【摘要】：目的臨床研究已表明，不僅降低圍術(shù)期機體應(yīng)激反應(yīng)有助于術(shù)后康復(fù)和完善手術(shù)效果，而且加強圍術(shù)期營養(yǎng)支持和減少圍術(shù)期患者機體的分解代謝對其產(chǎn)生的影響也很明顯。但目前對不同全身麻醉維持藥物對手術(shù)患者機體分解代謝及營養(yǎng)狀況的影響了解甚少。目前臨床上常用的全麻維持藥物的復(fù)合方式是七氟醚復(fù)合瑞芬太尼和丙泊酚復(fù)合瑞芬太尼，該課題目的就是比較以上兩種全麻維持方式下行經(jīng)腹會陰聯(lián)合直腸癌根治術(shù)的患者的應(yīng)激激素、肌肉蛋白質(zhì)分解代謝和內(nèi)臟蛋白水平方面的差異。 方法將要行經(jīng)腹會陰聯(lián)合直腸癌根治術(shù)的54個患者，ASA(American Society Of Anesthesiologists,美國麻醉醫(yī)師協(xié)會)Ⅰ-Ⅲ級，年齡在25~65歲之間。將以上患者隨機分為兩組:一組接受七氟醚復(fù)合瑞芬太尼全麻維持，即七氟醚組（S組，n=27）；另一組接受丙泊酚復(fù)合瑞芬太尼靜脈全麻維持，即丙泊酚組（P組，n=27）。尿標本自手術(shù)切皮時（0h）每小時收集一次(0h，0-1h，1-2h，2-3h，3-4h)，直至手術(shù)結(jié)束，檢測尿液中3-甲基組氨酸與肌酐的比值（3MH/Cr），以此作為反映機體蛋白質(zhì)分解量的指標。血標本自手術(shù)切皮時（0h）每兩小時收集一次，直至手術(shù)結(jié)束，至少收集三次(0h，2h，4h)，，檢測血清中胰島素、皮質(zhì)醇含量。并于手術(shù)切皮時(0h)，術(shù)后6h以及術(shù)后第1天和術(shù)后2天的的清晨抽取空腹靜脈血，檢測血清內(nèi)臟蛋白【前白蛋白（prealbumin,PRE）、視黃醇結(jié)合蛋白（retinal-bindingprotein,RbP）】的水平。呼吸商（RQ）作為反應(yīng)機體代謝情況的重要指標，自手術(shù)切皮時（0h）每小時記錄一次平均值（0h，0-1h，1-2h，2-3h，3-4h），直至手術(shù)結(jié)束。 結(jié)果在兩組中，與0h，0-1h的3-MH/Cr值相比，1-2h，2-3h的明顯升高。但是丙泊酚組1-2h(15.7vs18.2,P＜0.05)和2-3h(15.9vs18.1,P＜0.05)的3MH/Cr值(nmol/umol)均比七氟醚組低。并且在這兩個時間點P組的RQ也比S組要明顯降低。兩組中的內(nèi)臟蛋白均在術(shù)后兩天內(nèi)持續(xù)下降，但是丙泊酚組在術(shù)后第2天的下降幅度明顯小于七氟醚組。 結(jié)論推測因為丙泊酚脂肪乳中的甘油三酯作為供能物質(zhì)被機體分解利用，從而減少了機體肌肉蛋白的分解，所以丙泊酚組的3-MH/Cr值和呼吸商小于七氟醚組。并且丙泊酚用于全麻維持能有效減小術(shù)后體內(nèi)臟蛋白水平的下降幅度，有利于機體營養(yǎng)狀態(tài)早日恢復(fù)。
[Abstract]:Objective Clinical studies have shown that not only reducing the stress response in perioperative period is helpful to postoperative rehabilitation and improving the effect of surgery, but also strengthening nutritional support during perioperative period and reducing the effect of catabolism on perioperative patients. However, little is known about the effects of different general anesthesia maintenance drugs on catabolism and nutritional status in patients undergoing surgery. At present, sevoflurane combined with remifentanil and propofol combined with remifentanil are commonly used in clinical practice. The aim of this study was to compare the differences in stress hormones, muscle protein catabolism and visceral protein levels in patients undergoing transabdominal perineum combined rectal cancer radical resection under the two general anesthesia maintenance modes. Methods Fifty-four patients (, ASA (American Society Of Anesthesiologists, American Association of Anesthesiologists), aged between 25 and 65 years, who were undergoing radical resection of rectal cancer through abdominal perineum were enrolled in this study. The patients were randomly divided into two groups: one group received sevoflurane combined with remifentanil general anesthesia, namely sevoflurane group (S group, n = 27), the other group received propofol combined remifentanil intravenous general anesthesia maintenance, namely propofol group (P group, n = 27). Urine samples were collected every hour (0 h, 0 h, 1 h, 2 h, 3 h) at the end of operation. The ratio of 3-methylhistidine to creatinine (3MH/Cr) in urine was determined. This is used as an index to reflect the amount of protein decomposition in the body. The blood samples were collected every two hours at the time of skin incision until the end of the operation. The serum insulin and cortisol contents were measured at least three times (0 h / 2 h / h). Fasting venous blood was collected at the time of skin incision (0 h), 6 h after operation, 1 day after operation and 2 days after operation. The serum levels of visceral protein (prealbumin,PRE) and retinol binding protein (retinal-bindingprotein,RbP) were measured. Respiratory quotient (RQ), as an important indicator of metabolism, was recorded once an hour (0 h / h) at the time of skin incision (0 h / h) (0 h / h 0 ~ 1 h) and 2 ~ 2 h / 2 h / 3 h / h, until the end of the operation. Results in the two groups, the 3-MH/Cr value of 1-2hu 2-3h was significantly higher than that of 0hU 0-1h. However, the 3MH/Cr (nmol/umol) of propofol group was lower than that of sevoflurane group at 1-2 h (15.7 vs 18.2) and 2-3 h (15.9 vs 18.1 P < 0.05). The RQ of P group was significantly lower than that of S group at these two time points. The visceral protein in both groups decreased continuously on the 2nd day after operation, but the decrease in propofol group was significantly lower than that in sevoflurane group on the second day after operation. Conclusion because the triglyceride in propofol fat emulsion is decomposed by the body as energy supply, thus reducing the decomposition of muscle protein, the 3-MH/Cr value and respiratory quotient of propofol group are lower than that of sevoflurane group. And propofol used in maintenance of general anesthesia can effectively reduce the decrease of body visceral protein level, which is beneficial to the early recovery of body nutrition.
【學(xué)位授予單位】：鄭州大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2014
【分類號】：R614

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