本文選題：極化液 + 體外循環(huán)�。� 參考：《第四軍醫(yī)大學(xué)》2014年碩士論文

【摘要】：研究背景 絕大部分器質(zhì)性心血管疾病的結(jié)構(gòu)異常只能通過(guò)手術(shù)來(lái)糾治，而大部分心臟手術(shù)的實(shí)施需要依賴心肺轉(zhuǎn)流（cardiopulmonary bypass, CPB）技術(shù)，CPB又稱為體外循環(huán)（extracorporeal circulation, ECC）。CPB的技術(shù)雖然日漸成熟，但是其血液灌注模式仍舊和機(jī)體正常生理狀態(tài)下灌流模式有很大的差別，加之機(jī)體強(qiáng)烈的應(yīng)激反應(yīng)，可能導(dǎo)致術(shù)后重要臟器的功能損害，并影響患者術(shù)后功能的恢復(fù)。CPB期間機(jī)體出現(xiàn)高血糖和高胰島素，但是胰島素的靶組織對(duì)胰島素敏感性降低出現(xiàn)葡萄糖的利用降低，最終導(dǎo)致急性胰島素抵抗（insulin resistance, IR），引起相關(guān)臟器功能受損。所以如何降低手術(shù)中IR，一直是心臟及重要臟器保護(hù)領(lǐng)域研究的熱點(diǎn)。葡萄糖-胰島素-氯化鉀（Glucose-Insulin-Potassium, GIK）用于心臟圍術(shù)期心肌保護(hù)已經(jīng)有50余年的歷史，但是其臨床應(yīng)用效果卻參差不齊。本課題以心臟手術(shù)患者為研究對(duì)象，探討CPB時(shí)是否誘發(fā)IR，改良GIK對(duì)心臟是否存在保護(hù)作用，并研究其對(duì)其他重要臟器的作用，以及觀察改良GIK是否對(duì)患者術(shù)后并發(fā)癥及死亡率有無(wú)影響。 目的 1.探討CPB下心臟手術(shù)患者是否出現(xiàn)急性IR，，并觀察改良GIK對(duì)急性IR的作用； 2.探討心臟術(shù)后患者重要臟器功能的變化，改良GIK對(duì)其是否具有保護(hù)作用； 3.觀察心臟術(shù)后患者并發(fā)癥以及死亡率，探討改良GIK對(duì)其預(yù)后的影響。 方法 ⑴連續(xù)選取我院心血管外科診斷為心血管疾病并需要行心血管手術(shù)治療的患者1000例，根據(jù)隨機(jī)數(shù)表，分為2組：GIK組497例，對(duì)照組（CON組）503例。⑵GIK組患者在麻醉誘導(dǎo)后立即經(jīng)由中心靜脈通過(guò)微量注射泵給予改良GIK液（20%葡萄糖750ml，普通胰島素50u，10%氯化鉀45ml），速度60ml/h，而CON組在同時(shí)間同種方式給予乳酸林格。⑶所有患者術(shù)前均行常規(guī)檢查，根據(jù)患者病情，并且充分考慮家屬和患者意見(jiàn)，按照規(guī)范化模式實(shí)施相應(yīng)手術(shù)。實(shí)驗(yàn)一兩組患者均于手術(shù)前、CPB5min、開(kāi)放升主動(dòng)脈5min、CPB結(jié)束、術(shù)后1h、術(shù)后6h、術(shù)后12h、術(shù)后24h、術(shù)后48h采取動(dòng)脈血樣，分別測(cè)定血糖（blood glucose, BG）、血清鉀離子（serum kalium, K+）、乳酸（lactic acid, Lac）水平；隨機(jī)選取兩組患者各20名，分別在上下腔靜脈阻閉后，升主動(dòng)脈阻閉前和升主動(dòng)脈開(kāi)放后兩個(gè)時(shí)間點(diǎn)，同時(shí)抽取動(dòng)脈和冠狀動(dòng)脈竇血液，進(jìn)行血糖檢測(cè)，并求兩者血糖差值，即心肌攝取葡萄糖量。實(shí)驗(yàn)二兩組患者分別于手術(shù)前、術(shù)后24h和術(shù)后48h采取靜脈血樣，分別測(cè)定谷草轉(zhuǎn)氨酶（AST）、乳酸脫氫酶（LDH）、肌酸激酶（CK）、肌酸激酶同工酶（CK-MB）、羥丁酸脫氫酶（HBDH）、谷丙轉(zhuǎn)氨酶（ALT）、膽紅素（BIL）、尿素氮（BUN）、肌酐（CR）水平；于手術(shù)前、術(shù)后6h、術(shù)后24h和術(shù)后48h采取靜脈血樣，測(cè)定肌鈣蛋白I（cTnI）；于手術(shù)前、術(shù)后24h和術(shù)后7天測(cè)量左心室射血分?jǐn)?shù)（LVEF）。實(shí)驗(yàn)三自患者手術(shù)完成進(jìn)入ICU后開(kāi)始，計(jì)算機(jī)械通氣時(shí)間、ICU治療時(shí)間、住院時(shí)間；記錄出現(xiàn)術(shù)后并發(fā)癥例數(shù)，其主要包括：休克、中樞神經(jīng)系統(tǒng)功能障礙、術(shù)后新發(fā)生的房顫、腎臟替代治療等，并記錄患者出院前死亡例數(shù)。 統(tǒng)計(jì)分析 所有數(shù)據(jù)應(yīng)用SPSS17.0統(tǒng)計(jì)軟件進(jìn)行處理。計(jì)量資料結(jié)果正態(tài)分布以均數(shù)±標(biāo)準(zhǔn)差（x±SD）表示，并進(jìn)行t檢驗(yàn)，組間比較采用LSD方法；偏態(tài)分布以中位數(shù)和四分位間距（M，IQR）表示，兩組間進(jìn)行非參數(shù)mann-whitney-U秩和檢驗(yàn)；計(jì)數(shù)資料采用卡方分析；等級(jí)資料采用Mann-Whitney檢驗(yàn)，當(dāng)P＜0.05為統(tǒng)計(jì)結(jié)果有統(tǒng)計(jì)學(xué)差異。 結(jié)果 實(shí)驗(yàn)一兩組患者鉀離子水平在各個(gè)觀測(cè)點(diǎn)基本保持一致；兩組患者的血糖和乳酸水平在手術(shù)后有不同程度的升高，其中GIK組血糖水平在術(shù)中特別是在開(kāi)放升主動(dòng)脈5min時(shí)高于CON組（P0.05），但仍低于8mmol/L，且在術(shù)后6h顯著低于CON組（P0.05）。兩組患者在手術(shù)前乳酸水平處于正常水平，并且沒(méi)有統(tǒng)計(jì)學(xué)差異；GIK組乳酸水平在術(shù)后特別是在術(shù)后1小時(shí)、術(shù)后6小時(shí)、術(shù)后12小時(shí)低于CON組（P0.05）。GIK組在升主動(dòng)脈阻閉前和升主動(dòng)脈開(kāi)放后兩個(gè)時(shí)間點(diǎn)，心肌糖攝取量明顯高于CON組（P0.001）。實(shí)驗(yàn)二術(shù)后7d時(shí)GIK組LVEF明顯高于CON組(P0.01)；GIK組AST、CK、LDH、HBDH、CK-MB、cTnI在術(shù)后24h和術(shù)后48h相對(duì)于CON組明顯降低（P0.05，P0.01，P0.001）；而非體外循環(huán)下冠狀動(dòng)脈旁路移植術(shù)者心肌酶譜在兩組間無(wú)統(tǒng)計(jì)學(xué)差異。GIK組部分患者ALT、BIL、BUN、CR在術(shù)后24h和術(shù)后48h相對(duì)于CON組有不同程度降低。實(shí)驗(yàn)三GIK組部分患者機(jī)械通氣時(shí)間和ICU治療時(shí)間明顯低于CON組（P＜0.05）；手術(shù)后突發(fā)各種休克和新發(fā)房顫GIK組明顯低于CON組(P0.05)；出現(xiàn)中樞神經(jīng)系統(tǒng)功能障礙、急性腎功能衰竭行床旁持續(xù)腎替代治療和死亡例數(shù)在兩組間無(wú)顯著性差異。 結(jié)論 心臟手術(shù)和CPB等強(qiáng)烈刺激使機(jī)體發(fā)生急性IR，并對(duì)心臟和其他重要臟器造成損傷。改良GIK可以使圍術(shù)期患者血糖和鉀離子保持相對(duì)穩(wěn)定，并且可以緩解IR程度，還可以在一定程度上對(duì)臟器起到保護(hù)作用。圍術(shù)期給予改良GIK治療可以降低術(shù)后患者并發(fā)癥的發(fā)生，改善患者的預(yù)后。
