本文選題：右美托咪定 + 全弓置換�。� 參考：《鄭州大學(xué)》2017年碩士論文

【摘要】：研究背景主動(dòng)脈夾層(Aortic dissection,AD)是心外科最兇險(xiǎn)的疾病之一,發(fā)病急、病死率高,在我國的發(fā)病率有增高的趨勢(shì)。AD指主動(dòng)脈壁內(nèi)膜破裂,受到強(qiáng)力血液沖擊,血液進(jìn)入主動(dòng)脈壁造成正常主動(dòng)脈壁分離從而在壁內(nèi)形成真假兩腔。臨床上一旦懷疑為主動(dòng)脈夾層,應(yīng)盡快明確診斷,盡早手術(shù)。主動(dòng)脈夾層手術(shù)是一項(xiàng)復(fù)雜、耗時(shí)的手術(shù),大部分是在深低溫停循環(huán)(deep hypothermic circulatory arrest,DHCA)選擇性腦灌注技術(shù)輔助下實(shí)施的,很容易造成機(jī)體重要臟器的缺血缺氧。DHCA造成的中樞神經(jīng)系統(tǒng)損傷,已經(jīng)成為影響手術(shù)患者生存和預(yù)后重要危險(xiǎn)的因素之一。CPB是一種非生理性的生命支持手段,腦損傷仍然是體外循環(huán)術(shù)后主要并發(fā)癥。如何防止和減輕大血管術(shù)后腦損傷,己然成為復(fù)雜的心血管手術(shù)腦保護(hù)關(guān)鍵問題所在。S100β蛋白主要分布于中樞神經(jīng)系統(tǒng)的神經(jīng)膠質(zhì)細(xì)胞中,當(dāng)大腦受到缺血缺氧性損傷后,腦組織中的S100β蛋白釋放入血可以被檢測(cè)到。神經(jīng)元特異性烯醇化酶(neuron-specific enolase,NSE)主要分布于神經(jīng)元和神經(jīng)內(nèi)分泌細(xì)胞中,腦損傷時(shí)神經(jīng)元死亡崩解,NSE可從細(xì)胞內(nèi)釋放至腦脊液及血液中,S100β蛋白和NSE可作為腦損傷生化標(biāo)志物。頸靜脈球部血氧飽和度(SjvO_2)可反映腦氧供與氧耗的匹配程度。動(dòng)脈-頸內(nèi)靜脈血氧含量差(Da-jvO_2)反映了腦攝取氧的能力,腦氧攝取率(CERO_2)的意義與Da-jvO_2相似,但其不受Hb的影響,更適合用于評(píng)估腦氧代謝的變化情況。右美托咪定(dexmedetomidine,DEX)作為一種新型高選擇性α2腎上腺素受體激動(dòng)劑是安全有效的麻醉輔助用藥,產(chǎn)生抗交感、抗焦慮、鎮(zhèn)靜、鎮(zhèn)痛、抗炎等作用,對(duì)于患者腦保護(hù)具有積極意義。右美托咪定在全弓置換術(shù)中的腦保護(hù)作用研究較少,本研究擬探討右美托咪定對(duì)體外循環(huán)(CPB)下全弓置換術(shù)患者腦缺血損傷有無保護(hù)作用,為心血管外科手術(shù)麻醉輔助用藥的選擇提供臨床依據(jù)。目的探討右美托咪定對(duì)全弓置換術(shù)患者血清S-100β蛋白、NSE及腦氧代謝的影響。方法2014年10月-2016年12月因A型急性主動(dòng)脈夾層于我院行體外循環(huán)下全弓置換手術(shù)患者38例,性別不限,年齡33~68歲,體重44~87 kg,美國麻醉醫(yī)師協(xié)會(huì)(ASA)分級(jí)Ⅲ或Ⅳ級(jí),根據(jù)術(shù)中應(yīng)用藥物的不同,將其隨機(jī)分為2組:對(duì)照組(C組,19例)和右美托咪定組(Dex組,19例),常規(guī)麻醉誘導(dǎo)后氣管插管,術(shù)中采用靜吸復(fù)合麻醉。Dex組于常規(guī)麻醉誘導(dǎo)前靜脈輸注右美托咪定1μg/kg,輸注時(shí)間15 min,繼之以0.5μg/(kg·h)的速率輸注至術(shù)后12h;C組以等容量生理鹽水替代。兩組患者分別于麻醉誘導(dǎo)前(T0)、CPB30min(T1)、CPB結(jié)束后1h(T2)、CPB結(jié)束后6h(T3)、CPB結(jié)束后12h(T4)、CPB結(jié)束后24h(T5)時(shí)采用ELISA法檢測(cè)血清S-100β蛋白和神經(jīng)元特異性烯醇化酶(NSE)濃度,并采集橈動(dòng)脈和頸內(nèi)靜脈球部血樣進(jìn)行血?dú)夥治?記錄并計(jì)算頸靜脈血氧飽和度(SjvO_2)、動(dòng)脈-頸內(nèi)靜脈血氧含量差(Da-jvO_2)以及腦氧攝取率(CERO_2)水平。本實(shí)驗(yàn)的所有數(shù)據(jù)采用SPSS 20.0統(tǒng)計(jì)學(xué)軟件進(jìn)行統(tǒng)計(jì)學(xué)分析,計(jì)量資料用均數(shù)±標(biāo)準(zhǔn)差((χ|-)±S)表示,兩組間各指標(biāo)比較采用t檢驗(yàn);各時(shí)間點(diǎn)NSE,S100β蛋白血清水平以及血?dú)夥治鲋笜?biāo)的差異采用重復(fù)測(cè)量資料的方差分析,計(jì)數(shù)資料采用χ2檢驗(yàn)進(jìn)行比較。α=0.05為檢驗(yàn)水準(zhǔn)。結(jié)果1、兩組患者性別、年齡、體重與LVEF以及手術(shù)時(shí)間、CPB時(shí)間、主動(dòng)脈阻斷時(shí)間組間與組內(nèi)比較差異無統(tǒng)計(jì)學(xué)意義(P0.05)。2、兩組患者T1-T5時(shí)間點(diǎn)血清S-100β蛋白、NSE水平均高于T0時(shí)間點(diǎn),差異有統(tǒng)計(jì)學(xué)意義(P0.05)。Dex組患者T1-T5時(shí)間點(diǎn)血清S-100β蛋白、NSE水平均低于C組,差異有統(tǒng)計(jì)學(xué)意義(P0.05)。3、兩組患者T1-T3時(shí)間點(diǎn)SjvO_2高于T0時(shí)間點(diǎn),Da-jvO_2、CERO_2低于T0時(shí)間點(diǎn),差異有統(tǒng)計(jì)學(xué)意義(P0.05)。Dex組患者T1-T3時(shí)間點(diǎn)SjvO_2水平高于C組,Da-jvO_2、CERO_2水平低于C組,差異有統(tǒng)計(jì)學(xué)意義(P0.05)。結(jié)論1、在全弓置換術(shù)手術(shù)中右美托咪定組與對(duì)照組相比S100β蛋白、NSE水平降低。2、在全弓置換術(shù)患者圍手術(shù)期使用右美托咪定可以降低腦氧攝取率,穩(wěn)定腦氧合平衡,有一定的腦保護(hù)作用。
