兔心脏骤停模型复苏早期PiCCO与心脏超声测量指标的相关性研究

发布时间：2018-08-12 19:54

【摘要】：心脏骤停(Cardiac arrest,CA)是临床最急危的重症之一,随着医疗服务体系的优化和心肺复苏的普及推广,CA发生后,自主循环恢复(Return of spontaneous circulation,ROSC)率有一定的提高。ROSC后早期快速、简便、准确的获得血流动力学相关指标,可指导优化临床治疗。由于心脏骤停临床过程的特殊性,临床研究受多种因素干扰,建立合理科学简便的动物模型,对深入研究其病理生理过程很有必要。脉搏指示连续心输出量(Pulse indicator continuous cardiac output,Pi CCO)监测仪是一种简便、微创、监测血流动力学参数的工具,但是作为一项有创监测目前在心脏骤停自主循环恢复后的应用仍然受诸多客观因素制约。床旁超声在急危重症的应用越发普及,通过超声检查亦可简便快捷的获得一些心脏功能相关的动力学指标,查阅国内外相关文献,并未发现关于Pi CCO和超声对比监测心脏骤停自主循环恢复早期血流动力学的研究。本研究用室颤法建立家兔CA模型,分别用Pi CCO和心脏超声监测家兔心脏骤停模型复苏早期的心脏功能变化,评估二者部分测量指标的一致性和相关性。筛选适宜的检查方法,为临床上指导CA患者ROSC后的血流动力学优化治疗提供参考。目的探讨室颤法家兔心脏骤停模型复苏早期心脏功能变化,并用Pi CCO与心脏超声测量相关指标,评估其相关性。方法30只健康家兔经皮电刺激室颤法制备心脏骤停模型,观察复苏前后家兔生命体征及心电图的变化,记录自主循环恢复时间,记录复苏成功率及家兔6h存活率。于造模开始前(基础状态)(t0)、ROSC即刻(t1)、ROSC 15min(t2)、ROSC60min(t3)、ROSC 120min(t4)、ROSC 6h(t5),记录Pi CCO测得心排血量(Cardiac output,CO)、全心舒张末血容量指数(Global end diastolic volume index,GEDVI、脉搏连续心输出量(Pulse continuous cardiac output,PCCO)、外周血管阻力指数(Systemic vascular resistance index,SVRI);心脏超声测得的每搏出量(stroke volume,SV)、左室前后径(Left Ventricular diameter,LVd)右室前后径(Right Ventricular diameter,RVd)、左室射血分数(Left Ventricular Ejection Fractions,LVEF),比较相对应指标的相关性,自主循环恢复6h后处死家兔,取心脏病理标本进行HE染色,观察心脏骤停模型自主循环恢复早期的心脏病理变化。结果1.模型的复苏结果给予5s的30V交流电刺激后,30只家兔均可诱发VF,但很快恢复室上性心律,再给予加大交流电刺激及延长电刺激时间后,实验家兔均成功诱导CA,CA成功率100%,CA诱导的时间为68.5±9.1s,此时心电图表现为VF(25,83%)、PEA(3,10%)、ASY(2,7%),CA持续5min后开始进行CPR时,30只家兔中,21只家兔的心电图仍表现为VF(21,70%),有2只家兔的心电图由VF转为PEA,2只由VF转为ASY。CPR后,4只家兔(CPR时心电图分别为2只PEA、2只ASY,)未复苏成功,成功率为86.67%(26/30),自主循环恢复时间为210.9±21.32s。1只家兔自主循环恢复后30min,心电图转为VF,给予再次复苏,复苏未成功。其他只家兔均存活至ROSC6h,6h生存率96.15%(25/26)。造模前MAP为87.97±1.34mm Hg,降至20mm Hg时间为70.8±6.2S,开始CPR时MAP为10.66±3.67 mm Hg。心肺复苏后MAP变化明显,ROSC即刻为112.52±16.75 mm Hg,15 min后下降维持在68.21±6.68 mm Hg。造模前心率(HR)为212.76±8.34次/分,ROSC即刻为253.16±11.23次/分,而后维持在较高水平。2.两种监测方法结果t0、t1、t2、t3、t4、t5时利用Pi CCO热稀释法测量的CO与心脏超声测量的CO呈显著正相关,利用脉搏轮廓法与心脏彩超测量的CO呈正相关。测得的GEDVI与LVd,GEDVI与RVd均有较高的相关性。t0、t1、t2、t3、t4、t5时,Pi CCO热稀释法与心脏超声测得的CO偏倚均在可接受的误差范围之内,Pi CCO热稀释法与心脏超声测得的CO值具有一致性。t1、t2、t3、t5,表示Pi CCO脉搏轮廓法与心脏超声测得的CO在一致性好。t4时,Pi CCO脉搏轮廓法测得的CO值心脏超声测量值偏向平均差异值直线一侧,此时Pi CCO脉搏轮廓法测得的CO与心脏超声测得的CO在一致性差。3.心肌病理表现家兔心室肌肉病在光学显微镜下可见:心肌纤维排列紊乱,发生局部坏死。部分细胞横纹消失,细胞质红染,,部分细胞质内可见空泡,存在炎性细胞浸润和红细胞渗出。结论1.家兔心脏骤停自主循环恢复60min后心脏收缩射血功能降低,有效循环血量减少。2.心脏超声可实时、动态地进行心脏功能监测,指导心脏骤停自主循环恢复早期血流动力学的优化,改善预后。
[Abstract]:Cardiac arrest (CA) is one of the most critical clinical symptoms. With the optimization of medical service system and the popularization of cardiopulmonary resuscitation, the rate of automatic circulation recovery (ROSC) has been improved after the occurrence of CA. Due to the particularity of the clinical process of cardiac arrest, clinical research is interfered by many factors. It is necessary to establish a reasonable, scientific and simple animal model for further study of its pathophysiological process. As a tool for monitoring hemodynamic parameters, it is still restricted by many objective factors. Bedside ultrasonography is becoming more and more popular in critical illness. Through ultrasonography, some cardiac function-related dynamic indexes can be obtained easily and quickly. In this study, a rabbit model of CA was established by ventricular fibrillation, and the changes of cardiac function in the early stage of resuscitation were monitored by Pi CCO and echocardiography respectively. Objective To investigate the changes of cardiac function in rabbits with ventricular fibrillation and cardiac arrest in early stage of resuscitation, and to evaluate