸 恶心、呕吐
2、恶心、呕吐 循环循环 麻醉对于器官功能的影响麻醉对于器官功能的影响 器官保护器官保护 器官损害器官损害 OR 临床研究？ 基础研究 麻醉药物具有器官保护作用，结果明确！ 作用广泛（心、脑、肺、肝、肾 ） 麻醉药物器官保护作用机制复杂，研究深入！ Anesthesiology. 2016 Jun;124(6):1230-45. 吸入麻醉药吸入麻醉药肺功能肺功能 吸入麻醉药吸入麻醉药肺功能肺功能 吸入麻醉药吸入麻醉药肺功能肺功能 吸入麻醉药吸入麻醉药肺功能肺功能 Anesthesiology. 2016 Jun;124(6):1230-45. 吸入麻醉药吸入麻醉药肺功能肺功能 Effects of
3、 volatile and intravenous anesthesia on the alveolar and systemic inflammatory response inthoracic surgical patients Anesthesiology. 2011 Jul;115(1):65-74 CONCLUSIONS: One-lung ventilation(OLV) increases the alveolar concentrations of proinflammatory mediators in the ventilated lung. Both desflurane
4、 and sevoflurane suppress the local alveolar, but not the systemic, inflammatory responses to OLV and thoracic surgery. CONCLUSION: One-lung ventilation increases the alveolar concentrations of proinflammatory mediators in the ventilated lung. Both desflurane and sevoflurane suppress the local alveo
5、lar, but not the systemic, inflammatory responses to OLV and thoracic surgery. 吸入麻醉药吸入麻醉药肾功能肾功能 Volatile anesthetics in preventing acute kidney injury after cardiac surgery: A systematic review and meta-analysis J Thorac Cardiovasc Surg. 2014;148(6):3127-36. FIGURE 2. Forest plot of relative risks i
6、n the incidence of AKI (A) 吸入麻醉药吸入麻醉药肾功能肾功能 吸入麻醉药吸入麻醉药肾功能肾功能 吸入麻醉药吸入麻醉药肾功能肾功能 Conclusion： propofol anesthesia significantly reduced the incidence and severity of acute kidney injury in patients undergoing valvular heart surgery with cardiopulmonary bypass compared with sevoflurane. This beneficial e
7、ffect of propofol may be related to its ability to attenuate the perioperative increase in proinflammatory mediators. 吸入麻醉药吸入麻醉药肝功能肝功能 A randomized controlled trial on pharmacological preconditioning in liver surgery using a volatile anesthetic. Ann Surg. 2008 Dec;248(6):909-18. RESULTS: Sevoflurane
8、 preconditioning significantly limited the postoperative increase of serum transaminase levels by 261 U/L (95% CI, 65 to 458; P = 0.01) for the ALT and by 239 (95% CI, -2 to 480; P = 0.05) for the AST corresponding to decreases of baseline levels of 35% and 31%, respectively. CONCLUSION: This first
9、randomized trial of pharmacological preconditioning in liver surgery in humans showed a protective effect of preconditioning with volatile anesthetics. This strategy may provide a new and easily applicable therapeutic option to protect the liver and to lower complication rates. Anesth Analg. 2010 Oc
10、t;111(4):1036-41. 吸入麻醉药吸入麻醉药肝功能肝功能 Anesth Analg. 2010 Oct;111(4):1036-41. 吸入麻醉药吸入麻醉药肝功能肝功能 吸入麻醉药吸入麻醉药心脏保护心脏保护 吸入麻醉药吸入麻醉药心脏保护心脏保护 Meta-analysis of cardiac troponin in OPCAB/MIDCAB. Meta-analysis of cardiac troponin in on-pump coronary artery bypass graft surgery in 2578 patients in 30 randomised cont
11、rol trials. 吸入麻醉药吸入麻醉药心脏保护心脏保护 吸入麻醉药的吸入麻醉药的 心脏保护作用心脏保护作用 毋庸置疑！毋庸置疑！ 吸入麻醉药吸入麻醉药心脏保护心脏保护 然而然而 对于高危心脏手术患者（合并瓣膜及冠脉疾病），七氟对于高危心脏手术患者（合并瓣膜及冠脉疾病），七氟 烷在烷在ICUICU停留时间及死亡率方面并没有任何优势。停留时间及死亡率方面并没有任何优势。 在非体外循环冠脉搭桥手术中，与丙泊酚相比，七氟烷在非体外循环冠脉搭桥手术中，与丙泊酚相比，七氟烷 和地氟烷没有心肌保护方面的优势。和地氟烷没有心肌保护方面的优势。 非心脏手术中，吸入麻醉药和丙泊酚在心肌保护方面作非心脏手术中
12、，吸入麻醉药和丙泊酚在心肌保护方面作 用相似。用相似。 Volatile compared with total intravenous anaesthesia in patients undergoing high-risk cardiac surgery: a randomized multicentre study. Br J Anaesth. 2014 Dec;113(6):955-63. Myocardial protection during off pump coronary artery bypass surgery: a comparison of inhalational
13、anesthesia with sevoflurane or desflurane and total intravenous anesthesia. . Ann Card Anaesth. 2013 Jan-Mar;16(1):4-8. Volatile agents for cardiac protection in noncardiac surgery: a randomized controlled study. J Cardiothorac Vasc Anesth. 2011 Dec;25(6):902-7 远隔缺血预处理远隔缺血预处理- -心肌保护心肌保护 METHODS A pr
14、ospective, double-blind, multicenter, randomized, controlled trial involving adults who were scheduled for elective cardiac surgery requiring cardiopulmonary bypass under total anesthesia with intravenous propofol. The primary end point was a composite of death, myocardial infarction, stroke, or acu
15、te renal failure up to the time of hospital discharge. Secondary end points included the occurrence of any individual component of the primary end point by day 90. BACKGROUND Remote ischemic preconditioning (RIPC) is reported to reduce biomarkers of ischemic and reperfusion injury in patients underg
16、oing cardiac surgery, but uncertainty about clinical outcomes remains. 远隔缺血预处理远隔缺血预处理- -心肌保护心肌保护 CONCLUSIONS In this large-scale, double-blind, multicenter trial, no significant difference was observed between upper-limb RIPC and a sham intervention with respect to the rate of postoperative myocardial infarction, stroke, renal failure, and death within 90 days af
