【摘要】：目的:通過預(yù)先靜注磷酸肌酸鈉,觀察止血帶解除早期動(dòng)脈血液中的肺表面活性蛋白D的變化情況,來評(píng)價(jià)磷酸肌酸鈉預(yù)處理對(duì)止血帶誘發(fā)肺損傷的防治作用。方法:本研究選取擇期全麻下行下肢創(chuàng)傷性骨科手術(shù),年齡30-40歲ASA分級(jí)為I-II級(jí)的30例患者,隨機(jī)將患者分為兩組,A組為對(duì)照組,B組為磷酸肌酸鈉預(yù)處理組�；颊哌M(jìn)入手術(shù)室后均連接無創(chuàng)血壓,心電圖以及指脈氧飽和度,并開放外周靜脈,在鹽酸利多卡因局麻下行橈動(dòng)脈穿刺置管用于監(jiān)測(cè)有創(chuàng)動(dòng)脈壓及血樣的采集。準(zhǔn)備工作均完成后B組將磷酸肌酸鈉2g溶于100ml0.9%氯化鈉中通過外周靜脈在30分鐘內(nèi)輸注,而A組則用單純的0.9%氯化鈉100ml代替。待100ml液體輸注完成后進(jìn)行麻醉誘導(dǎo):步驟為靜脈注射咪達(dá)唑侖0.03mg/kg、順苯磺酸阿曲庫(kù)銨0.2mg/kg、依托咪酯0.25mg/kg、舒芬太尼0.6ug/kg。待肌松完全后插入喉罩,連接麻醉機(jī)進(jìn)行機(jī)械通氣,潮氣量的設(shè)定為8ml/kg,呼吸頻率的設(shè)定為12次/min,吸呼比的設(shè)定為1:2,并根據(jù)呼氣末二氧化碳分壓的數(shù)值來調(diào)整潮氣量,使其維持在35-40mm Hg之間�；颊咝g(shù)中麻醉維持均為輸注丙泊酚與瑞芬太尼,并根據(jù)麻醉深度(BIS值維持在40-60)以及循環(huán)情況,來調(diào)整丙泊酚和瑞芬太尼的輸注速度。術(shù)中監(jiān)測(cè)并記錄患者入手術(shù)室時(shí)(T0)、止血帶充氣即刻(T1)、止血帶充氣30分鐘(T2)、止血帶充氣1小時(shí)(T3)、止血帶放氣后1分鐘(T4)、止血帶放氣后30分鐘(T5)以及拔除喉罩后出室前(T6)時(shí)患者的收縮壓(SBP)、舒張壓(DBP)、心率(HR)及平均動(dòng)脈壓(MAP)。同時(shí)在T0、T5、T6以上三個(gè)時(shí)間點(diǎn)抽取橈動(dòng)脈血用于檢測(cè)肺表面活性蛋白D(SP-D)和動(dòng)脈血PH值、動(dòng)脈血氧分壓(Pa O 2)、動(dòng)脈血二氧化碳分壓(Pa CO 2)、并依此計(jì)算肺泡氣動(dòng)脈血氧分壓差PO2(A-a)以及呼吸指數(shù)(RI)。結(jié)果:1、兩組不同時(shí)間SP-D比較從組內(nèi)看,A組、B組不同時(shí)點(diǎn)間差異有統(tǒng)計(jì)學(xué)意義(P0.05),表現(xiàn)為T5時(shí)明顯高于T0時(shí),T6時(shí)明顯高于T5時(shí)。從組間來看,在T0時(shí),兩組差異無統(tǒng)計(jì)學(xué)意義(P0.05);在T5、T6時(shí),兩組差異有統(tǒng)計(jì)學(xué)意義(P0.05),結(jié)果顯示A組明顯高于B組。2、兩組不同時(shí)間PH和Pa CO2比較A組、B組兩組間和組內(nèi)的PH和Pa CO2差異均無統(tǒng)計(jì)學(xué)意義。3、兩組不同時(shí)間Pa O2比較從組間看,T0時(shí),兩組差異無統(tǒng)計(jì)學(xué)意義;T5、T6時(shí),兩組差異有統(tǒng)計(jì)學(xué)意義(P0.05),均表現(xiàn)為B組明顯高于A組。從組內(nèi)看,A組、B組不同時(shí)點(diǎn)間差異有統(tǒng)計(jì)學(xué)意義(P0.05),進(jìn)一步互相比較,兩組均表現(xiàn)T5時(shí)Pa O2明顯高于T0、T6時(shí),差異有統(tǒng)計(jì)學(xué)意義(P0.05),T0與T6差異無統(tǒng)計(jì)學(xué)意義。4、兩組PO2(A-a)、RI比較從組間比較T0時(shí),A組與B組PO2(A-a)、RI差異無統(tǒng)計(jì)學(xué)意義;T6時(shí),A組PO2(A-a)、RI高于B組,差異有統(tǒng)計(jì)學(xué)意義(P0.05)。結(jié)論:在下肢創(chuàng)傷性骨科手術(shù)的患者中,磷酸肌酸鈉預(yù)處理在一定程度上可以抑制缺血再灌注所引起的肺損傷,對(duì)止血帶誘發(fā)的肺換氣功能損傷起到保護(hù)作用。
[Abstract]:Aim: to observe the changes of pulmonary surfactant D in the early arterial blood of tourniquet after intravenous injection of creatine phosphate sodium in advance, and to evaluate the preventive and therapeutic effect of sodium phosphate on lung injury induced by tourniquet. Methods: 30 patients aged 30-40 years with ASA grade of I-II grade were randomly divided into two groups: group A (control group) and group B (pretreatment group with sodium phosphate creatine phosphate). After entering the operating room, the patients were connected with non-invasive blood pressure, electrocardiogram and finger oxygen saturation, and the peripheral vein was opened. The radial artery puncture catheter was used to monitor the invasive arterial pressure and blood sample collection under the local anesthesia of lidocaine hydrochloride. After all the preparations were completed, group B dissolved 2g creatine phosphate in 100ml 0.9% sodium chloride through peripheral vein for 30 minutes, while group A was replaced by a single 0.9% sodium chloride 100ml. Anesthesia induction was performed after 100ml infusion: intravenous midazolam 0.03 mg / kg, atracurium cisbenzenesulfonate 0.2 mg / kg, etomidate 0.25 mg / kg, sufentanil 0.6 ugg / kg. When the muscle release is complete, the laryngeal mask is inserted and the anesthetic machine is connected to