[Abstract]:Aortic dissection (AD) is one of the most dangerous diseases in cardiac surgery. The incidence of the disease is urgent and high, and the incidence of the disease is high in our country. The incidence of the aortic dissection is higher in our country..AD refers to the rupture of the intima of the aorta, which is subjected to strong blood shock and the blood enters the aorta and causes the normal aorta wall separation to form the true and false two cavities in the wall. Once suspected as aortic dissection, diagnosis and operation as soon as possible. Aortic dissection surgery is a complex, time-consuming operation, most of which are assisted by selective cerebral perfusion (deep hypothermic circulatory arrest, DHCA), which can easily cause ischemic and anoxic.DHCA in the body's important organs. The damage of central nervous system has become one of the important risk factors affecting the survival and prognosis of the patients..CPB is a non physiological means of life support. Brain injury is still the main complication after cardiopulmonary bypass. How to prevent and reduce the brain damage after large vessel operation has become the key question of complex cardiovascular surgery. The.S100 beta protein is mainly distributed in the neuroglia cells of the central nervous system. When the brain is damaged by ischemia and hypoxia, the release of S100 beta protein into the blood can be detected. Neuron specific enolase (neuron-specific enolase, NSE) is mainly distributed in neurons and neuroendocrine cells and brain damage. NSE can be released from cell to cerebrospinal fluid and blood, S100 beta protein and NSE can be used as biochemical markers of brain damage. The blood oxygen saturation (SjvO_2) of the jugular bulb can reflect the matching degree of brain oxygen supply and oxygen consumption. The difference of oxygen content (Da-jvO_2) in the arterial and internal jugular vein (Da-jvO_2) reflects the ability of brain oxygen uptake and brain oxygen uptake (C) ERO_2) is similar to Da-jvO_2, but it is not affected by Hb and is more suitable for evaluation of changes in brain oxygen metabolism. As a new type of high selective alpha 2 adrenergic receptor agonist, right metoimidine (dexmedetomidine, DEX) is a safe and effective anesthetic adjuvant, which produces anti sympathetic, anti anxiety, sedative, analgesic, anti-inflammatory and other effects, The protective effect of right metodetomidine in total arch replacement is less. The purpose of this study is to explore the protective effect of right metoimidin on cerebral ischemia injury in patients with total arch replacement under cardiopulmonary bypass (CPB), and to provide a clinical basis for the choice of adjuvant medication for cardiovascular surgery. The effect of dexmedetomidin on serum S-100 beta protein, NSE and brain oxygen metabolism in patients with total arch replacement. Methods in December October 2014, 38 patients with total arch replacement under cardiopulmonary bypass due to