实验犬脾、肾创伤急性失血性休克及复苏期的超声造影特征研究

发布时间：2018-03-24 05:13

本文选题：超声造影　切入点：脾脏　出处：《中国人民解放军医学院》2014年博士论文

【摘要】：目的：评价实验犬脾、肾创伤急性失血性休克及复苏期的超声造影特征。方法：（1）15只健康杂种犬常规麻醉，开腹制造40处脾脏Ⅲ-Ⅳ级创伤出血灶（参照美国创伤外科协会（AmericanAssociation for the Surgery of Trauma,AAST）分级标准），并模拟建立临床失血性休克及休克复苏的动物模型。分别于休克前，休克期及休克复苏期，行常规超声、超声造影（Contrast-enhanced Ultrasound,CEUS）及增强CT（Contrast-enhanced Computed Tomography, CECT)检查。观察并记录创伤区活动性出血灶的常规超声、CEUS表现，将其结果与CECT进行对照。此外，应用CEUS定量评价失血性休克复苏前后创伤脾脏的血流动力学参数（始增时间（AT）、达峰时间（TTP）、峰值强度（PI）、廓清时间（WT））变化。（2）25只健康杂种犬常规麻醉，开腹制造25处肾脏Ⅲ～Ⅳ级创伤（参照美国创伤外科协会（AmericanAssociation for the Surgery of Trauma,AAST）分级标准），并采用间歇放血法制造不同程度失血性低血压休克模型（轻度，70%基础血压；中度，50%基础血压；重度，40%基础血压）。休克前及休克进程中，应用CEUS及CECT对照研究肾脏创伤灶的显影特征。并应用CEUS动态评价失血性休克进程中创伤肾脏的血流动力学参数（始增时间（AT）、达峰时间（TTP）、峰值强度（PI）、廓清时间（WT））变化。结果：(1)无论在休克前、休克期还是休克复苏期，Ⅲ～Ⅳ脾脏创伤CEUS与CECT比较在创伤灶的显示率方面无明显差异（P0.05）。休克前，40处脾脏创伤出血灶，CEUS显示34处活动性出血（显示率85.00%，34/40），显示为无增强和/或低增强创伤区内的异常增强。随休克进展，活动性出血均逐渐停止，CEUS显示脾脏内动脉的微小分支减少,呈“枯枝状”，变细，造影剂聚积于小动脉分支末梢,呈絮状聚积，但无活动性出血的异常增强。休克复苏后，30处创伤灶再出血，CEUS显示28处创伤区内再次出现异常增强，提示再出血的发生（显示率93.33%,28/30）。此外，CEUS定量评价创伤脾脏血流灌注改变，休克期各参数变化明显异于其他两组（P0.01），体现在：AT、TTP及WT显著延迟、PI明显减低。(2)不同休克程度时，Ⅲ～Ⅳ肾脏创伤CEUS与CECT比较在创伤灶的显示率方面无明显差异（P0.05）。CEUS显示：休克前，造影剂注入后，肾脏各级动脉呈“放射状”快速增强，于创伤灶处中断，创伤灶呈无增强和/或低增强。存在活动性出血时，可见造影剂快速从破裂的肾被膜处向被膜外溢出，呈“涌泉”状或“云雾”状；或于无/低增强的创伤灶内出现大小不等的“团块状”异常增强。随着休克的进展，肾脏创伤区与周围肾组织造影增强强度对比度下降，创伤灶呈轮廓模糊的无增强区，活动性出血异常增强聚集增强减少/消失。应用CEUS动态评估创伤肾脏血流灌注发现，定量参数：造影始增时间（Arrival Time,AT）及达峰时间（Time to Peak, TTP）最早出现变化，并随休克程度的加重，愈发显著；峰值强度（Peak Intensity, PI）在中-重度休克时发生明显下降；廓清时间（Wash Time,WT）在中-重度休克时明显延长。结论：本研究表明，，(1)CEUS不仅可以有效诊断脾脏、肾脏创伤活动性出血灶，还可以用于实时监测失血性休克时脾、肾创伤出血灶的变化及休克复苏期再出血的发生。(2)CEUS可以有效监测休克及复苏进程中，脾脏、肾脏的血流灌注变化，并进行定量评估。从而，为拓展CEUS在临床创伤重症监护中的作用提供动物实验依据。
[Abstract]:Objective: To evaluate the characteristics of contrast-enhanced ultrasound in experimental dog spleen, acute hemorrhagic shock and resuscitation during renal trauma.
Methods: (1) 15 healthy mongrel dogs anesthesia, laparotomy manufacturing 40 spleen III - IV trauma hemorrhage (referring to the American Association for the surgery of trauma (AmericanAssociation for the Surgery of Trauma, AAST), and to simulate the grading standard) to establish an animal model of clinical hemorrhagic shock and resuscitation. Respectively, before the shock. Shock and shock recovery, routine ultrasound and contrast-enhanced ultrasound (Contrast-enhanced Ultrasound, CEUS CT (Contrast-enhanced Computed) and enhanced Tomography, CECT) and conventional ultrasound examination. The observation and record of the trauma area active bleeding CEUS, the results were compared with that of CECT. In addition, the application of CEUS quantitative evaluation of blood flow dynamics the parameters of the spleen trauma before and after resuscitation (by the time before (AT), time to peak (TTP), peak intensity (PI), clearance time (WT)). (2) 25 healthy dogs anesthesia, open 2 5 kidney trauma grade III ~ IV (referring to the American Association for the surgery of trauma (AmericanAssociation for the Surgery of Trauma, AAST), and grading standard) using intermittent blood letting manufacturing different hemorrhagic hypotension shock model (mild, 70% moderate, 50% basic blood pressure; basic blood pressure; severe, 40% basic blood pressure) before the shock. And the shock process, the application of CEUS and CECT were developing characteristics of renal trauma lesions. Traumatic renal hemodynamics parameters and application of CEUS dynamic evaluation of hemorrhagic shock in the process (by the time before (AT), time to peak (TTP), peak intensity (PI), clearance time (WT)).
