超滤技术对体外循环下心脏手术中抗生素及炎性因子的影响

发布时间：2018-07-05 03:58

本文选题：超滤 + 体外循环　；参考：《北京协和医学院》2014年博士论文

【摘要】：研究总体思路：体外循环技术使得心脏手术得到很大发展,但非生理性的血液转流过程伴随着潜在的危害。患者血液与体外循环管道异物表面接触可引起炎性反应,导致毛细血管通透性增加。体外循环开始后,患者出现稀释性的血红蛋白降低及血清蛋白降低,导致炎性毛细血管渗漏,液体向组织间隙转移,出现组织水肿及终末器官灌注不良。血液稀释技术虽能增加体外循环期间组织灌注,允许在低流量甚至循环停止时使用深低温保护器官免受缺血损伤,并且减少体外循环过程中对异体血的需求。过度的血液稀释可能增加血容量,导致充血性心力衰竭或肾功能衰竭。超滤作为体外循环中的一项常用技术,1979年Darup等人报道了在体外循环中使用超滤技术。20世纪80年代,研究报道了体外循环中使用超滤可滤除体内多余的水分,有改善患者术后的心功能、肺功能、神经功能、减少输血、减轻炎症反应等优势。超滤除了其改善患者生理状态等优势的同时,研究报道了其可滤出各种药物,如麻醉药、阿片类药物、肌松药、抗生素等等。超滤对于体外循环中抗生素浓度的影响目前研究报道较少。心脏手术中由于体外循环转流、低温、血液稀释等因素使机体对外源性感染源的抵抗力下降,在心脏手术中常规应用抗生素预防感染成为外科医生普遍接受的常规。在体外循环下内环境发生极大的变化,各种抗生素的药代动力学和药效动力学亦随之发生改变。抗生素的用药策略在体外循环下的心脏手术中是否仍然合适是一个研究的热点。体外循环中影响抗生素的因素包括血液稀释、低温、血流动力学改变、药物代谢器官血液灌注的改变、药物与体外循环管路的接触以及超滤等等。本研究拟从模拟体外循环模型、小儿平衡超滤、及成人深低温停循环选择性脑灌注下两种超滤策略几个方面探讨超滤在心脏手术中对抗生素及炎性因子的影响。为今后制定更合理的药物使用策略提供依据。第一部分本研究使用体外循环模拟管路模拟体外循环过程,排除了临床研究中患者的个体差异、病情的差异及手术过程中的不可控因素,只关注于超滤技术对体外转流过程中抗生素浓度的影响。实验中管路预充、排气、降温、体外循环、肝素的使用与临床方案完全相同。分别从加药口加入头孢替安与头孢美唑两种抗生素。使用平衡超滤过程中在不同时间点留取血标本及滤液标本检测抗生素浓度,方法为高压液相技术。通过这一部分离体实验,探索超滤技术是否可以滤除血浆中的抗生素,以及超滤过程中血浆抗生素浓度的变化,及影响因素。离体实验的结果可为进一步临床研究提供理论依据。第二部分离体研究中证实了平衡超滤可呈剂量依赖性滤除血液中的抗生素。但临床上各种因素复杂多变,在患儿个体差异、病情差异、术中状况的差异下离体研究的结果是否可以在临床研究中得到证实是本研究的重点。在婴幼儿心脏手术中由于患儿体重小、血液稀释严重,因而超滤技术广泛应用于滤除体内多余的水分及炎性因子。但超滤对抗生素的影响尚无存争议。本研究选取单纯房间隔缺损及室间隔缺损矫治术的患儿,随机分为平衡超滤组及非平衡超滤组,在超滤前、超滤后分别取血标本进行炎性因子及抗生素浓度检测,并留取滤液标本检测炎性因子及抗生素浓度。本部分的目的是探索平衡超滤对儿科心脏手术中血浆炎性因子及抗生素浓度的影响,以及对术中血气及其他指标的影响。第三部分深低温停循环下的主动脉弓置换手术由于患者病情重、手术复杂、体外循环时间长及深低温停循环的打击,患者发生炎性反应激活、缺血再灌注损伤及酸中毒。深低温停循环手术中常需使用大剂量超滤来调节改善内环境,滤除多余水分及炎性因子。美国胸外科学会指南对心脏外科手术中的预防性应用抗生素的剂量和间隔给了推荐性意见,然而未纳入主动脉置换手术及心脏移植手术。而深低温停循环手术中抗生素的药代动力学及药效动力学缺乏研究证据。深低温停循环下的主动脉弓置换手术中超滤对于抗生素的影响文献报道较少。