【作者】 陈鸶；

【导师】 马武华；

【作者基本信息】 广州中医药大学 ， 中西医结合临床， 2008， 硕士

【摘要】 目的:机械通气（mechanical ventilation MV）已广泛应用于手术麻醉、危重病医学、急诊医学、内科学等多个临床领域,但使用呼吸机本身所引起的机械通气肺损伤（ventilator-induced lung injury,VILI）,亦成为影响危重病患者预后的重要因素之一。本实验采用分子生物学技术,将IL-10基因转染到肺组织以抑制VILI细胞因子、炎性介质的释放,并通过观察TNF-α、IL-1β、IL-8、IL-10及肺组织形态学的变化对该治疗方法进行评价,为临床防治机械通气肺损伤提供了新的实验性理论依据。方法:将54只SD雄性健康大鼠随机分为9组,每组6只。A组为空白对照组;L组为低压力组（气道压力设为15cmH₂O）,根据通气时间分为2小时组（L₂）和4小时组（L₄）;H组为高压力组（气道压力设为25cmH₂O）,根据通气时间分为2小时组（H₂）和4小时组（H₄）;B组为空白病毒转染组（气道压力设为25cmH₂O）,根据通气时间分为2小时组（B₂）和4小时组（B₄）;T组为IL-10基因转染组（气道压力设为25cmH₂O）,根据通气时间分为2小时组（T₂）和4小时组（T₄）。处理组大鼠以10%的水合氯醛0.3g/kg行腹腔注射麻醉,于颈部正中切口行气管插管,机械通气的条件下于胸骨左缘3、4肋间开胸,于右心室注射进行转染,其中L与H组为乳酸钠林格液,B组为空白病毒,T组为含白介素10的腺病毒（剂量均为0.1ml）。关胸后每日肌肉注射青霉素10万单位预防感染。转染48小时后,重新切开气管并插管进行持续机械通气,通气过程中根据体动酌情追加麻醉药。达到预定通气时间后,于腹主动脉采血5ml,以3000r/min的速度离心15分钟,取上清液保存于-80℃冰箱待检测;取肺组织,分别做电镜和光镜的检查。集中检测TNF-α、IL-1β、IL-8、IL-10。实验结果均以均数±标准差（（?）±s）表示,各组间比较采用独立样本t检验,组内比较采用配对t检验,应用SPSS11.5统计分析软件对实验数据进行统计学处理,P＜0.05为有统计学意义。结果:（1）HE染色结果显示:光镜下A组肺泡结构未见异常,L组肺泡腔内略有渗出、血管周围有少量炎症细胞,随通气时间延长病变加重;H、B组上述病理改变加重;T组病理变化较B组为轻;（2）电镜结果显示:A组肺组织中Ⅰ型细胞、Ⅱ型细胞及内皮细胞结构完整,无明显异常;L、H、B、T组均可见不同程度的线粒体肿胀、脱落、嵴消失,内质网扩张,细胞核变大,细胞核与细胞质间隙增宽,染色质分布不均匀,板层小体肿胀,微绒毛减少;L组变化较轻,H、B组较为严重,T组较H、B组减轻;（3）血清中炎性因子检测结果显示:①血清中IL-1β的含量,L组、H组、B组、T组均高于A组（P＜0.01）;随通气时间延长,各组血清中IL-1β的含量明显增加（P＜0.01）;相同通气时间下,血清中IL-1β的含量H组较L组明显增多（P＜0.01）,T组较B组明显减少（P＜0.05）;②血清中TNF-α的含量,L组、H组、B组、T组均高于A组（P＜0.01）;随通气时间延长,各组血清中TNF-α的含量明显增加（P＜0.01）;相同通气时间下,血清中TNF-α的含量H组较L组明显增多（P＜0.01）,T组较B组明显减少（P＜0.05或0.01）;③血清中IL-8的含量,L组、H组、B组、T组均高于A组（P＜0.01）;随通气时间延长,各组血清中IL-8的含量明显增加（P＜0.01）;相同通气时间下,血清中IL-8的含量H组较L组明显增多（P＜0.01）,T组较B组明显减少（P＜0.05或0.01）;④血清中IL-10的含量,L组、H组、B组、T组均高于A组（P＜0.01）;随通气时间延长,各组血清中IL-10的含量明显增加（P＜0.05）;相同通气时间下,血清中IL-10的含量H组较L组明显增多（P＜0.05或0.01）,T组较B组明显增多（P＜0.01）。结论:①VILI大鼠肺间质明显水肿、增宽,大量炎性细胞聚集,肺泡出血,肺泡表面透明膜形成;②相同通气压力条件下,VILI大鼠血清中TNF-α、IL-1β、IL-8、IL-10的含量随通气时间延长而增加;③相同通气时间条件下,VILI大鼠血清中TNF-α、IL-1β、IL-8、IL-10的含量随通气压力升高而增加;④通过IL-10基因转染能够改善VILI大鼠肺组织形态学变化,减轻肺组织水肿及炎性细胞浸润;⑤通过IL-10基因转染能够使VILI大鼠血清中TNF-α、IL-1β、IL-8表达下调,同时IL-10表达上调,从而可以提高肺组织抗炎能力,减轻肺组织损伤。目的:探讨全身麻醉机械通气期间体位改变对肺内分流的影响,并观察参附注射液对肺内分流的影响,了解参附注射液的肺保护作用,为临床使用参附注射液提供依据。方法:将24例评级为Ⅰ-Ⅱ级的择其行后路脊柱手术的患者随机分为两组,每组12例。其中试验组采用参附注射液1ml/kg进行预注射,对照组不予参附注射液,余处理相同。患者入室后进行血压、心率、血氧饱和度监测。麻醉诱导相同,采用咪达唑仑0.04mg/kg,芬太尼3-4ug/kg,丙泊酚1-1.5mg/kg,阿曲库铵0.6mg/kg或维库溴铵0.1mg/kg进行麻醉诱导,插入加强型气管导管。呼吸机潮气量为8—9ml/kg,频率为12次/分。行左侧桡动脉和右颈内静脉穿刺,监测直接动脉压和中心静脉压。手术期间采用七氟醚和丙泊酚进行麻醉维持。比较两组患者气管插管后30分钟（T₁）及俯卧位后30分钟（T₂）的血压、心率、血氧饱和度、呼气末二氧化碳分压、气道压及肺顺应性的变化,并经桡动脉采血行动脉血气分析,观察动脉血PaO₂及PaCO₂的变化。通过简化的公式计算肺内分流率,Qs/Qt=A-aDO2×0.0031/A-aDO2×0.0031+5A-aDO2=（760-age）×FiO2-（PaGO2×1/0.8）-PaO2（FiO2为1.0）。对所有数据采用SPSS11.5软件包进行统计学处理,检验标准设为0.05。结果:（1）两组病人的年龄、性别无统计学差异;（2）对照组病人收缩压在两时间点（T₁、T₂）有显著性差异（P＜0.01）,舒张压无统计学差异（P＞0.05）;参附组收缩压、舒张压的改变在两时间点均无统计学差异;（3）两组病人在不同时间点（T₁、T₂）的氧分压、二氧化碳分压、呼气末二氧化碳分压的改变无统计学意义（P＞0.05）;（4）两组病人在T₁时间点的肺顺应性有统计学差异（P＜0.05）,在T₂时间点无统计学差异（P＞0.05）,组内两时间点比较无统计学意义（P＞0.05）;（5）两组病人肺内分流率在T₂时间点较T₁呈现增加的趋势,但无统计学差异（P＞0.05）。结论:通过本试验可以看出,当病人体位由仰卧位转变成俯卧位以后,肺内分流率呈现一定程度的增加,但无统计学意义;参附注射液用于肺功能正常病人,对病人的血压稳定性及肺顺应性有一定积极作用,但对肺内分流率改变未见明显影响。更多还原

