右美托咪定对全弓置换术患者血清S-100β蛋白、NSE及脑氧代谢的影响

发布时间：2018-05-26 06:25

  本文选题：右美托咪定 + 全弓置换　； 参考：《郑州大学》2017年硕士论文

【摘要】：研究背景主动脉夹层(Aortic dissection,AD)是心外科最凶险的疾病之一,发病急、病死率高,在我国的发病率有增高的趋势。AD指主动脉壁内膜破裂,受到强力血液冲击,血液进入主动脉壁造成正常主动脉壁分离从而在壁内形成真假两腔。临床上一旦怀疑为主动脉夹层,应尽快明确诊断,尽早手术。主动脉夹层手术是一项复杂、耗时的手术,大部分是在深低温停循环(deep hypothermic circulatory arrest,DHCA)选择性脑灌注技术辅助下实施的,很容易造成机体重要脏器的缺血缺氧。DHCA造成的中枢神经系统损伤,已经成为影响手术患者生存和预后重要危险的因素之一。CPB是一种非生理性的生命支持手段,脑损伤仍然是体外循环术后主要并发症。如何防止和减轻大血管术后脑损伤,己然成为复杂的心血管手术脑保护关键问题所在。S100β蛋白主要分布于中枢神经系统的神经胶质细胞中,当大脑受到缺血缺氧性损伤后,脑组织中的S100β蛋白释放入血可以被检测到。神经元特异性烯醇化酶(neuron-specific enolase,NSE)主要分布于神经元和神经内分泌细胞中,脑损伤时神经元死亡崩解,NSE可从细胞内释放至脑脊液及血液中,S100β蛋白和NSE可作为脑损伤生化标志物。颈静脉球部血氧饱和度(SjvO_2)可反映脑氧供与氧耗的匹配程度。动脉-颈内静脉血氧含量差(Da-jvO_2)反映了脑摄取氧的能力,脑氧摄取率(CERO_2)的意义与Da-jvO_2相似,但其不受Hb的影响,更适合用于评估脑氧代谢的变化情况。右美托咪定(dexmedetomidine,DEX)作为一种新型高选择性α2肾上腺素受体激动剂是安全有效的麻醉辅助用药,产生抗交感、抗焦虑、镇静、镇痛、抗炎等作用,对于患者脑保护具有积极意义。右美托咪定在全弓置换术中的脑保护作用研究较少,本研究拟探讨右美托咪定对体外循环(CPB)下全弓置换术患者脑缺血损伤有无保护作用,为心血管外科手术麻醉辅助用药的选择提供临床依据。目的探讨右美托咪定对全弓置换术患者血清S-100β蛋白、NSE及脑氧代谢的影响。方法2014年10月-2016年12月因A型急性主动脉夹层于我院行体外循环下全弓置换手术患者38例,性别不限,年龄33~68岁,体重44~87 kg,美国麻醉医师协会(ASA)分级Ⅲ或Ⅳ级,根据术中应用药物的不同,将其随机分为2组:对照组(C组,19例)和右美托咪定组(Dex组,19例),常规麻醉诱导后气管插管,术中采用静吸复合麻醉。Dex组于常规麻醉诱导前静脉输注右美托咪定1μg/kg,输注时间15 min,继之以0.5μg/(kg·h)的速率输注至术后12h;C组以等容量生理盐水替代。两组患者分别于麻醉诱导前(T0)、CPB30min(T1)、CPB结束后1h(T2)、CPB结束后6h(T3)、CPB结束后12h(T4)、CPB结束后24h(T5)时采用ELISA法检测血清S-100β蛋白和神经元特异性烯醇化酶(NSE)浓度,并采集桡动脉和颈内静脉球部血样进行血气分析,记录并计算颈静脉血氧饱和度(SjvO_2)、动脉-颈内静脉血氧含量差(Da-jvO_2)以及脑氧摄取率(CERO_2)水平。本实验的所有数据采用SPSS 20.0统计学软件进行统计学分析,计量资料用均数±标准差((χ|-)±S)表示,两组间各指标比较采用t检验;各时间点NSE,S100β蛋白血清水平以及血气分析指标的差异采用重复测量资料的方差分析,计数资料采用χ2检验进行比较。α=0.05为检验水准。结果1、两组患者性别、年龄、体重与LVEF以及手术时间、CPB时间、主动脉阻断时间组间与组内比较差异无统计学意义(P0.05)。2、两组患者T1-T5时间点血清S-100β蛋白、NSE水平均高于T0时间点,差异有统计学意义(P0.05)。Dex组患者T1-T5时间点血清S-100β蛋白、NSE水平均低于C组,差异有统计学意义(P0.05)。3、两组患者T1-T3时间点SjvO_2高于T0时间点,Da-jvO_2、CERO_2低于T0时间点,差异有统计学意义(P0.05)。Dex组患者T1-T3时间点SjvO_2水平高于C组,Da-jvO_2、CERO_2水平低于C组,差异有统计学意义(P0.05)。结论1、在全弓置换术手术中右美托咪定组与对照组相比S100β蛋白、NSE水平降低。2、在全弓置换术患者围手术期使用右美托咪定可以降低脑氧摄取率,稳定脑氧合平衡,有一定的脑保护作用。
[Abstract]:Aortic dissection (AD) is one of the most dangerous diseases in cardiac surgery. The incidence of the disease is urgent and high, and the incidence of the disease is high in our country. The incidence of the aortic dissection is higher in our country..AD refers to the rupture of the intima of the aorta, which is subjected to strong blood shock and the blood enters the aorta and causes the normal aorta wall separation to form the true and false two cavities in the wall. Once suspected as aortic dissection, diagnosis and operation as soon as possible. Aortic dissection surgery is a complex, time-consuming operation, most of which are assisted by selective cerebral perfusion (deep hypothermic circulatory arrest, DHCA), which can easily cause ischemic and anoxic.DHCA in the body's important organs. The damage of central nervous system has become one of the important risk factors affecting the survival and prognosis of the patients..CPB is a non physiological means of life support. Brain injury is still the main complication after cardiopulmonary bypass. How to prevent and reduce the brain damage after large vessel operation has become the key question of complex cardiovascular surgery. The.S100 beta protein is mainly distributed in the neuroglia cells of the central nervous system. When the brain is damaged by ischemia and hypoxia, the release of S100 beta protein into the blood can be detected. Neuron specific enolase (neuron-specific enolase, NSE) is mainly distributed in neurons and neuroendocrine cells and brain damage. NSE can be released from cell to cerebrospinal fluid and blood, S100 beta protein and NSE can be used as biochemical markers of brain damage. The blood oxygen saturation (SjvO_2) of the jugular bulb can reflect the matching degree of brain oxygen supply and oxygen consumption. The difference of oxygen content (Da-jvO_2) in the arterial and internal jugular vein (Da-jvO_2) reflects the ability of brain oxygen uptake