【作者】 闵佳；

【导师】 赵为禄；

【作者基本信息】 南昌大学医学院 ， 麻醉学（专业学位）， 2013， 博士

【摘要】 目的：体外循环后的炎症反应是心内直视术后的严重并发症,麻醉专家学者们一直希望可以通过麻醉干预和麻醉手段尽量减轻体外循环后的炎症反应。本研究通过比较丙泊酚和七氟烷对体外循环术后炎症反应的影响,为体外循环手术麻醉药物的选择提供参考依据；通过研究体外循环病人外周血单个核细胞Toll样受体4(TLR4)的表达变化,探讨TLR4在体外循环术后炎症反应中的作用,为寻找体外循环术后炎症反应的防治手段提供理论依据。方法：选择40例体外循环下心脏瓣膜置换手术患者,年龄18-45岁,心功能Ⅱ-Ⅲ级,病例排除标准为：术前存在急性感染表现；肝肾功能障碍；术前2周内使用过皮质激素、非甾体消炎镇痛剂等药物。将病例随机分为丙泊酚组(P组,n=20)和七氟烷组(S组,n=20)。两组患者全部用咪唑安定注射液(0.05-0.15mg/kg),枸橼酸芬太尼注射液(5ug～30ug/kg),丙泊酚注射液(1～2.5mg/kg),维库溴铵注射液(0.08～0.12mg/kg)静脉推注诱导麻醉,术中间断推注咪唑安定注射液,维库溴铵注射液和枸橼酸芬太尼注射液维持麻醉,P组术中丙泊酚注射液微量泵入(2.5～5mg/kg-h),S组术中持续吸入七氟烷(1-2MAC),两组术中均维持脑电双频指数(BIS)40-60。两组均于麻醉诱导前(T1),体外循环前(T2),体外循环结束后即刻(T3),体外循环结束后4小时(T4),体外循环结束后24小时(T5)分别记录病人的体温、呼吸频率和心率；并于上述五个时点分别取病人的外周静脉血,测定白细胞计数、中性粒细胞计数、肿瘤坏死因子(TNF)和白细胞介素6(IL-6)的浓度,以及TLR4的表达水平。其中TNF和IL-6的浓度测定采用放免分析法,TLR4表达水平的测定采用半定量逆转录聚合酶链反应(RT-PCR)法。结果：1、两组患者的性别、年龄、体重、心功能、体外循环时间和阻断时间均无显著差异(P>0.05)。2、两组患者五个时间点体温、呼吸频率和心率均无显著差异(P>0.05)。3、两组患者外周血白细胞计数于T1、T2无显著差异(P>0.05),S组T3-T5明显低于P组(P<0.05)。组内比较,与术前相比,两组外周血白细胞计数均于T3开始逐渐升高,T3～T5与T1～T2有显著差异(P<0.05)。P组T1～T5白细胞计数分别为(4.93±1.62)×109/L,(5.42±1.90)×109/L,(7.53±2.76)×109/L,(15.33±3.86)×109/L,(16.89±4.13)×109/L；S组T1～T5白细胞计数分别为(4.58±1.19)×109/L,(4.56±1.10)×109/L,(6.01±1.59)×109/L,(12.90±2.87)×109/L,(14.09±3.38)×109/L。4、两组患者外周血中性粒细胞计数于T1、T2无显著差异(P>0.05),S组T3～T5明显低于P组(P<0.05)。组内比较,与术前相比,两组外周血中性粒细胞计数均于T3开始逐渐升高,T3～T5与T1～T2有显著差异(P<0.05)。P组T1～T5中性粒细胞计数分别为(3.21±1.27)×109/L,(3.86±1.53)×109/L,(5.78±2.34)×109/L,(13.69±3.76)×109/L,(15.17±3.85)×109/L：S组T1～T5中性粒细胞计数分别为(3.07±1.27)×109/L,(3.39±1.02)×109/L,(4.52±1.29)×109/L,(11.20±2.49)×109/L,(12.71±3.46)×109/L。5、两组患者TNF浓度于T1无显著差异(P>0.05),S组T2～T5明显低于P组(P<0.05)。组内比较,两组患者TNF均于T2开始升高,此后一直处于较高水平状态,T3达到高峰。T2～T5与T1比较有显著差异(P<0.05)。P组T1～T5TNF浓度分别为0.24±0.04ng/ml,0.37±0.09ng/ml,0.77±0.12ng/ml,0.69±0.13ng/ml,0.61±0.11ng/ml; S组T1～T5TNF浓度分别为0.22±0.07ng/ml,0.30±0.10ng/ml,0.67±0.11ng/ml,0.58±0.10ng/ml,0.49±0.12ng/ml。6、两组患者IL-6浓度于T1无显著差异(P>0.05),S组T2～T5明显低于P组(P<0.05)。组内比较,两组患者IL-6浓度均于T2开始升高,此后一直处于较高水平状态,T4达到高峰。T2～T5与T1比较有显著差异(P<0.05)。P组T1～T5IL-6浓度分别为65.05±12.56pg/ml,84.40±17.39pg/ml,134.20±29.43pg/ml,261.55±49.10pg/ml,207.45±54.20pg/ml; S组T1～T5IL-6浓度分别为58.10±10.09pg/ml,73.15±13.18pg/ml,116.85±19.48pg/ml,226.95±36.36pg/ml,172.85±42.82pg/ml。7、两组患者TLR4浓度于T1～T3无显著差异(P>0.05),S组T4～T5明显低于P组(P<0.05)。组内比较,与术前相比,两组患者TLR4的表达水平均于T2,T3下降(与T1比较,差异有显著性,P<0.05),T4时表达水平上升,T5时仍在进一步升高(T4与T1比较,差异无显著性；T5与T1比较,差异有显著性；T4～T5与T2～T3比较,差异有显著性,P<0.05)。P组T1～T5TLR4表达水平分别为0.325±0.072,0.241±0.057,0.244±0.055,0.362±0.082和0.461±0.102；S组T1-T5TLR4表达水平分别为0.305±0.071,0.220±0.056,0.224±0.055,0.312±0.057和0.403±0.065。结论：体外循环病人术后可出现全身性炎症反应,TLR4表达水平变化在其发生发展中有一定作用,七氟烷对体外循环病人术后炎症反应有抑制作用,其效果优于丙泊酚。更多还原

