【作者】 张晓东；

【导师】 杨天德；

【作者基本信息】 第三军医大学 ， 麻醉学， 2010， 硕士

【摘要】 研究目的和背景:Kirklin等[1]提出(cardiopulmonary bypass,CPB)能够诱发全身炎症反应综合征(systemic inflammatory response syndrome,SIRS)以来,人们对CPB启动的炎症反应极为关注。这种炎症反应的病理生理机制尚不完全清楚,可能与CPB的非生理性灌注、手术创伤、缺血再灌注有关、体温变化等引起。SIRS可引起一系列术后并发症,包括呼吸衰竭、肾功能障碍、出血紊乱、多器官功能衰竭,甚至死亡。如何有效地预防和控制CPB后的SIRS一直是人们研究的热点。星状神经节阻滞(stellate ganglion block,SGB)作为一种微创治疗方法,主要应用于疼痛治疗领域,大多采用利多卡因作为阻滞用药,应用罗哌卡因的报道少见。目前SGB在非疼痛治疗领域亦得到发展,可通过稳定植物神经系统,调节免疫、心血管和内分泌系统等起到广泛的治疗作用。为此,我们观察了SGB对体外循环炎症反应的影响,并它对体外后SIRS的预防和控制效应。方法:本研究随机选取进行CPB下MVR的手术患者30例,分为对照组(10例)、利多卡因(LID)组(10例)、罗哌卡因(ROP)组(10例)。分别于麻醉前20min(T1),麻醉诱导后20min(T2),手术开始后20min(T3),体外循环20min(T4),体外循环后20min(T5),提取样本,测皮质醇(Cortisol,Cor)、血糖(Blood glucose,BG)、收缩压(Systolic blood pressure,SBP)、平均动脉压(Mean arterial pressure,MAP)、白介素-1β(Interleukin-1β,IL-1β)、白介素-6(Interleukin-6,IL-6)、肿瘤坏死因子-α(Tunmor necrosis factor-α,TNF-α)等指标。BG采用光电方法测得;Cor、IL-1β、IL-6、TNF-α采用放射免疫的方法测得;SBP、MAP通过有创血压直接测得。结果:1、在麻醉诱导期,插管后3minLID组、ROP组SBP较对照组稳定(P<0.01、P<0.05);插管后3minLID组MAP较对照组稳定(P<0.05),而LID组和ROP组无明显差异(P>0.05)。2、T4和T5患者的BG显著地升高(P<0.01);ROP组T4和T5较对照组血糖上升缓慢些(P<0.05)。而LID组和ROP组无明显差异(P>0.05)。3、三组Cor浓度于T1、T2时无明显区别(P>0.05),T3、T4、T5时LID组与对照组有明显区别(P<0.05),而LID组和ROP组无明显差异(P>0.05)。4、三组患者的IL-1β均有上升的趋势,转流后比转流前明显升高。T4、T5时LID组比对照组有明显降低(P<0.05),T5时ROP组与对照组有明显降低(P<0.05)。而LID组和ROP组无明显差异(P>0.05)。5、三组患者的IL-6均有上升的趋势,T1、T2、T3时三组之间并无明显差异。而T4、T5时转流后比转流前明显升高。LID组和ROP组与对照组有明显降低(P<0.05)。但LI D组和ROP组无明显差异(P>0.05)。6、三组患者的TNF-α均有上升的趋势,T1、T2、T3时三组之间无明显差异(P>0.05),而T4、T5明显升高。T4、T5时LID组和ROP组与对照组有明显区别(P<0.05),LID组和ROP组无明显差异(P>0.05)。结论:1、SGB可减轻因气管插管引起的血压升高的心血管反应。2、CPB后血糖异常升高,SGB可降低血糖升高的程度。3、由于患者术前所处的应激状态,Cor异常增高;SGB可减轻手术带来的应激反应,使Cor血浆浓度回落。4、因心脏手术和CPB的应激强烈,导致了炎症反应,早期即出现炎性细胞因子的升高;SGB可降低炎症因子的血浆浓度,从而有效地减轻炎症反应。5、罗哌卡因应用于SGB,可达到LID同样的阻滞效果;长期的效果可待进一步研究。更多还原