the correlation between Pi CCO and echocardiography. Cardiac arrest model was established by ventricular fibrillation. The vital signs and electrocardiogram of rabbits were observed before and after resuscitation. The recovery time of spontaneous circulation, the success rate of resuscitation and the survival rate of rabbits at 6 hours were recorded. Cardiac output (CO), global end diastolic volume index (GEDVI), pulse continuous cardiac output (PCCO), peripheral vascular resistance index (SVRI), stroke volume (SV), left ventricular anterior and posterior diastolic diameter (Le) FT Ventricular diameter (LVd), right ventricular diameter (RVd) and left ventricular ejection fractions (LVEF) were compared. Rabbits were sacrificed 6 hours after recovery of spontaneous circulation. Heart samples were stained with HE to observe the early recovery of spontaneous circulation in cardiac arrest model. Result 1. The resuscitation of the model could induce VF in 30 rabbits after 5 seconds of 30 V AC stimulation, but the supraventricular rhythm could be restored quickly. After increasing AC stimulation and prolonging electrical stimulation time, CA was successfully induced in all rabbits. The success rate of CA was 100%, and the induction time of CA was 68.5 [9.1 s]. At this time, ECG showed VF (25. Of the 30 rabbits, 21 still showed VF (21,70%), 2 changed from VF to PEA, 2 from VF to ASY. After CPR, 4 rabbits (2 PEA and 2 ASY respectively at CPR) failed to recover successfully (86.67% (26/30), and spontaneous circulation was restored successfully (26/30). The other rabbits survived to 6 hours of ROSC, and the 6-hour survival rate was 96.15%(25/26). The MAP before modeling was 87.97 (+1.34 mm Hg) and decreased to 70.8 (+6.2 S) for 20 mm Hg. At the beginning of CPR, the MAP was 10.66 (+3.67 mm Hg). The heart rate (HR) was 212.76+8.34 beats/minute before modeling, and the ROSC was 253.16+11.23 beats/minute immediately before modeling, and then maintained at a higher level. There was a significant positive correlation between pulse profile and CO measured by color Doppler echocardiography. There was a high correlation between GEDVI and LVd, GEDVI and RVd. Consistency. t1, t2, t3, t5, indicating that Pi CCO pulse contour method and cardiac ultrasound measured CO in good consistency. t4, Pi CCO pulse contour method measured CO value of cardiac ultrasound measured bias to the linear side of the average difference, at this time Pi CCO pulse contour method measured CO and cardiac ultrasound measured CO in poor consistency. 3. Myocardial pathological performance of rabbit ventricular myocardium The myocardial fibers were disordered and necrosis was observed under the light microscope. Some of the myocardial fibers disappeared, the cytoplasm was red stained, vacuoles were found in some cytoplasm, inflammatory cell infiltration and erythrocyte exudation were observed. Conclusion 1. The systolic and ejective function of the heart was decreased and the effective circulatory blood volume was decreased 60 minutes after the recovery of autonomic circulation after cardiac arrest in rabbits. Less. 2. Echocardiography can monitor cardiac function in real time and dynamically, guide the optimization of hemodynamics and improve prognosis in the early recovery of autonomic circulation after cardiac arrest.
【学位授予单位】：郑州大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R459.7;R-332

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