【Abstract】 Objective:inflammation is the serious complications during cardiopulmonary bypass (CPB). Anesthesiologists always want to mitigate inflammation during cardiopulmonary bypass (CPB) by anesthetic intervention and means. In this study, in order to provide a reference of the choice of narcotic drugs during CPB, propofol was compared to sevoflurane about the effect on inflammation during CPB. In order to probe the effect of TLR4on inflammation during CPB, and to provide a theoretical basis of means of prevention and cure for inflammation during CPB, the change of the expression of Toll like receptor four (TLR4) in peripheral mononuclear cell was analyzed.Methods:Forty patients, eighteen to forty-five years old, and ASA Ⅱ-Ⅲ, with heart valve diseases underwent CPB, were divided into two groups:group P (propofol group, n=20) and group S (sevoflurane group, n=20). It was excluded patients with liver and kidney dysfunction, and who has used glucocorticoid or non-steroidal anti-inflammatory drugs in two weeks. In both two groups, anesthesia was induced with intravenous injection of midazolam(0.05～0.15mg/kg), fentanyl (5ug-30ug/kg), propofol(1～2.5mg/kg), and vecuronium(0.08～0.12mg/kg), and maintained with intermittent intravenous injection of midazolam, fentanyl and vecuronium. Propofol (2.5～5mg/kg-h)was pumped in group P and sevoflurane(1～2MAC) was inhaled in group S for maintenance of anesthesia. Bispectral Index (BIS) was fluctuated from forty to sixty.The changes of body temperature, respiratory frequency and heart rate were observed at five different time points--pre-anesthesia, pre-CPB,0hours,4hours and24hours post CPB. At each time peripheral venous blood was sampled. The white blood cell count, neutrophil count, the concentration of IL-6and TNF, the expression level of TLR4were detected at these five different time points. Both the concentration of IL-6and TNF were measured by radioimmunoassay; and the expression level of TLR4was measured by RT-PCR. Results:1. There was no significant difference in patients’gender, age, body weight, cardiac function, time for CPB, and time for aortic occlusion between two groups(P>0.05).2. There was no significant difference in temperature, respiratory rate and heart rate in these five time points between two groups(P>0.05).3. There was no significant difference in white blood cell count in point T1and T2between two groups(P>0.05). It was lower in group S than in group P in point T3-T5(P<0.05). Compared with pre-operation within group, the white blood cell count was continued to rise from T3in both group P and group S. There was significant difference between T3-T5to T1-T2. In group P, the white blood cell count from T1to T5were (4.93±1.62)×109/L,(5.42±1.90)×109/L,(7.53±2.76)×109/L,(15.33±3.86)×109/L,(16.89±4.13)×109/L; in group S, the white blood cell count from T1to T5were(4.58±1.19)×109/L,(4.56±1.10)×109/L,(6.01±1.59)×109/L,(12.90±2.87)×109/L,(14.09±3.38)×109/L.4. There