脓毒症心功能障碍的临床与实验研究

发布时间：2018-06-26 09:14

本文选题：脓毒症 + 心律失常　；参考：《大连医科大学》2015年博士论文

【摘要】：目的本研究分析脓毒症时新发生心律失常的诱因、主要类型及对预后的影响；研究脓毒症心功能障碍时中性粒细胞明胶酶相关载脂蛋白在血及尿中的改变以及在脓毒症心肌损害中的诊断价值；探讨脓毒症心肌线粒体损伤、NLRP3炎症小体活化致心功能障碍的机制,以及不同剂量乌司他丁干预治疗对心功能的影响。方法第一部分收集2012年12月至2014年4月ICU内共748例患者的临床资料,应用SPSS统计软件分析心律失常的诱因、主要类型及对预后的影响。第二部分留取脓毒症患者入院4小时内血及尿标本,患者及正常对照组血标本立即送检化验脑钠肽(BNP)。通过实时定量PCR法检测心功能不全组、非心功能不全组及健康对照组外周血单个核细胞NGAL的mRNA表达,采用ELISA方法检测心功能不全组、非心功能不全组及健康对照组血浆中及尿中NGAL的蛋白表达,比较组间差异。第三部分雄性清洁Wistar大鼠65只,分为空白对照组、假手术组、盲肠结扎穿孔组、乌司他丁干预组,制作大鼠脓毒症模型,分别给予小剂量及大剂量乌司他丁干预治疗。造模48小时后观察各组大鼠左室心肌病理学及超微结构改变；ELISA法检测各组大鼠外周血中肌钙蛋白I(cTnI).B型脑钠肽(BNP).TNF-α和IL-1β的变化；通过RT-PCR检测左室心肌细胞中NLRP3和caspase-1的mRNA表达,Western blot法检测各组左室心肌细胞中NLRP3和caspase-1蛋白的表达,比较组间差异。结果第一部分ICU内心律失常的发生率为18.85%,心律失常的主要危险因素包括年龄、急诊手术、脓毒症、急性呼吸窘迫综合征、心血管疾病和电解质紊乱、机械通气、应用血管活性药物、入ICU时较高的APACHE Ⅱ评分。脓毒症是主要危险因素(43.26%),房颤是脓毒症患者最常见的心律失常。脓毒症新发生心律失常组患者的病死率为29.50%,而无心律失常组13.66%(p0.01),脓毒症存活患者中心律失常组患者的ICU住院天数明显长于无心律失常组(17.10±9.30 vs11.25±5.50,p0.01)。第二部分非心功能不全组、心功能不全组与对照组相比血及尿中NGAL mRNA及蛋白表达均有显著性差异,P0.05；心功能不全组与非心功能不全相比血中NGAL mRNA表达无显著性差异,P0.05：血中及尿中蛋白表达有显著性差异,P0.05。第三部分脓毒症大鼠血清中cTnI、BNP、TNF-α、IL-1 β均明显升高；组织学检测发现,CLP组大量心肌细胞水肿、坏死、炎性细胞浸润及线粒体水肿、结构破坏。免疫组化显示脓毒症模型中大鼠心肌NLRP3和caspase-1均表达增强,实时定量PCR技术及免疫印迹技术显示NLRP3和caspase-1的mRNA及蛋白表达均增强,且与cTnI、BNP、TNF-α、IL-1β水平相关。小剂量UTI干预组及大剂量UTI干预组心肌损伤标志物水平、炎症介质水平、组织病变程度、NLRP3和caspase-1的mRNA表达及蛋白表达均比CLP组改善,且大剂量UTI干预组的病理改变轻,NLRP3和caspase-1的mRNA表达及蛋白表达弱于小剂量UTI干预组。结论1.脓毒症是ICU内心律失常发生的主要危险因素,房颤是脓毒症诱发的心律失常的主要类型,心律失常增加了ICU患者的ICU住院天数及死亡风险。2.脓毒症患者血BNP升高,心功能不全时血中BNP升高更明显。脓毒症患者存在血及尿NGAL升高,心功能不全时血中NGAL升高更明显,且与BNP成正相关,NGAL可做为心肌损害的标记物,与其他心脏标记物联合应用。3.脓毒症时大鼠心肌组织结构改变,线粒体损伤,心肌标志物水平与炎症介质水平升高,脓毒症可导致心肌损伤。脓毒症时大鼠心肌NLRP3炎症小体活化、caspase-1蛋白增加,NLRP3炎症小体的活化参与了脓毒症导致的大鼠心肌损害。乌司他丁对脓毒症心肌损害具有保护作用且大剂量乌司他丁治疗效果更明显,其机制可能与乌司他丁抑制TNF-α、IL-1β等炎症介质的释放、下调NLRP3小体活化导致的下游级联反应有关。
[Abstract]:Objective to analyze the causes, main types and prognosis of cardiac arrhythmia in sepsis, study the changes of neutrophilic gelatinase related apolipoprotein in blood and urine and the diagnostic value in sepsis myocardial damage during sepsis, and explore the myocardial mitochondrial damage and NLRP3 inflammation in sepsis. The mechanism of cardiac dysfunction by small body activation and the effect of different doses of ulinastatin on cardiac function. Methods the first part collected the clinical data of 748 patients in ICU from December 2012 to April 2014, and applied the SPSS statistical software to analyze the causes of arrhythmia, the main types and the effect on the prognosis. The second part retained the sepsis. The blood and urine specimens of the patients were admitted to the hospital for 4 hours, the patients and the normal control group were immediately tested for brain natriuretic peptide (BNP). The mRNA expression of NGAL in the peripheral blood mononuclear cells in the non cardiac insufficiency group and the healthy control group was detected by real-time quantitative PCR method, and the ELISA method was used to detect the heart dysfunction group, and the non cardiac insufficiency was detected by the ELISA method. The protein expression of NGAL in the plasma and urine of the control group and the healthy control group was compared. Third male Wistar rats were divided into blank control group, sham operation group, cecum ligation and perforation group, ulinastatin group, and the rat model of sepsis was made, and a small dose and large dose of Ulinastatin were given for 48 hours. The changes of left ventricular myocardium and ultrastructure of left ventricular myocardium were observed in each group, and the changes of I (cTnI).B type natriuretic peptide (BNP).TNF- alpha and IL-1 beta in peripheral blood were detected by ELISA. The mRNA expression of NLRP3 and caspase-1 in left ventricular myocytes was detected by RT-PCR. The expression of pase-1 