目标液体治疗对失血性休克犬水孔蛋白、血气及血生化的影响

发布时间：2018-05-07 23:44

本文选题：液体治疗 + 低血容量性休克　；参考：《昆明医科大学》2016年博士论文

【摘要】：[目的]有30%的临床死亡是由失血性休克造成,而液体治疗是临床医生抢救失血性休克患者生命的重要手段。将目标液体治疗(goal-directed fluid therapy, GDFT)用于围手术期的液体管理,可防范围手术期不易发现的输液量不足而进一步改善患者的预后。水孔蛋白(aquaporins,AQP)的主要作用是调节自由水的跨细胞运输,为水的高速转运提供孔道,平衡机体内的肺水及肠水。但目前尚不清楚目标液体治疗是否会影响水孔蛋白的表达,也不明白目标液体治疗是否会对血气及血生化造成影响。本实验旨在探讨:(1)、目标液体治疗是否会造成输液量增多并影响肺水孔蛋白1(AQP)及肠水孔蛋白3(AQP3)的变化；(2)、不同比例(1:3、1:2、1:1、2:1和3:1)的乳酸林格氏液／羟乙基淀粉(LR/HES)的初期目标液体治疗是否会对失血性休克犬的达标时间、乳酸和肺A0P,及肠AQP3表达产生影响,从而寻找较为适合于失血性休克犬初期目标液体治疗的LR/HES比例；(3)、比例为1:3、1:2、1:1、2:1和3:1的LR/HES的后期目标液体治疗是否会对失血性休克犬的血气、血生化及肺水产生影响,从而寻找较为适合于失血性休克犬后期目标液体治疗的乳酸林格氏液／羟乙基淀粉比例。[方法](1)、将32只比格犬随机分为四组(每组8只):假手术组(S组),目标液体治疗组(G组),中心静脉压指导输液组(C组)及定量输液组(Q组)。G组、C组和Q组建立失血性休克模型并维持休克状态60min,随后分别采用目标液体、定量输液和中心静脉压指导的输液方案行液体复苏并观察4h。用于液体复苏的乳酸林格氏液与羟乙基淀粉(LR/HES)的输液比例为1:1。实验结束后,记录复苏4h的输液量；通过RT-PCR及Western-Blotting检测肺组织A0P1及肠组织AQP3的表达水平。(2)、将48只比格犬随机分为6组(n=8):1个假手术对照组(S组)及5个实验组。S组仅给予插管及观察。5个实验组犬被制作成失血性休克模型后,按液体复苏时输入LR/HES的比例不同又随机分为:3:1组、2:1组、1:1组、1:2组及1:3组。实验组的输液目标为每搏量变异度(stroke volume variation,SVV)达到10～8%,输血目标为血红蛋白(hemoglobin,Hb)达到10.0～11.0g/dL。记录各组放血前的基础值(T0)、休克后1h(T1)、复苏2h(T2)及复苏4h(T4)时的血乳酸浓度。记录各组的每搏量变异度(SVV)及血红蛋白(Hb)达标时间。实验结束后测定各组犬的血浆渗透压。实验结束后取肺及结肠组织,通过RT-PCR及Western-Blotting方法检测肺AQP,及肠AQP3的表达情况。(3)、将40只杂种犬制作成失血性休克模型后,按液体复苏时输入LR/HES的比例不同随机分为5组(n=8):3:1组、2:1组、1:1组、1:2组和1:3组。输液目标为每搏量变异度达到并维持在10～8%,输血目标为血红蛋白达到并维持在10.0～11.0g/dL。测定并记录基础值(Baseline,BL)、放血休克即时(Shock 0,S0)、开始复苏时(R0)、复苏2h时(R2)、复苏4h时(R4)及复苏24h时(R24)的血气(酸碱度[pH],动脉血氧分压[PaO2],剩余碱[BE])、血生化(血钠,血氯,血红蛋白,血浆肌酐清除率)及血管外肺水指数(ELWI)。[结果](1)、目标液体治疗组的输液量多于定量输液组和中心静脉压指导输液组(P0.05)。目标液体治疗组肺AQP1及肠AQP3的表达和定量输液组、中心静脉压及及假手术组差异无统计学意义。(2)、失血性休克犬行初期(4h)目标液体治疗后:1:3组及1:2组的乳酸少于3:1组(P0.05)。1:3组及1:2组的每搏量变异度及血红蛋白的达标时间快于3:1组(P0.05)。而3:1组的肺AQP1及肠AQP3的表达低于1:2组及1:3组,血浆渗透压也低于1:2组及1:3组(P0.05)。(3)、在失血性休克犬的后期(24h)目标液体治疗中连续24h使用LR/HES为3:1的液体治疗可能引起肺水增加及低氧血症；而使用1:3和1:2的液体则可能造成高钠血症、高氯血症、高氯性酸中毒及肾功能减退。[结论](1)、单一乳酸林格氏液/羟乙基淀粉比例的目标液体治疗并不影响肺AQP1及肠AQP3的表达。(2)、在失血性休克犬的初期(4h)目标液体治疗中,乳酸林格氏液/羟乙基淀粉比例为1:3及1:2的目标液体治疗在乳酸、每搏量变异度及血红蛋白达标时间方面好于3:1。不同乳酸林格氏液/羟乙基淀粉比例的目标液体治疗会影响失血性休克犬肺AQP1及肠AQP3的表达。(3)、在失血性休克犬的后期(24h)目标液体治疗中使用乳酸林格氏液／羟乙基淀粉比例为2:1和1:1的液体在维持血气及血生化方面优于3:1,1:2及1:3。
[Abstract]:[Objective] 30% of the clinical deaths are caused by hemorrhagic shock, and liquid treatment is an important means of life for patients with hemorrhagic shock. Target liquid therapy (goal-directed fluid therapy, GDFT) is used in the perioperative liquid management, which can prevent the insufficiency of the amount of transfusion which is not easy to be found during the operation period and further improve the patient's suffering. The main role of aquaporins (AQP) is to regulate the transcellular transport of free water, provide a channel for the high speed transport of water, balance the lung water and intestinal water in the body, but it is not clear whether the target liquid