acute aortic dissection in December -2016, gender, age 33~68, weight 44~87 kg, American anesthesiologist Association (ASA) grade III or grade IV, root According to the different application of drugs, they were randomly divided into 2 groups: control group (group C, 19 cases) and right metomimidine group (group Dex, 19 cases), tracheal intubation after routine anesthesia induction, and intravenous infusion of.Dex group before induction of intravenous infusion of right metomomidine 1 mu, infusion time 15 min, followed by the rate of 0.5 g/ (kg h) infusion. 12h (T0), CPB30min (T1), 1H (T2) at the end of CPB, 6h (T3) after the end of CPB, after the end of CPB, after the end of CPB, and after the end of CPB, the concentration of serum beta egg white and neuron specific enolase were detected and the radial and internal jugular veins were collected. Blood gas analysis of the ball blood samples, recorded and calculated the oxygen saturation (SjvO_2) of the jugular vein, the difference of oxygen content (Da-jvO_2) and the level of brain oxygen uptake (CERO_2) in the arterial and internal jugular veins. All the data in this experiment were statistically analyzed by SPSS 20 statistical software, and the measurement data were expressed with the mean standard deviation ((chi square) + S), and each of the two groups The index was compared with t test; the difference of the serum level of NSE, S100 beta protein and the blood gas analysis index were analyzed by the variance analysis of the repeated measurement data. The count data were compared by the chi 2 test. The alpha =0.05 was the test level. Results 1, the sex, age, weight and LVEF of the two groups, the time of operation, the time of operation, the time of CPB, the time of aortic occlusion. There was no significant difference between the group and the group (P0.05).2. The serum S-100 beta protein at the T1-T5 time point in the two groups was higher than the T0 time point, and the difference was statistically significant (P0.05) in the T1-T5 time point of the.Dex group, the NSE level was lower than that of the C group, and the difference was statistically significant. Higher than T0 time point, Da-jvO_2, CERO_2 lower than T0 time point, the difference was statistically significant (P0.05).Dex group T1-T3 time SjvO_2 level was higher than the C group, Da-jvO_2, CERO_2 level was lower than the C group, the difference was statistically significant. Conclusion 1, in the total arch replacement surgery, the right metomomidin group compared with the control group compared with the control group, the level of protein decreased, Conclusion: Dexmedetomidine can reduce cerebral oxygen uptake rate and stabilize cerebral oxygenation balance during perioperative period in patients undergoing total arch replacement.
【學(xué)位授予單位】：鄭州大學(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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本文編號(hào)：1936273