【摘要】：目的:觀察上、下肢體缺血后處理兩種處理方法對體外循環(huán)直視下成人心臟瓣膜置換術(shù)患者血清cTnT濃度及術(shù)后恢復(fù)的影響，探討不同的肢體遠(yuǎn)隔缺血后處理模式的心肌保護(hù)效果。方法:將48例在體外循環(huán)下擬行心臟瓣膜置換術(shù)的成年患者，隨機(jī)分為三組，即對照組（C組，n=16）、上肢缺血后處理組（S組, n=16）、下肢缺血后處理組（X組, n=16）。入室后常規(guī)監(jiān)測生命體征，靜注鹽酸戊乙奎醚注射液0.01~0.02mg/kg，以鎮(zhèn)靜、鎮(zhèn)痛、肌松的順序靜脈緩慢注射誘導(dǎo)后行氣管插管及機(jī)械通氣；行左橈動脈穿刺監(jiān)測有創(chuàng)血壓及右頸內(nèi)靜脈穿刺監(jiān)測中心靜脈壓；通過外周靜脈持續(xù)泵注枸櫞酸芬太尼、維庫溴銨以及咪唑安定以維持麻醉深度。C組除對上、下肢體不做任何處理外，其它的處置和方法均與S組、X組相同；S組在體外循環(huán)(cardiopulmonary bypass，CPB)期間，主動脈開放后即刻使預(yù)先系于右上肢上臂的止血帶充氣（寬6cm，下緣離肘關(guān)節(jié)2~3cm，壓力保持200mmHg），保持3min阻斷/3min復(fù)流，重復(fù)3次，共計18min；X組主動脈開放后即刻使預(yù)先系于左下肢大腿止血帶（寬8cm，下緣離膝關(guān)節(jié)3~4cm，充氣后壓力保持250mmHg）充氣，，持續(xù)3min阻斷/3min復(fù)流，重復(fù)3次過程，共計18min；三組患者CPB期間維持平均動脈壓(MAP)在50~70mmHg之間，術(shù)中持續(xù)監(jiān)測HR、CVP、SpO2、、ECG、SBP、DBP、MAP、 PetCO2，間斷檢測血氣分析、全血凝固時間（ACT），并記錄CPB的時間、主動脈阻斷的時間、心臟自動復(fù)跳比例。分別于麻醉誘導(dǎo)后即刻（T1）、主動脈開放后2h(T2)、12h（T3）、24h（T4）、36h（T5）的5個時間點采集動脈血標(biāo)本，將收集好的標(biāo)本冷藏用于測定血清肌鈣蛋白-T(cTnT)，所有患者術(shù)畢都帶管送入ICU繼續(xù)治療，并記錄呼吸機(jī)輔助呼吸時間、拔出氣管導(dǎo)管時間、ICU留觀時間、血管活性藥物的使用時間、追蹤患者愈后過程中有無受處理肢體異常并記錄住院時間。結(jié)果:1.三組病人在年齡、男/女比例、體重（W）、NYHA分級、術(shù)前心率（HR）、術(shù)前平均動脈壓（MAP）、術(shù)前SpO2、術(shù)前射血分?jǐn)?shù)（EF）、單/雙瓣手術(shù)類型比例的比較均無統(tǒng)計學(xué)意義（p0.05）；2.三組病人CPB時間、主動脈阻斷時間、手術(shù)時間的比較均無統(tǒng)計學(xué)意義（p0.05）；3. S組、X組主動脈開放后心臟自動復(fù)跳率均明顯高于C組（p0.01），而S組和X組組之間心臟自動復(fù)跳率比較無差異（p0.05）；4.三組患者之間血清cTnT濃度的基礎(chǔ)值（T1）比較無顯著差異性（p0.05）；三組患者在T2-5各時間點，血清cTnT濃度與各自的基礎(chǔ)值（T1）相比較顯著增高（p0.01），但均明顯低于C組（p0.01），S組和X組組之間血清cTnT濃度比較無顯著差異（p0.05）；5.術(shù)后ICU留觀時間、呼吸機(jī)輔助呼吸時間、拔出氣管導(dǎo)管時間、術(shù)后血管活性藥物的使用時間、住院時間與C組比較有顯著差異性（p0.01）；術(shù)后隨訪均未見S組、X組病人受缺血后處理肢體發(fā)生任何異常；6.三組病人T1-5各時間點血流動力學(xué)（HR、MAP、CVP）組內(nèi)及組間比較均無差異（p0.05）結(jié)論:1.右上肢缺血后處理和左下肢缺血后處理這兩種方式均可有效降低CPB下行瓣膜置換的患者術(shù)中及術(shù)后血清cTnT的濃度并提高心臟自動復(fù)跳率，表明這兩種肢體缺血后處理方法均能有效發(fā)揮心肌保護(hù)效應(yīng)；2.兩組缺血后處理方法均能降低術(shù)后ICU留觀時間、術(shù)后呼吸機(jī)輔助呼吸時間、拔出氣管導(dǎo)管時間、術(shù)后血管活性藥物的使用時間、住院時間，表明這兩種肢體缺血后處理方法均可能有效促進(jìn)術(shù)后心功能恢復(fù)；3.S組和X組兩種處理方法降低血清cTnT濃度的升幅及縮短術(shù)后ICU留觀時間的作用相近，提示在臨床上可酌情選擇單一肢體進(jìn)行缺血后處理即可；4.觀察期間，三組病人的血流動力學(xué)指標(biāo)無顯著差異性，提示兩種肢體后處理方法對循環(huán)系統(tǒng)功能不會造成不利影響。隨訪未發(fā)現(xiàn)處理組患者受處理肢體發(fā)生異常，表明所用方法具有簡便、無創(chuàng)、經(jīng)濟(jì)、有效、安全、可行的優(yōu)點。
[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.
【學(xué)位授予單位】：瀘州醫(yī)學(xué)院
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2014
【分類號】：R654.2

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