protein was compared between groups. Results the incidence of arrhythmia in part one ICU was 18.85%. The main risk factors for arrhythmia were age, emergency operation, sepsis, acute respiratory distress syndrome, cardiovascular disease and electrolyte disorder, mechanical ventilation, vasoactive drugs, and higher APACHE II evaluation at ICU. Sepsis is the main risk factor (43.26%). Atrial fibrillation is the most common arrhythmia in patients with sepsis. The fatality rate of patients with sepsis new arrhythmia group is 29.50%, while no arrhythmia group is 13.66% (P0.01). The number of ICU hospitalization days in the patients with central arrhythmia group of sepsis surviving patients is significantly longer than that of the non cardiac arrhythmia group (17.10 + 9.30 vs11.). 25 + 5.50, P0.01). There were significant differences in the expression of NGAL mRNA and protein in the blood and urine compared with the control group in the second part of non cardiac insufficiency group, P0.05. There was no significant difference in the expression of NGAL mRNA in the heart function group and the non cardiac insufficiency, P0.05: the protein expression in the blood and urine was significantly different, P0.05. The serum levels of cTnI, BNP, TNF- a, and IL-1 beta in the third part of the sepsis rats were significantly increased. Histological examination revealed that a large number of cardiac myocytes were edema, necrosis, inflammatory cell infiltration and mitochondrial edema and structural damage in CLP group. Immunohistochemistry showed that the expression of NLRP3 and caspase-1 in the myocardium of rats in the sepsis model was enhanced, and the real-time quantitative PCR technology and immunity were quantified. The expression of mRNA and protein in NLRP3 and caspase-1 were enhanced and related to the levels of cTnI, BNP, TNF- alpha and IL-1 beta. The level of myocardial damage markers in the small dose UTI intervention group and the large dose UTI intervention group, the level of the inflammatory mediators, the degree of tissue lesion, the NLRP3 and caspase-1 mRNA expression and protein expression were better than those of the group. The pathological changes of the intervention group were light. The expression and protein expression of NLRP3 and caspase-1 were weaker than the small dose UTI intervention group. Conclusion 1. sepsis is the main risk factor for arrhythmia in ICU. Atrial fibrillation is the main type of arrhythmia induced by sepsis. Arrhythmia increases the number of ICU hospitalization days and death risk.2. sepsis in ICU patients. The increase of blood BNP in the patients and the increase of BNP in the blood were more obvious in the patients with cardiac insufficiency. The increase of blood and urine NGAL in the patients with sepsis and the increase of NGAL in the blood were more obvious when the heart function was incomplete, and it was positively related to BNP, and NGAL could be used as a marker of myocardial damage, and the structure of the myocardium in the rats with.3. sepsis was combined with other cardiac markers. Injury, the level of myocardial markers and the level of inflammatory mediators, sepsis can lead to myocardial injury. The activation of NLRP3 inflammatory bodies in the myocardium of sepsis, the increase of Caspase-1 protein, and the activation of NLRP3 inflammatory corpuscle involved in the myocardial damage caused by sepsis. The effect of the therapy is more obvious. The mechanism may be related to the release of Ulinastatin to inhibit the release of TNF- a, IL-1 beta and other inflammatory mediators, and down the downstream cascade reaction caused by the activation of NLRP3 corpuscle.
【学位授予单位】：大连医科大学
【学位级别】：博士
【学位授予年份】：2015
【分类号】：R459.7

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