前期离体及小儿心脏手术中的发现是否能在成人深低温停循环的情况下得以证实是第三部分的重点。本研究中分别采用常规超滤和体外循环过程中全程超滤两种不同的超滤管理技术,探索超滤技术对炎性因子及抗生素浓度的影响。第一部分离体模型下研究平衡超滤技术对抗生素浓度的影响背景与目的心外科手术常规预防性使用抗生素防止围术期感染。然而体外循环对内环境产生的极大干扰,使得抗生素的分布和代谢发生变化,其中平衡超滤技术对体内抗生素浓度的影响尚不清楚。因此本研究拟在体外模拟模型下,研究平衡超滤技术是否能对围术期血浆抗生素浓度产生影响。方法建立体外循环体外模拟环路,包括回流室、膜肺、婴儿动脉滤器。血液浓缩器安装在动脉滤器和储血室之间。新鲜全血与乳酸林格氏液预充体外循环管路,并保持最终红细胞压积在24-28%。头孢替安(320mg)和头孢咪唑(160mg)一次性加入循环管路中。30分钟体外循环后开始零平衡超滤,通过Hoffman钳维持动脉管路压力约100mmHg。超滤速度控制在12mL/min。使用勃脉力A持续滴入管路维持红细胞压积。平衡超滤过程中每5分钟采取血浆和超滤液标本,使用高压液相色谱检测技术分别动态监测头孢替安和头孢美唑的药物浓度。结果头孢替安和头孢美唑在不同时点的超滤液中均可检测到。血浆中抗生素的浓度随着超滤液量的增加呈线性降低。超滤结束时,血浆头孢替安浓度为104.96±44.36μg/ml,大约为初始浓度的44.38%±7.42%(初始浓度238.95±101.12μg/ml)(p0.001)；而血浆头孢美唑浓度降低至25.76±14.78μg/ml,约为初始浓度的49.69%±10.49%(初始浓度51.49±28.03μg/ml)(p0.001)；超滤液中头孢替安的含量为总给药量的27.16%±12.17%,头孢美唑的含量占总给药量的7.74%±4.17%。结论平衡超滤能够滤出血液中的抗生素,其滤出量与蛋白结合率显著相关；超滤技术对于围术期抗生素的血药浓度具有显著影响,因而术中抗生素的应用策略应考虑此影响因素。第二部分婴幼儿心脏手术中平衡超滤对炎性因子及抗生素浓度的影响背景与目的体外循环管路预充液对于小儿来说会造成比较严重的血液稀释,因而超滤技术在儿科心脏手术中成为常规应用以滤除体内多余水分以及体外循环预充液,及减少炎性因子。然而由于超滤对抗生素也有滤除作用,且儿童心脏手术中超滤对抗生素的滤除作用研究报道较少。为证实第一部分离体研究的结果,本部分研究探讨平衡超滤对行体外循环的婴幼儿体内炎性因子及抗生素血药浓度的影响,为临床抗生素的指导用药提供理论依据。方法选取2012年7月-2013年5月期间于本院心脏外科接受房间隔缺损、室间隔缺损矫治手术的先天性心脏病患儿,心功能Ⅰ-Ⅱ,入选患者随机分成平衡超滤组(Balanced Ultrafiltration, BU F)和非平衡超滤组(non-Balanced Ultrafiltration, NBUF),于胸部切皮前30分钟通过静脉给予头孢美唑0.03mg/kg。分别于体外循环转流开始前(t1),超滤前(t2),体外循环结束后5分钟(t3),抽取t1、t2、t3时刻动脉血测定血气及胶体渗透压,并留取血液和超滤液标本。使用酶联免疫吸附法(ELISA)检测炎性介质指标包括白细胞介素(Interleukin, IL)-1、IL-6、IL-10、中性粒细胞弹性蛋白酶(Neutrophil Elastase, NE)以及肿瘤坏死因子(Tumor Necrosis Factor, TNF)-a,使用高压液相色谱检测技术检测抗生素浓度。结果停体外循环后,IL-1、IL-6、IL-10、TNF-α及NE的血浆浓度较超滤前显著升高(p0.05)。IL-1、IL-6、NE停体外循环时两组之间的血浆浓度无显著差别(p0.05)。IL-10、TNF-α停体外循环时血浆浓度在BUF组低于NBUF组(p0.05)。