持续泵入胰岛素在二尖瓣置换术中的心肌保护研究

发布时间：2018-04-09 08:57

本文选题：二尖瓣置换术　切入点：胰岛素　出处：《新乡医学院》2014年硕士论文

【摘要】：背景体外循环下行二尖瓣置换术是最常见的心内直视手术之一,是目前公认的治疗二尖瓣膜病变最有效的方法。但是体外循环带来的间质体液增加、血小板减少、溶血、发热、血管收缩、肺、肾功能异常,异常出血,易受感染等,尤其是心脏直视手术结束后开放主动脉带来的心肌细胞缺血再灌注损伤。在整个手术及围手术期过程中手术的创伤、术中的麻醉、体外循环中全身的肝素化、术中低温、术后疼痛等,会导致机体在出现葡萄糖代谢紊乱,造成的应激性高血糖,这种机体应激性升高的血糖水平一方面进一步加剧了二尖瓣置换术中的心肌缺血再灌注损伤,近几十年来,关于胰岛素对心肌保护的话题一直备受关注。目的1.研究胰岛素对体外循环下二尖瓣置换术病人的心肌保护作用；2,探讨其作用机制。方法在新乡市中心医院伦理委员会批准的条件下,于2012年3月5日至2013年5月27日,选择36例首次体外循环下行二尖瓣置换术的择期手术患者,并在知情同意书上签字。将36例病人随机分为胰岛素治疗组(insulin,Ⅰ组)、对照组(control,C组),每组18例,Ⅰ组术中经患者中心静脉持续泵入胰岛素,使术中血糖控制在3.9---11.0mmol/L,术后控制在4.0---12.0mmol/L;对照组C组不泵胰岛素,术中血糖不处理,术后血糖控制在4.0---12.0mmol/,记录血糖变化水平。并分别于切皮前(T1)、主动脉开放后5min(T2)、主动脉开放后4h(T3)、主动脉开放后12h(T4)、主动脉开放后24h(T5)抽取桡动脉血,检测血浆乳酸脱氢酶(LDH)、肌酸激酶同工酶(CK-MB)、肌钙蛋白I(cTnI)、血浆超氧化物歧化酶(SOD)水平,并在切开右心房和缝合右心房时取少许心肌组织,分别在光镜、电镜下观察右心房心肌组织形态结构和超微结构的变化,记录体外循环时间、主动脉阻断时间、心脏复跳情况、辅助通气时间、术后机械通气时间及术后48h正性肌力药物的应用情况。结果 1.实验组(Ⅰ组)与对照组(C组)两组病人的辅助通气时间、体外循环时间、主动脉阻断时间均无显著差异(P0.05)。 2.两组血浆SOD含量术前无明显差异(P0.05),术后各时间点均较术前显著降低(P0.05),各个时刻：Ⅰ组SOD含量均显著高于C组(P0.05)。 3.心肌酶血浆乳酸脱氢酶、肌酸激酶同工酶及肌钙蛋白Ⅰ,术前,两组无显著差异(P0.05),术后各时间点均较术前显著升高(P0.05),各个时刻：Ⅰ组LDH、CK-MB、cTnI含量均显著低于C组(P0.05)。 4.开放主动脉后实验组(Ⅰ组)心脏自动复跳率为74.37%,对照组(C组)为32.55%,Ⅰ组的心脏自动复跳率明显高于C组(P0.05)。 5.术后48小时内的正性肌力药物应用,Ⅰ组与C组相比较,多巴胺、肾上腺素剂量有显著性差异(P0.05) 6.电镜、光镜下可见两组心肌组织术前无明显差异,术后两组心肌组织均有不同程度损伤,其损伤程度Ⅰ组明显轻于C组。结论本研究表明：1、在体外循环下二尖瓣置换术患者经中心静脉持续泵入胰岛素能有效的保护心肌细胞,减轻体外循环后心肌缺血再灌注损伤,减少术后心律失常的发生率,减少术后血管活性药物用量,改善心脏跳动的术后自然回复率,发挥心肌保护作用。 2、体外循环下非糖尿病患者二尖瓣置换术中持续泵入胰岛素的心肌保护作用可能与胰岛素具备促修复和增进心肌细胞生存、抑制炎性物质、促活化心肌细胞、抗凋亡作用有关。另外可能与术中胰岛素降低应急反应所产生的高血糖促进缺血心肌对葡萄糖的摄取代谢有关。
[Abstract]:The background of the cardiopulmonary bypass mitral valve replacement surgery is one of the most common heart, is currently the treatment of mitral valve disease is recognized as the most effective. But the cardiopulmonary bypass has increased interstitial fluid, thrombocytopenia, hemolytic anemia, fever, vasoconstriction, pulmonary, renal dysfunction, abnormal bleeding, vulnerable to infection. Especially after open heart surgery and opening after myocardial ischemia reperfusion injury caused by aortic surgery in the perioperative period. And the whole operation process of the trauma, anesthesia, cardiopulmonary bypass in systemic heparinization, intraoperative hypothermia and postoperative pain, can cause the body in glucose metabolism, stress high blood sugar caused by the stress of elevated blood sugar levels on the one hand, further exacerbating the mitral valve replacement in myocardial ischemia reperfusion injury, in recent decades, with insulin on myocardial protection The topic of protection has always been the focus of attention.
Objective 1. to study the myocardial protective effect of insulin on patients with mitral valve replacement under cardiopulmonary bypass (CPB) and 2 to explore the mechanism of its action.
In the method approved by the ethics committee of Xinxiang Central Hospital conditions, from March 5, 2012 to May 27, 2013, 36 cases of patients undergoing elective surgery for mitral valve replacement under extracorporeal circulation, and signed the informed consent. 