不同肢体远隔缺血后处理方法对瓣膜置换术患者血清cTnT浓度及术后恢复的影响

发布时间：2018-09-08 19:24

【摘要】：目的:观察上、下肢体缺血后处理两种处理方法对体外循环直视下成人心脏瓣膜置换术患者血清cTnT浓度及术后恢复的影响，探讨不同的肢体远隔缺血后处理模式的心肌保护效果。方法:将48例在体外循环下拟行心脏瓣膜置换术的成年患者，随机分为三组，即对照组（C组，n=16）、上肢缺血后处理组（S组, n=16）、下肢缺血后处理组（X组, n=16）。入室后常规监测生命体征，静注盐酸戊乙奎醚注射液0.01~0.02mg/kg，以镇静、镇痛、肌松的顺序静脉缓慢注射诱导后行气管插管及机械通气；行左桡动脉穿刺监测有创血压及右颈内静脉穿刺监测中心静脉压；通过外周静脉持续泵注枸橼酸芬太尼、维库溴铵以及咪唑安定以维持麻醉深度。C组除对上、下肢体不做任何处理外，其它的处置和方法均与S组、X组相同；S组在体外循环(cardiopulmonary bypass，CPB)期间，主动脉开放后即刻使预先系于右上肢上臂的止血带充气（宽6cm，下缘离肘关节2~3cm，压力保持200mmHg），保持3min阻断/3min复流，重复3次，共计18min；X组主动脉开放后即刻使预先系于左下肢大腿止血带（宽8cm，下缘离膝关节3~4cm，充气后压力保持250mmHg）充气，，持续3min阻断/3min复流，重复3次过程，共计18min；三组患者CPB期间维持平均动脉压(MAP)在50~70mmHg之间，术中持续监测HR、CVP、SpO2、、ECG、SBP、DBP、MAP、 PetCO2，间断检测血气分析、全血凝固时间（ACT），并记录CPB的时间、主动脉阻断的时间、心脏自动复跳比例。分别于麻醉诱导后即刻（T1）、主动脉开放后2h(T2)、12h（T3）、24h（T4）、36h（T5）的5个时间点采集动脉血标本，将收集好的标本冷藏用于测定血清肌钙蛋白-T(cTnT)，所有患者术毕都带管送入ICU继续治疗，并记录呼吸机辅助呼吸时间、拔出气管导管时间、ICU留观时间、血管活性药物的使用时间、追踪患者愈后过程中有无受处理肢体异常并记录住院时间。结果:1.三组病人在年龄、男/女比例、体重（W）、NYHA分级、术前心率（HR）、术前平均动脉压（MAP）、术前SpO2、术前射血分数（EF）、单/双瓣手术类型比例的比较均无统计学意义（p0.05）；2.三组病人CPB时间、主动脉阻断时间、手术时间的比较均无统计学意义（p0.05）；3. S组、X组主动脉开放后心脏自动复跳率均明显高于C组（p0.01），而S组和X组组之间心脏自动复跳率比较无差异（p0.05）；4.三组患者之间血清cTnT浓度的基础值（T1）比较无显著差异性（p0.05）；三组患者在T2-5各时间点，血清cTnT浓度与各自的基础值（T1）相比较显著增高（p0.01），但均明显低于C组（p0.01），S组和X组组之间血清cTnT浓度比较无显著差异（p0.05）；5.术后ICU留观时间、呼吸机辅助呼吸时间、拔出气管导管时间、术后血管活性药物的使用时间、住院时间与C组比较有显著差异性（p0.01）；术后随访均未见S组、X组病人受缺血后处理肢体发生任何异常；6.三组病人T1-5各时间点血流动力学（HR、MAP、CVP）组内及组间比较均无差异（p0.05）结论:1.右上肢缺血后处理和左下肢缺血后处理这两种方式均可有效降低CPB下行瓣膜置换的患者术中及术后血清cTnT的浓度并提高心脏自动复跳率，表明这两种肢体缺血后处理方法均能有效发挥心肌保护效应；2.两组缺血后处理方法均能降低术后ICU留观时间、术后呼吸机辅助呼吸时间、拔出气管导管时间、术后血管活性药物的使用时间、住院时间，表明这两种肢体缺血后处理方法均可能有效促进术后心功能恢复；3.S组和X组两种处理方法降低血清cTnT浓度的升幅及缩短术后ICU留观时间的作用相近，提示在临床上可酌情选择单一肢体进行缺血后处理即可；4.观察期间，三组病人的血流动力学指标无显著差异性，提示两种肢体后处理方法对循环系统功能不会造成不利影响。随访未发现处理组患者受处理肢体发生异常，表明所用方法具有简便、无创、经济、有效、安全、可行的优点。
[Abstract]:AIM: To observe the effects of upper and lower limb ischemic postconditioning on serum cTnT concentration and postoperative recovery in adult patients undergoing open heart valve replacement under cardiopulmonary bypass, and to explore the myocardial protective effect of different limb ischemic postconditioning modes. Patients were randomly divided into three groups: control group (group C, n = 16), upper limb ischemic postconditioning group (group S, n = 16) and lower limb ischemic postconditioning group (group X, n = 16). After entering the room, vital signs were monitored routinely. Penehyclidine hydrochloride injection 0.01-0.02 mg/kg was injected intravenously to induce tracheal intubation and mechanical ventilation in the order of sedation, analgesia and muscle relaxation. Invasive blood pressure was monitored by left radial artery puncture and central venous pressure was monitored by right internal jugular vein puncture. Fentanyl citrate, vecuronium bromide and midazolam were continuously injected into peripheral vein to maintain the depth of anesthesia. During ardiopulmonary bypass (CPB), the tourniquet was inflated (6 cm wide, 2-3 cm from the lower limb to the elbow joint, 200 mmHg) immediately after the aorta was opened, and the tourniquet was blocked for 3 minutes / 3 minutes and repeated for 18 minutes. In group X, the tourniquet was fastened to the left leg immediately after the aorta was opened (8 cm wide, the lower limb was off the knee). Joint pressure was maintained at 250 mmHg at 3 to 4 cm, 3 min occlusion / 3 min reflux and 3 times repetition for 18 min. Mean arterial pressure (MAP) was maintained at 50 to 70 mmHg during CPB in all three groups. HR, CVP, SpO2, ECG, SBP, DBP, MAP, PetCO2 were monitored during operation, blood gas analysis, whole blood coagulation time (ACT) was measured intermittently, and CPB time