滤液中可检测到所有这几种炎性因子的存在,各种炎症介质在滤液中的浓度在两组之间未见差别(p0.05)。BUF组,血浆头孢美唑由超滤前初始浓度72.03±23.77μg/ml降低至停止体外循环时40.04±12.38μg/ml(53.47%±13.60%)。在NBUF组,停止体外循环时血浆头孢美唑由超滤前的初始浓度80.04±30.30μg/ml降低至58.02±18.86μg/ml(69.11%±9.0%)。两组间血浆抗生素浓度的减少量之间的差别有统计学意义(p=0.018)=BUF组超滤液中头孢美唑总含量占总给药量的7.25%±3.83%,NBUF组超滤液中头孢美唑总含量占总给药量的2.83%±1.71%,两组之间有显著差异(p=0.004)。结论平衡超滤可选择性滤除血浆中的炎症介质。体外循环中超滤的使用确切可以滤除血液中的抗生素,且平衡超滤的使用增加了抗生素在滤液中的滤出量。第三部分全程超滤对深低温停循环下主动脉弓置换手术中血浆炎性因子及抗生素浓度的影响背景与目的深低温停循环下的主动脉弓置换手术中,由于手术时间长并且需要经历低温及缺血等严重的打击,从而引起机体酸碱平衡紊乱及氧化应激损伤,并产生大量炎性因子。因而常规使用超滤技术滤除循环内多余水分,调节电解质及酸碱平衡,滤除炎性因子。然而,由于超滤可滤除抗生素,且与超滤的剂量呈正相关,因此在深低温停循环手术中大量的超滤可能会对抗生素血药浓度产生影响。因而本实验拟研究深低温停循环下不同超滤技术对术中抗生素浓度、炎症反应程度以及术后感染等临床指标的影响。方法纳入需深低温停循环下行主动脉弓置换手术的患者,随机分为两组：全程组(主动脉阻断10分钟后开始全程超滤至停止体外循环),复温组(开始复温时开始超滤至停止体外循环)。切皮前静脉给予头孢呋辛1.5g,体外循环转流2小时追加0.75g。分别于体外循环转流开始升主动脉阻断后10分钟(T1)、体外循环转流2小时(T2)、停体外循环时(T3),及停体外循环后4小时(T4)抽取动脉血4ml。体外循环结束时收集超滤液标本5ml,记录超滤液总量。使用高压液相色谱法检测抗生素浓度。使用酶联免疫吸附法(ELISA)检测炎性介质指标包括白细胞介素(IL)-1、IL-6、IL-10、中性粒细胞弹性蛋白酶(NE)以及肿瘤坏死因子(TNF)-α。结果全程组血浆头孢呋辛浓度从体外循环开始时94.23±30.21μg/ml,下降到体外循环2个小时的74.69±21.90μg/ml(下降17.86±11.52%)(p0.05)。复温组血浆头孢呋辛浓度从体外循环开始时85.63±32.76μg/ml,下降到体外循环2小时的73.68±22.86μg/ml(下降12.16%±6.85%)(p0.05),两组之间差异无统计学意义(p=0.083)。停体外循环后血浆头孢呋辛浓度全程组106.90±61.34μg/ml,复温组129.32±63.70μg/ml;停体外循环4个小时血浆头孢呋辛浓度全程组152.75±98.30μg/mL,复温组189.77±119.03μg/mL;两组间无统计学差异(p0.05)。IL-1和TNF-α的血浆浓度在整个过程中变化不显著(p0.05)。lL-6、IL-10及NE的血浆浓度在体外循环2小时的时候无显著变化,而在停体外循环时显著升高(p0.05)。IL-10血浆浓度从停体外循环时的319.03±67.51ng/L下降到停体外循环4小时的148.57±83.28ng/L(p0.05),IL-6及NE停体外循环4小时浓度未见显著下降(p0.05)。但各个时点每种炎性因子的浓度在两组间无显著差异(p0.05)。结论两种超滤方法对血浆头孢呋辛浓度的影响未见显著差别,因此在本给药策略下可以给患者保证足够的血药浓度。全程超滤可以滤除更多的炎性因子,但对血浆炎性因子的影响并未优于复温后超滤。
[Abstract]:Overall thinking :