Results: (1) no matter before shock, shock or shock during the recovery period, III ~ IV splenic trauma CEUS and CECT were no significant difference in the display rate of traumatic lesions (P0.05). Before the shock, 40 splenic trauma hemorrhage, CEUS showed 34 active bleeding (display rate of 85%, 34/40), showed no enhancement and / or low enhancement zone. With the enhancement of trauma shock progress, active bleeding were gradually stop, CEUS display tiny spleen artery branch was reduced, "deadwood", thinning, contrast agent accumulation in the arterial branch terminals, was flocculent accumulation, but no abnormal activity increased bleeding. Shock after resuscitation, 30 traumatic bleeding, CEUS showed 28 trauma in the region once again appear abnormal increased, suggesting that the occurrence of rebleeding (display rate of 93.33%, 28/30 CEUS). In addition, the quantitative evaluation of traumatic splenic blood perfusion changes, changes in the parameters were significantly different from the shock stage The other two groups (P0.01): AT, TTP, in and WT was significantly delayed, PI decreased significantly. (2) the different degree of shock, III ~ IV renal trauma CEUS and CECT were no significant difference in the rate of traumatic lesions showed.CEUS (P0.05) showed that before shock, after contrast injection, the kidney there is a rapid increase at all levels of the radial artery, in traumatic lesions were blocked, traumatic lesions were not enhanced and / or low enhanced. Active bleeding, visible contrast fast from the rupture of the renal capsule to the outer envelope of overflow, is "Yongquan" shape or "cloud" or in no shape; low / traumatic lesions enhanced in the size range of the "lumpy". With the progress of abnormal enhancement of shock, kidney and renal tissue around the wound area of contrast enhanced intensity contrast enhanced area decreased, a vague outline of traumatic lesions, bleeding, abnormal enhancement of aggregation enhanced reducing / CEUS dynamic disappear. The evaluation of trauma of renal perfusion, quantitative parameters: contrast enhancement beginning time (Arrival, Time, AT) and peak time (Time to, Peak, TTP) the earliest changes, and with the severity of shock, more significant; the peak intensity (Peak Intensity, PI) decreased obviously occurs in severe shock when the clearance time (Wash; Time, WT) in severe shock was significantly prolonged.
Conclusion: This study showed that (1) CEUS can not only diagnose the spleen, kidney trauma and active bleeding, but also can be used for real-time monitoring of hemorrhagic shock when the spleen, bleeding lesions and changes of renal trauma hemorrhage shock and resuscitation. (2) CEUS can effectively monitor the spleen shock and resuscitation in the process. The change of blood perfusion of kidney, and quantitative evaluation. Thus, to provide experimental basis for the development of CEUS in animal clinical trauma in ICU.

【学位授予单位】：中国人民解放军医学院
【学位级别】：博士
【学位授予年份】：2014
【分类号】：R445.1;R459.7

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