[Abstract]:Research background
The abnormal structure of only most organic cardiovascular disease through surgery to repair, and the implementation of most of the heart surgery depends on cardiopulmonary bypass (cardiopulmonary bypass, CPB CPB), also known as extracorporeal circulation (extracorporeal circulation, ECC).CPB technology, although increasingly mature, but still the blood perfusion model and the normal physiological state of the body under irrigation are very different flow patterns, combined with the body strong stress response, may lead to dysfunction of important organs after operation, and affect the function of patients with postoperative recovery of.CPB during the machine have high blood glucose and high insulin, but insulin target tissues to insulin sensitivity decreased glucose utilization decreased. Leading to acute insulin resistance (insulin resistance, IR), associated with organ dysfunction. So how to reduce the operation of IR, is a direct and important dirty heart Research focus in the field of protection. The glucose - insulin - potassium chloride (Glucose-Insulin-Potassium, GIK) for cardiac perioperative myocardial protection has more than 50 years of history, but its clinical effect is uneven. The cardiac surgery patients as the research object, to explore whether CPB induced IR, modified GIK on the heart whether there the protective effect, and to study the role of other important organs, and the effects of modified GIK in patients with postoperative complications and mortality have no effect.
objective
1. to investigate the incidence of acute IR in patients undergoing cardiac surgery under CPB, and to observe the effect of improved GIK on acute IR.
2. to investigate the changes of important organ function in patients after cardiac surgery, and to improve the protective effect of GIK on it.
3. to observe the complications and mortality of patients after cardiac surgery, and to explore the effect of improved GIK on its prognosis.
Method
The continuous selection of cardiovascular surgery in our hospital diagnosed 1000 cases of cardiovascular disease and need for cardiovascular surgery patients, according to randomly divided into 2 groups: GIK group 497 cases, control group (CON group) 503 Cases. The patients in group GIK immediately after induction of anesthesia via central vein through the micro injection pump for improvement GIK solution (20% 750ml glucose, insulin 50U, 10% potassium chloride 45ml), speed of 60ml/h, while the CON group given lactated Ringer's at the same time the same way. All the patients underwent a routine examination before operation, according to the patient's condition, and give full consideration to the families and patients, in accordance with the norms of the implementation of the corresponding operation mode of experiment one or two. All patients before the operation, CPB5min, open aorta 5min, CPB end, 1h after surgery, postoperative 6h, postoperative 12h, postoperative 24h, postoperative 48h arterial blood glucose were measured (blood glucose, BG), serum potassium (serum kalium, K+ ),涔抽吀(lactic acid, Lac)姘村鉤錛涢殢鏈洪

本文編號(hào)：1736878