In vitro circulation , cardiac surgery has been greatly developed , but the non - physiologic blood transfer process is accompanied by potential hazards . The patient ' s blood is in contact with the foreign body surface of the extracorporeal circulation pipeline to cause inflammatory reaction , which leads to an increase in capillary permeability . After the start of the extracorporeal circulation , the patient has decreased hemoglobin and decreased serum protein , resulting in inflammatory capillary leak , fluid - to - tissue clearance transfer , tissue edema and poor perfusion of the terminal organ .

ultrafiltration is used as a common technique in cardiopulmonary bypass . In 1979 , Darup et al . reported the use of ultrafiltration in cardiopulmonary bypass . In the 1980s , it was reported that the use of ultrafiltration in cardiopulmonary bypass could filter out the excess water in the body , improve the cardiac function , pulmonary function , nerve function , reduce blood transfusion and alleviate inflammatory response .

In the first part , this study used extracorporeal circulation to simulate the cardiopulmonary bypass . It excluded the individual difference of the patients , the difference of the condition and the uncontrollable factors in the course of surgery . It was only concerned with the effect of ultrafiltration on the concentration of antibiotics in the process of extracorporeal circulation .

In the study of the second part , it was proved that the balanced ultrafiltration can filter the antibiotics in the blood in dose - dependent manner . But the clinical factors are complicated . The results of the ex vivo study can be proved to be the focus of this study in the clinical study .

In this study , the effects of ultrafiltration on inflammatory factors and antibiotic concentration were investigated in this study .

Study on the effect of balanced ultrafiltration on the concentration of antibiotics in the first separated model

BACKGROUND & OBJECTIVE To prevent perioperative infections with antibiotics . However , the effects of balanced ultrafiltration on the concentration of antibiotics in the perioperative period are not clear due to the great interference caused by cardiopulmonary bypass . Therefore , it is proposed to study whether the balance ultrafiltration technology can influence the plasma antibiotic concentration in perioperative period .

Methods The extracorporeal circulation line of extracorporeal circulation was established , including reflux chamber , membrane lung and infant arterial filter . The blood concentrator was installed between the arterial filter and the reservoir . Fresh whole blood was pre - filled with lactated ringer ' s liquid in extracorporeal circulation line . The pressure of the final red blood cells was maintained at 24 - 28 % . The pressure of the final red blood cells was maintained at 12 mL / min . The plasma and ultrafiltrate samples were collected every 5 minutes during ultrafiltration . Plasma and ultrafiltrate were taken every 5 minutes during ultrafiltration , and the drug concentrations of ceftean and cefmetazole were dynamically monitored by high pressure liquid chromatography .

