Circulation：右美托咪啶可改善心脏手术患者预后

据胸外科医师协会报告，心脏瓣膜术和冠脉搭桥术术后主要并发症发生率高达30%。其主要并发症有术后谵妄、感染、急性肾衰以及包括永久性和短暂性脑卒中、昏迷、围手术期心梗、心脏传导阻滞和心脏骤停在内的主要心脑血管不良事件，有超过50%的不良事件为心血管事件。这些不良事件的原因是多方面的，其中一个主要因素是手术应激反应导致体内肾上腺素和去甲肾上腺素增加造成心肌氧供需失衡及心肌缺血。
右美托咪啶（α- 2受体激动剂）具有镇痛、抗焦虑、抑制中枢交感神经传出、减少去甲肾上腺素释放和改善心肌氧供需平衡保护心肌作用，有研究表明右美托咪啶可减少术后心血管并发症。这些研究的对象多为血管和非心脏外科手术患者。来自美国的Hong Liu等研究人员分析心脏直视手术患者围手术期予以右美托咪定治疗是否可改善预后并降低主要的心脑血管及其他系统并发症。研究结果发表在2013年4月16日的Circulation杂志上。
研究共纳入1134例接受冠脉搭桥术以及冠脉搭桥术联合瓣膜术或其他手术的患者。所有患者分为两组，其中568例患者接受右美托咪定静脉滴注，另外566例无右美托咪定治疗。数据经倾向指数校正后采用多元回归分析。主要结局指标包括死亡率、术后主要不良心脑血管事件（卒中、昏迷、围手术期心梗、心脏阻滞或心脏骤停）。次要结局指标有肾功能衰竭、败血症、谵妄、术后机械通气时间、住院天数和30天再入院率。
研究发现围手术期右美托咪啶可明显降低术后住院期间（1.23% 比 4.59%; 校正后OR= 0.34; 95%CI, 0.192–0.614; P<0.0001）、术后30天（1.76% versus 5.12%; 校正后OR=0.39; 95% CI, 0.226–0.655; P<0.0001）和术后1年（3.17% 比 7.95%; 校正后OR=0.47; 95% CI, 0.312–0.701; P=0.0002））的死亡率。研究同时发现右美托咪啶也可降低总体并发症（47.18%比54.06%; 校正后OR=0.80; 95% CI 0.68–0.96; P=0.0136）以及术后谵妄（5.46% 比 7.42%;校正后OR= 0.53; 95%CI, 0.37–0.75; P=0.0030）发生风险。
研究人员认为，在接受心脏手术的患者中，围手术期右美托咪啶治疗可减少手术之后至1年的死亡率，同时也减少术后并发症和谵妄发生风险。
该研究表明右美托咪啶在降低心脏外科手术后并发症和死亡率方面有重要作用，应考虑将其作为这一类手术患者围手术期用药方案之一。
与心脏相关的拓展阅读：

• JAMA：非心脏手术围手术期使用β-受体阻滞剂或可降低患者死亡率
• JCEM：PTH是心脏重构的决定性因素之一
• 刘晋萍：就一篇“应用自体脐带血为新生儿实施心脏手术”的论文提出疑问
• ACE抑制剂与β受体阻滞剂或许可预防化疗导致的心脏毒性
• Circulation：放疗增加癌症患者心脏手术死亡率
• APT：乳糜泻患者中缺血性心脏病的危险因素
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Perioperative dexmedetomidine improves outcomes of cardiac surgery.
BACKGROUND
Cardiac surgery is associated with a high risk of cardiovascular and other complications that translate into increased mortality and healthcare costs. This retrospective study was designed to determine whether the perioperative use of dexmedetomidine could reduce the incidence of complications and mortality after cardiac surgery.
METHODS AND RESULTS
A total of 1134 patients who underwent coronary artery bypass surgery and coronary artery bypass surgery plus valvular or other procedures were included. Of them, 568 received intravenous dexmedetomidine infusion and 566 did not. Data were adjusted with propensity scores, and multivariate logistic regression was used. The primary outcomes measured included mortality and postoperative major adverse cardiocerebral events (stroke, coma, perioperative myocardial infarction, heart block, or cardiac arrest). Secondary outcomes included renal failure, sepsis, delirium, postoperative ventilation hours, length of hospital stay, and 30-day readmission. Dexmedetomidine use significantly reduced postoperative in-hospital (1.23% versus 4.59%; adjusted odds ratio, 0.34; 95% confidence interval, 0.192-0.614; P<0.0001), 30-day (1.76% versus 5.12%; adjusted odds ratio, 0.39; 95% confidence interval, 0.226-0.655; P<0.0001), and 1-year (3.17% versus 7.95%; adjusted odds ratio, 0.47; 95% confidence interval, 0.312-0.701; P=0.0002) mortality. Perioperative dexmedetomidine therapy also reduced the risk of overall complications (47.18% versus 54.06%; adjusted odds ratio, 0.80; 95% confidence interval, 0.68-0.96; P=0.0136) and delirium (5.46% versus 7.42%; adjusted odds ratio, 0.53; 95% confidence interval, 0.37-0.75; P=0.0030).
CONCLUSION
Perioperative dexmedetomidine use was associated with a decrease in postoperative mortality up to 1 year and decreased incidence of postoperative complications and delirium in patients undergoing cardiac surgery.