was recorded. Arterial blood samples were collected at 5 time points immediately after anesthesia induction (T1), 2 hours (T2), 12 hours (T3), 24 hours (T4) and 36 hours (T5) after aortic opening. The collected samples were refrigerated for the determination of serum troponin-T (cTnT). All patients were transported to ICU for further treatment and their expiration was recorded. Suction-assisted breathing time, tracheal catheter extraction time, ICU observation time, the use of vasoactive drugs, follow-up of patients with any abnormalities in the process of prognosis and record the length of hospital stay. Results: 1. Three groups of patients in age, male/female ratio, weight (W), NYHA classification, preoperative heart rate (HR), preoperative mean arterial pressure (MAP), preoperative SpO2, preoperative SpO2, NYHA classification. There was no significant difference in preoperative ejection fraction (EF) and single/double valve type ratio (p0.05). 2. There was no significant difference in CPB time, aortic occlusion time and operation time among the three groups (p0.05). 3. In group S, the rate of cardiac automatic rebound after aortic opening in group X was significantly higher than that in group C (p0.01). There was no significant difference in the rate of beating and rebounding (p0.05); 4. There was no significant difference in the baseline serum cTnT concentration (T1) among the three groups (p0.05); the serum cTnT concentration of the three groups was significantly higher than their baseline values (T1) at each time point of T2-5 (p0.01), but significantly lower than that of the C group (p0.01), and the serum cTnT concentration between S group and X group. There was no significant difference (p0.05); 5. ICU observation time, ventilator-assisted breathing time, tracheal catheter extraction time, postoperative use of vasoactive drugs, hospitalization time compared with group C was significantly different (p0.01); postoperative follow-up did not see any S group, X group patients after ischemia limb occurrence of any abnormalities; 6. Time point hemodynamics (HR, MAP, CVP) within and between groups were no difference (p0.05). Conclusion: 1. Right upper extremity ischemic postconditioning and left lower extremity ischemic postconditioning can effectively reduce the concentration of serum cTnT in patients undergoing valve replacement under CPB and improve the rate of cardiac automatic rebound, indicating that the two limb ischemic posterior position. Physical methods can effectively exert myocardial protective effect; 2. Both groups of ischemic postconditioning methods can reduce postoperative ICU observation time, postoperative ventilator-assisted breathing time, tracheal catheter extraction time, postoperative use of vasoactive drugs, hospitalization time, indicating that these two limb ischemic postconditioning methods may effectively promote postoperative cardiac function. 3. The two treatment methods of S group and X group can reduce the increase of serum cTnT concentration and shorten the observation time of ICU, suggesting that a single limb can be selected for ischemic postconditioning in clinic. 4. During the observation period, there was no significant difference in hemodynamic parameters between the three groups, suggesting that the two methods of limb postconditioning can be used. No abnormal limbs were found in the treatment group during the follow-up, indicating that the method is simple, noninvasive, economical, effective, safe and feasible.
【学位授予单位】：泸州医学院
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R654.2

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