【Abstract】 Background and Objeetives:Since Kirklin found that systemic inflammatory response syndrome(SIRS) could be induced by cardiopulmonary bypass(CPB), these adverse inflammatory responses started by CPB remains an important concern. The pathophysiology of SIRS is not completely known,it results in non-physiological perfusion of CPB,mechanical stimuli of surgical trauma,organ ischemia-reperfusion and change of body temperature,ect. This inflammatory response may contribute to the development of postoperative complications,including respiratory failure,renal dysfunction,bleeding disorders,multiple organ failure,and even death. How to effectively prevent and control SIRS after CPB is constantly an investigative hotspot.As a minimally invasive therapeutic method,stellate ganglion block (SGB) has been used in the field of pain control. Lidocaine is mostly used in SGB,and SGB with ropivacaine is few. At present,SGB is developing in the treatment of non-pain,including stabilizing autonomic nervous system and cardiovascular system,adjusting immune system and endocrine system. So we investigate the influence of SGB on inflammatory responses under CPB,and explore the effect of SGB on preventing and controlling SIRS after CPB.Methods:30 patients with mitral valve replacement undergoing CPB were randomly allocated to three groups, control group(10 patients),SGB with lidocaine(LID) group(10 patients)and SGB with ropivacaine(ROP) group(10 patients). The samples were taken at twenty minutes before the anesthesia(T1),twenty minutes after the anesthesia(T2),twenty minutes after the surgery(T3), twenty minutes during CPB(T4) and twenty minutes after CPB(T5). BG was detected by photoelectric electrode method. Cor,IL-1β、IL-6 and TNF-αwere detected by radioimmunoassay method. SBP and MAP were directly measured by invasive method. Results:1. The SBP in LID group and ROP group are more stable than control group after lifesaver three minutes(P<0.01、P<0.05). The MAP in LID group is more stable than control group after lifesaver three minutes(P<0.05),and there is no significant difference between LID group and ROP group(P>0.05).2. The BG in all patients increased significantly at T4 and T5(P<0.01). The BG in ROP group increased more slowly than control group at T4 and T5(P<0.05),and there is no significant difference between LID group and ROP group(P>0.05).3. The Cor in all patients is no difference at T1 and T2. There is significant difference between LID group and control group(P<0.05),and there is no significant difference between LID group and ROP group(P>0.05).4. The IL-1βin all patients increased significantly,and it increased more significantly after CPB than before CPB(P<0.05). The IL-1βin LID group is lower than control group at T4 and T5(P<0.05). The IL-1βin ROP group is lower than control group at T5,and there is no significant difference between LID group and ROP group(P>0.05).5. The IL-6 in all patients increased significantly,and there is no significant difference at T1,T2 and T3. The IL-1βincreased higher at T4 and T5 after CPB than before CPB. The IL-1βin LID group and ROP group are lower than control group at T4 and T5(P<0.05),and there is no significant difference between LID group and ROP group(P>0.05).6. The TNF-αin all patients increased significantly,and there is no significant difference at T1,T2 and T3(P>0.05). The TNF-αincreased higher at T4 and T5 after CPB than before CPB. The TNF-αin LID group and ROP group are lower than control group at T4 and T5(P<0.05),and there is no significant difference between LID group and ROP group(P>0.05).Conelusion:1. SGB may mitigate cardiovascular responses induced by tracheal intubation.2. CPB may make BG highten significantly,and SGB can lower BG during CPB.3. With stringent state before surgery,the Cor of the patients increased abnormal. SGB may reduce the stress response to CPB,and make the plasma concentrations of Cor decline. 4. As the stress response of the surgery and CPB,the inflammatory reaction is induced,and inflammatory cytokine has increased in early stage. SGB may lower the plasma concentrations of inflammatory cytokine,then reduce the inflammatory reaction efficaciously.5. ROP will have the same block effect as LID on SGB. However the effect of long-term may be further studied.更多还原