【Abstract】 Objective:Mechanical ventilation（MV）is widely used in anesthesiology,critical care medicine,emergency,IntMED and so on,but at the same time,ventilator-induced lung injury effects prognosis for severe patients.The experiment takes molecular biology technique, gene transfect IL-10 to lung tissue to inhibit the releasing,of cytokine and phlegmonosis medium in VILI.The experiment is to evaluate the treatment from observing TNF-α,IL-1β,IL-8,IL-10 and changes of morphology in lung tissue.At last,it will offer a theory for clinic to prevent and cure VILI.Methods:54 male SD（Sprague Dawley）rats were randomly divided into 9 groups,6 every group.Group A:control group（have no deal）;Group L:low airway pressure（15cmH₂O）,it divided to L₂ and L₄,depending on time of mechanical vetilation; Group H:high airway pressure（25cmH₂O）,it divided to H₂ and H₄,depending on time of mechanical vetilation;Group B-.Ad-Blank gene transfection（25cmH₂O）,it divided to B₂ and B₄,depending on time of mechanical vetilation;Group T:ADS-h-IL-10 gene transfection（25cmH₂O）,it divided to T₂ and T₄,depending on time of mechanical vetilation. The experimental rats were injected with 10%chloraldurat（0.3g/kg）at abdominal cavity,and then cut-off trachea at the middle of neck.After inserting tracheal catheter and connecting breathing machine,open the pectoral cavity at lefe side between 3,4 cervical ribs,inject agentia from right ventricle.The agentia is respectively:Lactic Acid for groupL,H;Ad-Blank for group B;AD5-h-IL-10 for group T（all groups is 0.1ml）.Close the pectoral cavity,removal tracheal catheter and intramuscular injection penicillin 10⁵U to prevent infection.After 48 hours,recut-off trachea and insert tracheal catheter to give a persistent mechanical ventilation.In the process,boost 10%chloraldurat rely on your need.For the reservative time,open the abdominal cavity,collect blood from abdominal aorta. Then centrifugalization the blood at rate of 3000r/min for 15min,collect supernatant fluid to preserced in refrigerator（-80℃）.Take lung tissue to detect pathology change.At last,detet the contents of TNF-α,IL-1β,IL-8,IL-10 in blood serum.All the data were analyzed by SPSS11.5 statistics software,P value＜0.05 was considered to have statistical significance. Result:（1）Light microscope HE:Group A:pulmonary alveoli are as normal;Group L:there is a little effusion in pulmonary alveoli and some phlegmonosis cell besides the blood vessel;the extent aggregate with mechanical ventilate time;Group H and B is serious than L and T is lessen;（2）Electron microscope:Group A:structure of cellⅠ,Ⅱand endotheliocyte are as integrity as normal;Group L,H,B,T:bioblast swell、ablate and its crista disappear,endoplasmic broaden,cell nucleus enlarge,bland between cell nucleus and cell-substane broaden,caryotin bad-distribute,lamellar body swell,microvilli decrease with different degree;the change is not obvious;compared with group H and B,T is lessen in some entent;（3）Inflammatory factors from blood serum:①Content of IL-1β:Group L,H,B,T is higher than group A（P＜0.01）;content of IL-1βhighten with time prolong（P＜0.01）;with the same ventilation time,H is higher than L（P＜0.01）and T is lower than B（P＜0.05）;②Content of TNF-a:Group L、H、B、T is higher than group A（P＜0.01）;content of TNF-ahighten with time prolong（P＜0.01）;with the same MV time,group H is obvious ly higher than group L（P＜0.01）and group T is lower than group B（P＜0.05 or 0.01）;③Content of IL-8:Group L,H,B,T is higher than group A（P＜0.01）; content of IL-8 highten with time prolong（P＜0.01）;with the same MV time,group H is obviously higher