was no significant difference in neutrophil count in point T1and T2between two groups(P>0.05). It was lower in group S than in group P in point T3-T5(P<0.05). Compared with pre-operation within group, the neutrophil count was continued to rise from T3in both group P and group S. There was significant difference between T3-T5to T1-T2. In group P, the neutrophil count from T1to T5were (3.21±1.27)×109/L,(3.86±1.53)×109/L,(5.78±2.34)×109/L,(13.69±3.76)×109/L,(15.17±3.85)×109/L; in group S, the neutrophil count from T1to T5were (3.07±1.27)×109/L,(3.39±1.02×109/L,(4.52±1.29)×109/L,(11.20±2.49)×109/L,(12.71±3.46)×109/L.5. There was no significant difference in the concentration of TNF in point T1between two groups(P>0.05). It was lower in group S than in group S in point T2-T5(P<0.05). Compared with pre-operation within group, the concentration of TNF was rise from T2, peaked at T3, and then began to recover. There was significant difference between T2-T5to T1. In group P, the concentrations of TNF from Tl to T5were0.24±0.04ng/ml,0.37±0.12ng/ml,0.77±0.12ng/ml,0.69±0.13ng/ml,0.61±0.11ng/ml. In group S, the concentrations of TNF from T1-T5 were0.22±0.07ng/ml,0.30±0.10ng/ml,0.67±0.11ng/ml,0.58±0.10ng/ml,0.49±0.12ng/ml.6. There was no significant difference in the concentration of IL-6in point T1between two groups(P>0.05). It was lower in group S than in group S in point T2-T5(P<0.05). Compared with pre-operation within group, the concentration of TNF was rise from T2, peaked at T4, and then began to recover. There was significant difference between T2-T5to T1. In group P, the concentrations of IL-6from T1to T5were65.05±12.56pg/ml,84.40±17.39pg/ml,134.32±29.43pg/ml,261.55±49.10pg/ml,207.45±54.20pg/ml. In group S, the concentrations of IL-6from T1-T5were58.10±10.09pg/ml,73.15±13.18pg/ml,116.85±19.48pg/ml,226.95±36.36pg/ml,172.85±42.82pg/ml.7. There was no significant difference in the expression level of TLR4in T1-T3between two groups(P>0.05). It was lower in group S than in group S in point T4-T5(P<0.05). Compared with pre-operation within group, the expression level of TLR4down-regulated at T2and T3, and then began up-regulate at T4, and continued to rise at T5. In group P, the expression level of TLR4from T1-T5were0.33±0.07,0.24±0.06,0.24±0.05,0.36±0.08and0.46±0.10. In group S, the expression of TLR4from T1-T5were0.305±0.071,0.220±0.056,0.244±0.055,0.312±0.05and0.403±0.065.Conclusion:The systemic inflammatory response will be happened post cardiopulmonary bypass. The high expression level of TLR4play an important role in the pathogenesis of the inflammatory response post CPB (P<0.05). The effect of sevoflurane is more pronounced than propofol on preventting the inflammation during CPB.更多还原