and brain oxygen uptake (C) ERO_2) is similar to Da-jvO_2, but it is not affected by Hb and is more suitable for evaluation of changes in brain oxygen metabolism. As a new type of high selective alpha 2 adrenergic receptor agonist, right metoimidine (dexmedetomidine, DEX) is a safe and effective anesthetic adjuvant, which produces anti sympathetic, anti anxiety, sedative, analgesic, anti-inflammatory and other effects, The protective effect of right metodetomidine in total arch replacement is less. The purpose of this study is to explore the protective effect of right metoimidin on cerebral ischemia injury in patients with total arch replacement under cardiopulmonary bypass (CPB), and to provide a clinical basis for the choice of adjuvant medication for cardiovascular surgery. The effect of dexmedetomidin on serum S-100 beta protein, NSE and brain oxygen metabolism in patients with total arch replacement. Methods in December October 2014, 38 patients with total arch replacement under cardiopulmonary bypass due to acute aortic dissection in December -2016, gender, age 33~68, weight 44~87 kg, American anesthesiologist Association (ASA) grade III or grade IV, root According to the different application of drugs, they were randomly divided into 2 groups: control group (group C, 19 cases) and right metomimidine group (group Dex, 19 cases), tracheal intubation after routine anesthesia induction, and intravenous infusion of.Dex group before induction of intravenous infusion of right metomomidine 1 mu, infusion time 15 min, followed by the rate of 0.5 g/ (kg h) infusion. 12h (T0), CPB30min (T1), 1H (T2) at the end of CPB, 6h (T3) after the end of CPB, after the end of CPB, after the end of CPB, and after the end of CPB, the concentration of serum beta egg white and neuron specific enolase were detected and the radial and internal jugular veins were collected. Blood gas analysis of the ball blood samples, recorded and calculated the oxygen saturation (SjvO_2) of the jugular vein, the difference of oxygen content (Da-jvO_2) and the level of brain oxygen uptake (CERO_2) in the arterial and internal jugular veins. All the data in this experiment were statistically analyzed by SPSS 20 statistical software, and the measurement data were expressed with the mean standard deviation ((chi square) + S), and each of the two groups The index was compared with t test; the difference of the serum level of NSE, S100 beta protein and the blood gas analysis index were analyzed by the variance analysis of the repeated measurement data. The count data were compared by the chi 2 test. The alpha =0.05 was the test level. Results 1, the sex, age, weight and LVEF of the two groups, the time of operation, the time of operation, the time of CPB, the time of aortic occlusion. There was no significant difference between the group and the group (P0.05).2. The serum S-100 beta protein at the T1-T5 time point in the two groups was higher than the T0 time point, and the difference was statistically significant (P0.05) in the T1-T5 time point of the.Dex group, the NSE level was lower than that of the C group, and the difference was statistically significant. Higher than T0 time point, Da-jvO_2, CERO_2 lower than T0 time point, the difference was statistically significant (P0.05).Dex group T1-T3 time SjvO_2 level was higher than the C group, Da-jvO_2, CERO_2 level was lower than the C group, the difference was statistically significant. Conclusion 1, in the total arch replacement surgery, the right metomomidin group compared with the control group compared with the control group, the level of protein decreased, Conclusion: Dexmedetomidine can reduce cerebral oxygen uptake rate and stabilize cerebral oxygenation balance during perioperative period in patients undergoing total arch replacement.
【学位授予单位】：郑州大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R614
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本文编号：1936273