than group L（P＜0.01）and group T is lower than group B（P＜0.05 or 0.01）;④Content of IL-10:Group L,H,B,T is higher than group A（P＜0.01）;content of IL-10 highten with time prolong（P＜0.01）;with the same MV time,group H is obviously higher than group L（P＜0.05 or 0.01）and group T is higher than group B（P＜0.01）.Conclusioa:（1）VILI rats intertitium of lung edema、widen and many phlegmonosis cell collect,pulmonary alveoli bloodloss and form hyaline membrane in the surface;（2）At the same airway pressure,content of TNF-α,IL-1β,IL-8,IL-10 enhance with the time prolong;（3）With the same time of mechanical ventilation,content of TNF-α,IL-1β,IL-8,IL-10 enhance with the highten of airway pressure;（4）IL-10 gene tramsfection can amendment morphology change of lung tissue,lessen edema and infiltration of phlegmonosis cell;（5）IL-10 gene transfection down regulation the expression of TNF-α,IL-1β,IL-8 in blood serum and up regulation IL-10 to enhance the ability to anti-phlegmonosis,at last to lessen injury of lung. Objtctive:Approach influence on lung shunt fraction from changes of body position during general anaesthesia.Observing the influence of shenfu injection on lung shunt fraction,and comprehend the function of shenfu injection on protection of lung,at last provide an evidence for the use of shenfu injection in clinic.Methods:24 patients（ASAⅠ-Ⅱ）for back bone selective operation were randomly divided into 2 groups,12 every group.The experimental group give shenfu injection intravenously,with the dose of 1ml/kg.Monitoring BP,HR,SpO₂ after the patients in.All the patients use the same drug in induction of anaesthesia,including midazolam0.04mg/kg,fentanyl 3-4ug/kg,propofol 1-1.5mg/kg,atracurium 0.6mg/kg or vecuronium 0.1mg/kg.Aftering intubate the catheter,set the V_T 8-9ml/kg,rate is 12/min.Punct the left radial artery and right internal jugular vein to moitor BP and CVP.We use sevoflurane and propofol to maintenance anesthesia.Compared the BP、HR、SpO₂、P_ETCO₂、Raw and C_dynat T₁（30min of supine position）and T₂（30min of prone）.Cull blood from radial artery at two time point and do blood gas analysis.Compare the change of PaO₂ and PaCO₂.Calculate lung shunt fraction from the formula:Qs/Qt:=A-aDO2×0.0031/A-aDO2×0.0031+5 A-aDO2=（760-age）×FiO2-（PaCO2×1/0.8）-PaO2（FiO2为1.0）.All the data were analyzed by SPSS11.5 statistics soflware,P value＜0.05 was considered to have statistical significance.Result:（1）Patients in two groups have no difference in age and sex.;（2）SBP in patients of control group have significant difference at T₁、T₂（P＜0.01）,DBP have no difference at T₁、T₂;（3）PaO₂、PaCO₂ and P_ETCO₂ have no difference in two groups at T₁、T₂（P＞0.05）;（4）Cydn in two groups at T₁ time point have difference（P＜0.05）and T₂ have no difference.In the same group,there is no difference at two time points（P＞0.05）;（5）Lung shunt fraction present a tendency of rising,but have no difference in statistics（P＞0.05）.Conclusion:We can conclude that from the study,lung shunt fraction present a tendency of rising,but have no difference in statistics when the patients from supine position to prone position;shenfu injection has a function in sustaining the blood pressure and lung compliance during anaesthesia,but have no significant influrance on lung shunt fraction to health adult.更多还原