本文選題：丙泊酚 + 異氟醚�。� 參考：《上海交通大學(xué)》2014年博士論文

【摘要】：目的：乳腺癌是女性最常見的惡性腫瘤。麻醉下手術(shù)切除病灶仍是目前治療實(shí)體腫瘤的主要方法，然而圍術(shù)期免疫抑制的特點(diǎn)，可以造成腫瘤細(xì)胞免疫逃逸并發(fā)生腫瘤轉(zhuǎn)移。已有研究表明麻醉對(duì)免疫系統(tǒng)有調(diào)節(jié)作用，但關(guān)于不同麻醉用藥對(duì)惡性腫瘤患者圍術(shù)期細(xì)胞免疫功能影響的臨床研究甚少。本文旨在探討丙泊酚及異氟醚麻醉對(duì)浸潤性乳腺癌患者圍術(shù)期外周血輔助性T細(xì)胞各亞型及其相關(guān)細(xì)胞因子的影響，為腫瘤患者臨床麻醉方法的優(yōu)選提供依據(jù)。 方法：選擇浸潤性乳腺癌患者27例，ASAI~II級(jí)，年齡35~75歲，TNM分期I~II級(jí)，體重指數(shù)30kg/m2，，隨機(jī)分成三組，丙泊酚全憑靜脈麻醉組（靜脈組），丙泊酚復(fù)合異氟醚麻醉組（靜吸組），異氟醚吸入麻醉組（吸入組），每組各9例。患者入室后常規(guī)監(jiān)測無創(chuàng)動(dòng)脈血壓、心電圖、脈搏血氧飽和度和Nacrotrend指數(shù)。靜脈組及靜吸組選用咪達(dá)唑侖4g/kg，芬太尼2g/kg，丙泊酚1.5~2mg/kg，順苯磺酸阿曲庫銨0.15mg/kg靜脈順序誘導(dǎo)。吸入組用依托米酯0.3mg/kg替代丙泊酚，其余誘導(dǎo)用藥同靜脈組及靜吸組。插管成功后連接麻醉機(jī)行機(jī)械通氣，連續(xù)監(jiān)測并維持呼吸末二氧化碳在35~40mmHg之間。靜脈組采用微量泵TCI模式持續(xù)輸注丙泊酚維持麻醉，靶控濃度3~4g/ml；吸入組持續(xù)吸入1.5%~2%濃度的異氟醚；靜吸組應(yīng)用TCI靶控輸注丙泊酚1g/ml，全程不變，同時(shí)吸入1%~1.5%濃度的異氟醚。術(shù)中調(diào)整靜脈組丙泊酚靶控濃度及吸入組、靜吸組異氟醚吸入濃度，維持Nacrotrend指數(shù)于D0-2。間斷推注芬太尼50~100g和順苯磺酸阿曲庫銨3~4mg，維持患者術(shù)中血流動(dòng)力學(xué)穩(wěn)定及肌肉松弛。三組患者分別于手術(shù)當(dāng)日（D0），術(shù)后第一天（D1），術(shù)后第七天（D7）采集外周靜脈血3ml，流式細(xì)胞儀檢測外周血中CD4+CD25+Foxp3+調(diào)節(jié)性T淋巴細(xì)胞占CD4+輔助性T淋巴細(xì)胞的比例，流式液相多重蛋白定量法檢測血漿中細(xì)胞因子IL-17A、IFN-γ和IL-10濃度。 結(jié)果：三組患者在圍術(shù)期各檢測時(shí)點(diǎn)外周血CD4+CD25+Foxp3+調(diào)節(jié)性T淋巴細(xì)胞占CD4+輔助性T淋巴細(xì)胞的百分比及血漿IFN-γ的濃度未發(fā)生顯著變化（p0.05）；靜脈組患者血漿IL-17A濃度在D1時(shí)較D0時(shí)明顯下降（p0.001)，組間比較，D1時(shí)靜脈組IL-17A濃度明顯低于靜吸組和吸入組（p=0.002），至D7時(shí)刻，三組IL-17A水平之間差異不明顯（p0.05）；吸入組患者血漿IL-10濃度在D1時(shí)較D0時(shí)顯著增高（p=0.01），組間比較，D1時(shí)吸入組IL-10濃度顯著高于靜脈組（p=0.016）和靜吸組（p=0.043），至D7時(shí)刻，靜吸組和吸入組患者的IL-10水平仍明顯高于靜脈組患者（p=0.027）；相較于D0時(shí)，D1時(shí)吸入組患者血漿IFN-γ/IL-10比例明顯下降（p=0.006），與靜脈組比較，吸入組D1時(shí)刻IFN-γ/IL-10比值下降更顯著（p=0.024），至D7時(shí)刻，吸入組此比值仍明顯小于靜脈組（p=0.007）。 結(jié)論：1、丙泊酚和異氟醚麻醉對(duì)因浸潤性乳腺癌行乳房單純切除加淋巴結(jié)清掃術(shù)患者外周血CD4+CD25+Foxp3+調(diào)節(jié)性T細(xì)胞的含量沒有明顯影響。2、麻醉藥物能改變機(jī)體細(xì)胞因子分泌格局，相較于異氟醚，丙泊酚有益于抑制促腫瘤細(xì)胞因子IL-17A分泌，抑制IL-10的過度表達(dá)，阻止手術(shù)后免疫反應(yīng)由Th1型向Th2型漂移，可能有利于腫瘤患者圍術(shù)期的免疫保護(hù)。
[Abstract]:Objective : Breast cancer is one of the most common malignant tumors in women . surgical resection of the lesions under anesthesia is still the main method for the treatment of solid tumors . However , there is little clinical study on the effect of propofol and isoflurane on the immune function of peripheral blood in patients with malignant tumor .