36 patients were randomly divided into the insulin treatment group (insulin, group), control group (control group, C). Each group of 18 cases, group I patients by intraoperative central venous continuous infusion of insulin, the intraoperative blood glucose control in 3.9---11.0mmol/L, postoperative control in the 4.0---12.0mmol/L control group; group C blood glucose insulin pump, not in operation, postoperative blood glucose control in 4.0---12.0mmol/, the level of blood glucose change records. And respectively before skin incision (T1), 5min after aortic opening (T2), 4h after aortic opening (T3), 12h after aortic opening (T4), 24h after aortic opening (T5) from the radial artery blood, detection of plasma lactate dehydrogenase (LDH), creatine kinase isoenzyme ( CK-MB), troponin I (cTnI), plasma superoxide dismutase (SOD) levels, and the myocardium a little in the right atrium and right atrium incision suture, respectively in the light microscope, changes of right atrial myocardial tissue morphology and ultrastructure were observed under the electron microscope, record the cardiopulmonary bypass time, aortic clamping time. The heart Rebeating, ventilation time, postoperative mechanical ventilation time and postoperative 48h positive inotropic drug application.
Result
1. the time of auxiliary ventilation, the time of extracorporeal circulation and the interruption time of the aorta in the two groups of the experimental group (group I) and the control group (group C) had no significant difference (P0.05).
2., there was no significant difference in plasma SOD content between the two groups before operation (P0.05), which was significantly lower than those before operation (P0.05) at all time points after operation. The SOD contents in group I were significantly higher than those in C group at all times (P0.05).
3., there was no significant difference in plasma lactate dehydrogenase, creatine kinase isoenzyme and troponin I before operation between the two groups (P0.05), and the time points were significantly higher than those before operation (P0.05). The LDH, CK-MB and cTnI contents in group I were significantly lower than those in C group (P0.05).
4. the spontaneous cardiac recovery rate of the open aorta group (group I) was 74.37%, the control group (group C) was 32.55%, and the cardiac auto recovery rate in group I was significantly higher than that of the C group (P0.05).
5. the positive inotropic drug use within 48 hours after the operation. Compared with the C group, the dose of dopamine and adrenaline was significantly different (P0.05).
6. electron microscope. Under the light microscope, there was no significant difference in the two groups of myocardial tissue before operation. After operation, there were different degrees of injury in the two groups of myocardial tissue, and the degree of injury in group I was significantly lighter than that in group C.
Conclusion this study shows that: 1, under extracorporeal circulation of mitral valve replacement in patients with central venous continuous infusion of insulin can protect myocardial cells effectively, alleviate after CPB myocardial ischemia reperfusion injury, reduce the incidence of postoperative arrhythmia rate, reduce the dosage of vasoactive drugs after surgery, improve the heart beat after the natural recovery that play a role in myocardial protection.
2, the myocardial protection effect of extracorporeal circulation in non-diabetic patients with mitral valve replacement in continuous pump into insulin and insulin may have promoting rehabilitation and improving myocardial cell survival, inhibition of inflammatory substances, promoting the activation of myocardial cells, the anti apoptosis effect of pancreatic island. In addition with operation by reducing emergency response caused by high glucose promote the metabolism of glucose uptake in ischemic myocardium.

【学位授予单位】：新乡医学院
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R654.2

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