【作者】 王欣；

【导师】 高金贵；

【作者基本信息】 河北医科大学 ， 麻醉学， 2008， 硕士

【摘要】 目的:观察在靶控瑞芬太尼异丙酚全凭静脉麻醉下,CO₂气腹腹腔镜子宫切除术与开腹子宫切除术,手术前后患者凝血和纤溶系统的变化,通过特异性分子标志物的检测,评估机体发生深静脉血栓（DVT）的危险性。方法:选择30例行CO₂气腹腹腔镜子宫切除术病人作为观查组, 30例开腹子宫切除术病人作为对照组。ASAⅠ或Ⅱ级,心功能Ⅰ或Ⅱ级,年龄40⁵0岁,体质量指数（BMI）18.5²3kg/m2,无血栓形成高危因素（肥胖、高血压、冠心病、糖尿病等疾病）。术中常规血压、心率、心电图、脉搏血氧饱和度、体温、呼气末二氧化碳分压（PETCO₂）监测。腹腔冲洗液使用温盐水,手术室温度保持在25℃。两组病人均采用头低脚高+膀胱截石体位。手术时间控制在2³h之间,术中出血量小于400ml,无术中输血。围手术期均未使用促凝血药。两组病人术前用药为咪唑安定5mg,阿托品0.5mg,术前30min肌肉注射。麻醉诱导用靶控瑞芬太尼4ng/ml,咪唑安定0.1mg/kg,异丙酚1mg/kg,维库溴铵0.1mg/kg,气管插管后行机械通气,潮气量8¹0ml/kg,呼吸频率12¹4次/分。麻醉维持用靶控瑞芬太尼4⁸ng/ml,异丙酚2⁴μg/ml,根据血压心率的变化随时调整药物剂量,使术中血流动力学平稳。根据PETCO₂随时调整麻醉机呼吸参数使其始终在30³5mmHg的范围内波动。观察组用气腹机充入CO₂,压力维持在12mmHg。两组病人输液量,输液种类大致相同。所有患者均于术前1h（T₁）、术后24小时（T₂）及术后72小时（T3）抽取静脉血检测以下指标:1.血小板α颗粒膜蛋白（GMP-140）,2.组织纤溶酶原激活物（t-PA）,3.组织纤溶酶原激活物抑制剂-1（PAI-1）。GMP-140亦称P-选择素,定位于血小板α颗粒和内皮细胞Weibel-Palade小体内。当血小板被激活时,α颗粒可与细胞膜迅速融合,在细胞膜表面表达GMP-140。血小板活化是血栓形成的重要条件,GMP-140的血浆浓度能直接反映血小板活化程度,是血小板活化时特异性分子标志物。t-PA和PAI-1是纤溶系统的重要组成部分。其水平的高低对血栓的形成有重要的调节作用。t-PA能使纤溶酶原转变成纤溶酶,降解和消除纤维蛋白,在溶解血栓中起重要作用。PAI-1是t-PA的抑制物,可使有活性的纤溶酶生成减少,导致纤维蛋白降解障碍,有利于血栓形成。正常情况下,血浆t-PA及PAI-1处于动态平衡状态,对于人体起着保护血管完整性和保持血管通畅的作用。t-PA/PAI-1可以反映纤溶系统的活性,一旦t-PA降低,PAI-1升高,打破了两者之间的平衡,就有可能导致血栓形成。结果:1.观察组（LH）与对照组（OH）组间比较,反映凝血和纤溶系统活性的特异性分子标志物（GMP-140、t-PA、PAI-1）的浓度差异无统计学意义（P>0.05）。2.GMP-140的变化:两组GMP-140术后24h较术前1h均明显增高（P<0.01）,术后72h恢复到接近术前1h水平。3.t-PA的变化:两组t-PA术后24h较术前1h均明显升高（P<0.01）,术后72h恢复到术前1h水平。4.PAI-1的变化:两组PAI-1术后24h较术前1h均升高（P<0.05）,术后72h恢复到术前1h水平。5.t-PA/PAI-1的变化:两组t-PA/PAI-1术后24h较术前1h均升高（P<0.05）,术后72h恢复到术前1h水平。结论:应用靶控瑞芬太尼异丙酚全凭静脉麻醉,CO₂气腹腹腔镜子宫切除术与开腹子宫切除术在术后凝血和纤溶系统活性变化方面无差异,CO₂气腹腹腔镜子宫切除术未增加术后DVT的危险性。更多还原