Results Ceftean and cefmetazole could be detected in ultrafiltrate with different concentration . The concentration of antibiotic in plasma decreased linearly with the increase of ultrafiltrate . At the end of ultrafiltration , the concentration of ceftetiam was 104.96 卤 44.36渭g / ml , which was 44.38 % 卤 7.42 % ( initial concentration 238.95 卤 101.12 渭g / ml ) ( p0.001 ) .
The concentration of cefmetazole decreased to 25.76 卤 14.78 渭g / ml , which was 49.69 % 卤 10.49 % ( initial concentration 51.49 卤 28.03 渭g / ml ) ( p0.001 ) .
The content of ceftean in ultrafiltrate was 27.16 % 卤 12.17 % of the total dosage , and the content of cefmetazole accounts for 7.74 % 卤 4.17 % of the total dose . Conclusion Balance ultrafiltration can filter out the antibiotics in blood , and its filtrate amount is related to the protein binding rate .
The ultrafiltration technique has a significant effect on the plasma concentration of antibiotics in perioperative period , and the application strategy of antibiotics should consider this effect .

Effect of balanced ultrafiltration on inflammatory factor and antibiotic concentration in the second part of infant ' s heart surgery

BACKGROUND & OBJECTIVE To study the effect of ultrafiltration on the anti - inflammatory factors and the concentration of antibiotics in infants with cardiopulmonary bypass , and to provide a theoretical basis for the guidance of clinical antibiotics .

Methods The blood gas and colloid osmotic pressure were measured by enzyme - linked immunosorbent assay ( ELISA ) . Blood gas and colloid osmotic pressure were measured by using enzyme linked immunosorbent assay ( ELISA ) . The concentration of antibiotics was detected by enzyme linked immunosorbent assay ( ELISA ) .

The plasma concentrations of IL - 1 , IL - 6 , IL - 10 , TNF - 伪 and NE increased significantly ( p < 0.05 ) . The plasma concentrations of IL - 1 , IL - 6 and NE decreased to 58.02 卤 18.86 渭g / ml ( 53.47 % 卤 13.60 % ) .

Conclusion Balance ultrafiltration can selectively remove the inflammatory mediators in the plasma . The use of ultrafiltration in extracorporeal circulation can filter out the antibiotics in the blood , and the use of balanced ultrafiltration increases the leaching of antibiotics in the filtrate .

Effect of the third part of the whole course ultrafiltration on the plasma inflammatory factor and antibiotic concentration in aortic arch replacement surgery under deep and low temperature circulatory arrest

Background and Objective To study the effects of ultrafiltration on the concentration of antibiotics , the degree of inflammatory response and post - operative infection in patients with deep and low temperature circulatory arrest due to the long operative time and the need to undergo severe blows such as low temperature and ischemia .

Methods The patients were randomly divided into two groups : the whole course group ( after 10 minutes of aortic cross - cutting ) , the whole course was ultrafiltered to stop the extracorporeal circulation , and the arterial blood was collected 4 hours after the cardiopulmonary bypass ( T1 ) , the cardiopulmonary bypass was 2 hours ( T2 ) , the extracorporeal circulation was stopped ( T3 ) , and the total amount of the ultrafiltrate was recorded after the cardiopulmonary bypass . The indexes of inflammatory media were detected by enzyme linked immunosorbent assay ( ELISA ) including interleukin ( IL ) -1 , IL - 6 , IL - 10 , neutrophil elastase ( NE ) and tumor necrosis factor ( TNF ) - 伪 .

The plasma concentrations of IL - 6 , IL - 10 and NE decreased from 319.03 卤 32.76渭g / ml and 189.77 卤 19.03 渭g / ml at the beginning of cardiopulmonary bypass . There was no significant difference between the two groups ( p = 0.083 ) . The plasma concentrations of IL - 1 and TNF - 伪 decreased from 319.03 卤 67.51ng / ml to 148.57 卤 83.28ng / ml in cardiopulmonary bypass ( p = 0.083 ) .

Conclusion There are no significant differences in the effects of two ultrafiltration methods on plasma ceftiofur concentration . Therefore , it is possible to ensure adequate plasma concentration for patients under the present administration strategy . The whole course ultrafiltration can filter more inflammatory factors , but the effect of ultrafiltration on plasma inflammatory factors is not superior to ultrafiltration after rewarming .
【学位授予单位】：北京协和医学院
【学位级别】：博士
【学位授予年份】：2014
【分类号】：R726.1

【参考文献】