Methods : Twenty - seven patients with invasive breast cancer , ASAI - II , age 35 - 75 years , TNM stages I ~ II and body weight index of 30kg / m2 were randomly divided into three groups : propofol group ( vein group ) , propofol combined isoflurane anesthesia group ( static suction group ) and isoflurane inhalation anesthesia group ( inhalation group ) .
the inhalation group continuously inhales the isoflurane with the concentration of 1.5 % -2 % ;
The concentrations of CD4 + CD25 + Foxp3 + regulatory T lymphocytes in peripheral blood were measured by flow cytometry . The levels of cytokines IL - 17A , IFN - 緯 and IL - 10 in plasma were measured by flow cytometry .

Results : The percentage of CD4 + CD25 + Foxp3 + regulatory T lymphocytes in CD4 + CD25 + Foxp3 + regulatory T lymphocytes and the concentration of IFN - 緯 in peripheral blood of three groups were not significantly changed ( p < 0.05 ) .
The plasma levels of IL - 17A and IL - 17A were significantly lower ( p = 0.002 ) than those in group D ( p = 0.002 ) , and the level of IL - 17A was not significantly different between the three groups ( p < 0.05 ) .
The levels of IL - 10 were significantly higher at D1 ( p = 0 . 01 ) than those in intravenous group ( p = 0 . 016 ) and group D ( p = 0.043 ) . IL - 10 levels were still significantly higher than those in intravenous group ( p = 0.027 ) .
Compared with vein group , the ratio of IFN - 緯 / IL - 10 decreased significantly ( p = 0 . 024 ) , and the ratio of IFN - 緯 / IL - 10 in the inhalation group was still significantly lower than that in vein group ( p = 0.007 ) .

Conclusion : 1 , propofol and isoflurane anesthesia did not significantly affect the content of CD4 + CD25 + Foxp3 + regulatory T cells in peripheral blood of patients with invasive breast cancer .
【學(xué)位授予單位】：上海交通大學(xué)
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2014
【分類號(hào)】：R614;R737.9

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相關(guān)期刊論文 前2條

1 邵明海;王建華;丁維軍;胡煒;王碧云;;惡性腫瘤患者外周血CD_4~+CD_(25)~+調(diào)節(jié)性T細(xì)胞的檢測及其臨床意義[J];現(xiàn)代實(shí)用醫(yī)學(xué);2009年02期

2 林長賦;潘英麗;丁錦屏;李文志;任憲鳳;;丙泊酚對(duì)肺癌根治術(shù)患者T淋巴細(xì)胞可誘導(dǎo)協(xié)同刺激分子的影響[J];臨床麻醉學(xué)雜志;2010年04期

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