therapy will affect the expression of the water pore protein, and whether the target liquid treatment will affect the blood gas and blood biochemistry. The purpose of this experiment was to explore: (1) whether the target liquid therapy could cause the increase of infusion volume and the changes in the pulmonary pore protein 1 (AQP) and the entero Aquin 3 (AQP3); (2) whether the initial target liquid treatment of the lactate solution / hydroxyethyl starch (LR/HES) in different proportions (1:3,1:2,1:1,2:1 and 3:1) would be for hemorrhagic shock dogs The standard time, lactic acid and lung A0P, and the expression of AQP3 in the intestines are affected to find the proportion of LR/HES suitable for the initial target liquid treatment for hemorrhagic shock dogs. (3) whether the late target liquid treatment of LR/HES in 1:3,1:2,1:1,2:1 and 3:1 will affect the blood gas, blood biochemistry and lung water of the hemorrhagic Hugh dogs. To find the proportions of lactate liquid / hydroxyethyl starch suitable for target liquid therapy for hemorrhagic shock in dogs. [Methods] (1), 32 beagles were randomly divided into four groups (group S), target liquid treatment group (group G), central venous infusion group (group C) and quantitative infusion group (Group Q).G group, C group and Q group. The model of hemorrhagic shock and the state of shock 60min were maintained, and then the fluid resuscitation was performed with the target liquid, the infusion scheme guided by the quantitative infusion and central venous pressure was resuscitate and the infusion ratio of the lactate solution and hydroxyethyl starch (LR/HES) for the fluid resuscitation was observed at the end of the 1:1. experiment, and the infusion volume of the resuscitation 4H was recorded. RT-PCR was recorded by RT-PCR. The expression level of A0P1 in lung tissue and AQP3 of intestinal tissue was detected by Western-Blotting. (2) 48 beagle dogs were randomly divided into 6 groups (n=8): 1 sham operation control group (S group) and 5 experimental group.S group were given intubation and observation of.5 experimental group as hemorrhagic shock model, the proportion of LR/HES in the fluid resuscitation was different and randomly divided. Group 3:1, group 2:1, group 1:1, group 1:2 and 1:3 group. The target of infusion in the experimental group was 10 ~ 8% of stroke volume variation, SVV, and the target of hemoglobin (hemoglobin, Hb) reached 10 ~ (hemoglobin, Hb), and the concentration of blood lactic acid in the shock, resuscitation and resuscitation. The plasma osmotic pressure of each group of each group (SVV) and hemoglobin (Hb) was recorded. After the experiment, the plasma osmotic pressure was measured. After the experiment, the lung and colon tissues were taken. The lung AQP and the expression of intestinal AQP3 were detected by RT-PCR and Western-Blotting