【Abstract】 Objective: To observe the changes of coagulation and fibrinolysis system in patients undergoing laparoscopic （LH） and open hysterectomy （OH）,under total intravenous anaesthesia of target-controlled infusion of remifentanil in combination with propofol,and assess the risk rate of deep vein thrombosis,by detecting the concentration of specific molecule markers.Methods: To choice thirty patients,who were submitted to laparoscopic hysterectomy group（observe group）,and other thirty patients,who were submitted to open hysterectomy group（contrast group）.All patients were classified as grade I or II,according to the American Society of Anesthesiologists （ASA） grading system, heart function grade I or II,age 40⁵0 years, body mass index 18.5²3kg/m2. No high risk factors of thrombogenesis （obesity, hypertension, coronary heart disease, diabetes and other diseases）. Blood pressure,heart rate,pulse oxygen,temperature and end-tidal carbon dioxide partial pressure were monitored conventionally in the operation. Bathing abdominal cavity used warmed-brine. To maintain the temperature at 25℃in the operating room.This procedure of either group was performed under genenal anesthesia with Trendelenburg position.The time of operation was claimed between 2³h.The bleeding amount was less than 400ml, no blood transfusion. During Perioperative the patients were not given coagulant drugs.The two groups of patients used midazolam （5mg） and atropine （0.5mg） by intramuscular injection 30 minutes before operation. Induction of anesthesia used target-controlled infusion of remifentanil （4ng/ml）, intravenous injection of midazolam （0.1mg/kg） ,propofol （1mg/kg）, vecuronium （0.1mg/kg）, then tracheal intubation and assisted ventilation. Tidal volume （8¹0ml/kg）, respiratory frequency （12¹4times/min）.Using target-controlled infusion of remifentanil （4⁸ng/ml） plus propofol （2⁴μg/ml）, according to the changes of blood pressure and heart rate at any time,adjusted the dose of durgs to make sure intraoperative hemodynamic stability.Readjusting the respiratory parameters of anesthesia machine, to make sure the index of PETCO₂ always in 30³5 mmHg.Observe Group（LH） used the pneumoperitoneum be filling with CO₂, the pressure maintained at 12 mmHg.The quantity and type of infusion in the two groups were approximately same.Venous blood samples for determination of coagulation and fibrinolytic parameters were collected preoperatively 1h and at 24h and 72h postoperatively.The following parameters were measured:1.platelet granular membrane protein 140 （GMP-140） , 2.tissue plasminogen activator（t-PA）,3.plasminogen activator inhibitor-1（PAI-1）.GMP-140 also called P-selectin, was found in the plateletα-granule and Weibel–Palade body membrane of endothelial cells, which was expressed on the platelet surface membrane and shed into the plasma on platelet activation. Platelet activation had an important role in the process of thrombogenesis. the plasma level of GMP-140 could reflec the degree of platelet activation directly,was the specific molecular markers of platelet activation.t-PA and PAI-1 were important components of fibrinolysis system. The value of them played an important role in the formation of thrombus. t-PA could convert plasminogen into plasmin,which can eliminate fibrin, and played an important role in dissolving the thrombus. PAI-1 was the inhibitor of t-PA,which could result in the generation of activatory plasmin reduction and lead to the obstacle of fibrin degradation, in favor of thrombogenesis. Under normal circumstances, fibrin was lysed rapidly by the fibrinolysis system. t-PA/PAI-1 could reflect the activity of fibrinolysis system.Once the value of t-PA decreased or the value of PAI increased ,disturbing the equilibrium between coagulation and fibrinolysis meight lead to thrombosis.Results: 1.The comparison of LH and OH, the concentration of specific molecule markers （GMP-140, t-PA, PAI-1）,which reflecting the activity of coagulation and fibrinolysis system, have no statistical difference（P>0.05）. 2.The change of GMP-140:In both groups, the concentration of GMP-140 at T2 was significantly higher than at T₁（P<0.01）, the concentration at T3 restored to closely at T₁.3.The change of t-PA: In both groups, the concentration of t-PA at T2 was higher than at T₁（P<0.01）, the concentration at T3 restored to nearly at T₁.4.The change of PAI-1: In both groups, the concentration of PAI-1 at T2 was higher than at T₁（P<0.05）, the concentration at T3 restored to nearly at T₁.5.The change of t-PA /PAI-1: In both groups, the concentration of t-PA /PAI-1 at T2 was higher than at T₁（P<0.05）, the concentration at T3 restored to nearly at T₁.Conclusion: Using total intravenous anaesthesia of target-controlled infusion of remifentanil in combination with propofol,the activation of coagulation and fibrinolysis system between LH and OH is similar,The laparoscopic surgery of carbon dioxide Pneumoperitoneum did not enhance the risk rate of DVT,by detecting the concentration of specific molecule markers.更多还原