perform mechanical ventilation. The tidal volume is set to 8 ml / kg, and the respiratory frequency is set to 12 times / min, breathing ratio of 1: 2, and the moisture volume is adjusted according to the value of the partial pressure of carbon dioxide at the end of the breath. Keep it between 35-40mm Hg. Anesthesia was maintained by infusion of propofol and remifentanil during the operation. The infusion rate of propofol and remifentanil was adjusted according to the depth of anesthesia (BIS) and circulation. Intraoperative monitoring and recording of patients entering the operating room (T0), tourniquet inflating instant (T1), tourniquet inflating 30 minutes (T2), tourniquet inflating 1 hour (T3), tourniquet exhaling 1 minute (T4), tourniquet exhaling 30 minutes (T5) and removing larynx hood out of the room Systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR) and mean arterial pressure (MAP).) in patients with anterior (T6) At the same time, radial artery blood was extracted at three time points above T0 T5 and T6 to detect pulmonary surfactant protein D (SP-D) and arterial blood PH. Arterial partial pressure of oxygen (Pa O _ 2) and arterial partial pressure of carbon dioxide (Pa CO _ 2) were used to calculate PO2 (A-a) and respiratory index (RI). Results: 1. There were significant differences in SP-D between groups A and B at different time points (P0.05), showing that T5 was significantly higher than T0 and T6 was significantly higher than T5. At T0, there was no significant difference between the two groups (P0.05), but at T5 / T6, there was no significant difference between the two groups. The difference between the two groups was statistically significant (P0.05). The results showed that group A was significantly higher than group B. 2. PH and Pa CO2 in two groups were higher than those in group A at different time. There was no significant difference in PH and Pa CO2 between and within group B. 3. The Pa O 2 ratio of two groups at different time was higher than that in group B. When T0 is compared with other groups, There was no significant difference between the two groups. At T5 and T6, the difference between the two groups was statistically significant (P0.05), which showed that group B was significantly higher than group A. From the point of view of group A and group B, there was significant difference at different time points (P0.05). Further comparison between the two groups showed that Pa O 2 was significantly higher at T5 than that at T0 T6, and there was no significant difference between group A and group B at different time points (P0.05). The difference was statistically significant (P0.05), but there was no significant difference between T0 and T6. 4The PO2 (A-a), RI) was not significantly different between group A and group B when compared with T0 (P 0.05); at T6, PO2 (A-a), RI) in group A was higher than that in group B. the difference was statistically significant (P0.05). Conclusion: in the patients with traumatic orthopedic surgery of lower extremity, the pretreatment with creatine phosphate can inhibit the lung injury induced by ischemia and reperfusion to some extent, and protect the lung ventilation injury induced by tourniquet.
【學(xué)位授予單位】：大連醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R614

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