methods. (3) after making the hemorrhagic shock model, the 40 hybrid dogs were resuscitated according to the fluid resuscitation. The proportion of LR/HES input was randomly divided into 5 groups (n=8): Group 3:1, group 2:1, group 1:1, group 1:2 and group 1:3. The objective of infusion was to reach and maintain 10 to 8%, the target of blood transfusion was hemoglobin and maintained at 10 ~ 11.0g/dL. (Baseline, BL), and hemorrhagic shock was immediate (Shock 0, S0) and began to resuscitation, Recovery of 2H (R2), recovery of 4H (R4) and recovery of 24h (R24) blood gas (pH [pH], arterial oxygen partial pressure [PaO2], residual alkali [BE]), blood biochemistry (blood sodium, blood chlorine, hemoglobin, plasma creatinine clearance) and extravascular pulmonary water index (ELWI). [results] (1), the infusion volume of the target liquid treatment group was more than the quantitative infusion group and the central venous pressure guidance infusion. Liquid group (P0.05). The expression of lung AQP1 and intestinal AQP3 in the target liquid treatment group and the quantitative infusion group, the central venous pressure and the sham operation group had no statistical significance. (2) after the initial (4h) target liquid treatment for hemorrhagic shock dogs, the lactic acid in group 1:3 and 1:2 group was less than that of 3:1 group (P0.05).1:3 group and 1:2 group, and the standard of hemoglobin in the group of.1:3 and 1:2 group Time was faster than group 3:1 (P0.05). The expression of AQP1 and intestinal AQP3 in group 3:1 was lower than that in group 1:2 and 1:3 group, and plasma osmotic pressure was lower than that of group 1:2 and 1:3 group (P0.05). (3) the liquid therapy in the target liquid treatment of hemorrhagic shock dogs may cause pulmonary water increase and hypoxemia. Liquid may cause hypernatremia, hyperchloremia, Hyperchloric acid poisoning and renal dysfunction. [Conclusion] (1) the target liquid therapy of single lactate linger's solution / hydroxyethyl starch does not affect the expression of AQP1 and AQP3 in the lung. (2) in the initial (4h) target liquid treatment of hemorrhagic shock dogs, LRL / hydroxyethyl starch ratio The target liquid treatment for 1:3 and 1:2 in lactic acid, pacing measure variation and the time of hemoglobin attainment were better than the target liquid therapy of 3:1. different lactate lillinger's solution / hydroxyethyl starch. (3) the expression of AQP1 and intestinal AQP3 in dogs with hemorrhagic shock. (3) the use of milk in the late (24h) target liquid treatment of the hemorrhagic Hugh dog. The ratio of acid Ringer's solution / hydroxyethyl starch to 2:1 and 1:1 is superior to 3:1,1:2 and 1:3. in maintaining blood gas and blood biochemistry.

【学位授予单位】：昆明医科大学
【学位级别】：博士
【学位授予年份】：2016
【分类号】：R459.7

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