【作者】 王瑞；

【导师】 许煊；

【作者基本信息】 暨南大学 ， 儿科学， 2010， 硕士

【摘要】 目的：利用先天性心脏病患儿血浆脑利钠肽(BNP)及其前体(NT-pro-BNP)的水平,评价体外循环(CPB)前后先天性心脏病患儿早期心功能的变化,本文重点研究体外循环术中升主动脉阻断时间、术中体温、低温持续时间及CPB时间对心功能的影响。方法：病例组(心脏病组)来源于2008年7月-2009年1月在武警广东总队医院心胸外科住院的40例先天性心脏病患儿,于CPB前、CPB结束时、术后24小时三个时间点分别采取静脉血3ml,3000转／min离心分离出血浆,置—20℃冰箱保存,对照组静脉血标本来源于30例该院同期门诊健康体检儿童,采用酶联免疫吸附法定量测定心脏病组和对照组血浆BNP及NT-pro-BNP浓度。结果：心脏病组在CPB前的血浆BNP及NT-pro-BNP分别是315.45±120.45 pg／ml、331.67±131.83 pg/ml,对照组的血浆BNP及NT-pro-BNP分别是11.65±8.66pg/ml53.12±23.90pg/ml,两组比较差异有统计学意义(P=0.000)；心脏病组CPB结束时血浆BNP及NT-pro-BNP分别是165.91±65.65pg/ml、182.50±65.35pg／ml,与CPB前比较,差异有统计学意义(P=0.000)；心脏病组术后24小时血浆BNP及NT-pro-BNP浓度分别是439.08±154.75pg/m、460.29±167.85pg/ml,均较CPB前升高,且与CPB前比较有统计学意义(P=0.000)。应用多元线性回归分析,升主动脉阻断时间因素未筛选出。CPB结束时,血浆BNP浓度与术中体温呈负相关(相关系数R=0.379,偏回归方程Y1=434.042-10.061X1)；血浆NT-pro-BNP浓度与术中低温持续时间呈负相关(R=0.442,Y2=493.096-11.655X2)。术后24小时,血浆BNP浓度与CPB时间呈正相关、与术中低温持续时间呈负相关(R=0.635,Y3=248.38+3.51X3-2.84X4),CPB时间、术中低温持续时间的标准偏回归系数分别为1.302、-0.754,因此CPB时间对术后24小时血浆BNP的作用大于术中低温持续时间；血浆NT-pro-BNP水平与术中低温持续时间呈负相关(R=0.588,Y4= 1523.31-39.8995).术中体温≤28℃组CPB结束时、术后24小时血浆BNP及NT-pro-BNP水平均高于>28℃组,两组差异有统计学意义(P<0.05)。术中降温时间≤40min组和>40min组,比较CPB结束时、术后24小时血浆BNP及NT-pro-BNP水平,术后24小时,≤40min组低于>40min组,两组差异有统计学意义(P<0.05), CPB结束时血浆BNP及NT-pro-BNP水平比较,差异无统计学意义。CPB时间≤60min组CPB结束时、术后24小时血浆BNP及NT-pro-BNP水平均低于>60min组,两组差异有统计学意义(P<0.05)。结论：利用血浆BNP及NT-pro-BNP水平作为评价早期心功能变化的指标,有利于临床医生及时监测心功能的动态情况,特别是在术后24小时最有帮助,及时使用相应的血管活性药物,防止及纠正低心排、心衰等危险情况的发生,降低先心病患儿术后死亡率。血浆BNP及NT-pro-BNP浓度与术中体温及术中低温持续时间呈负相关,与CPB时间呈正相关。术中控制体温≥28℃以上(低于30℃)、降温时间≦40min、CPB时间≤60min时其血浆BNP及NT-pro-BNP水平相对降低,可认为对心功能具有保护作用。更多还原

【Abstract】 Objective:To observe the level of (BNP) and its precursor (NT-pro-BNP) before and after the surgery in children with congenital heart disease, and evaluate the early heart function. Focus on research ascending aortic clamp time, intraoperative body temperature, cooling time and CPB time of cardiac function before and after surgery.Methods:To select 40 cases of children with heart disease lived in the Guangdong Armed Police Corps Hospital from 2008.7 to 2009.1,and acquired the venous blood at pre-CPB, at the end of CPB and 24 hours after CPB repectively, then separated out the plasma and to freeze it in-70℃refrigerator.At the same time choose 30 cases of healthy control in the same period in the hospital and acquired the venous blood. To detect the concentration of (BNP) and its precursor (NT-pro-BNP) of the plasma using the method of enzyme-linked immunosorbent assay.Results:The concentration of BNP and NT-pro-BNP in the group with heart disease is 315.45±120.45 pg/ml,331.67±131.83 pg/ml, in the control group is 11.65±8.66pg/ml,53.12±23.90pg/ml respectively, the comparetion between the two groups have statistically significance(P= 0.000); the concentration in the end of CPB in the group with heart disease is 165.91±65.65pg/ml,182.50±65.35 pg/ml, compared with the pre-CPB, the difference was statistically significant (P= 0.000); 24 hours after CPB is 439.08±154.75pg/ml,460.29±167.85pg/ml, higher than those in pre-CPB, and compared with the pre-CPB the difference was statistically significant (P= 0.000). Using multiple linear regression analysis, aortic clamping time factor is not selected.At the end of CPB, plasma BNP concentration and intraoperative body temperature were negatively correlated (correlation coefficient R=0.379, partial regression equation Y1= 434.042-10.061X1); plasma NT-pro-BNP concentration and duration of intraoperative hypothermia were a negative correlation (R= 0.442, Y2= 493.096-11.655X2). After 24 hours of the surgery, the plasma BNP concentration was positively correlated with CPB time, and negatively correlated with duration of intraoperative hypothermia (R= 0.635, Y3= 248.38+3.51 X3-2.84X4), the standard deviation of CPB time and duration of intraoperative hypothermia were 1.302 and-0.754, the standard deviation of CPB time was bigger, so the role of CPB time on plasma BNP is greater than the duration of intraoperative hypothermia after 24 hours of the surgery; plasma NT-pro-BNP level was negatively correlation with duration of intraoperative hypothermia (R=0.588, Y4= 1523.31-39.89X5). The plasma of BNP and NT-pro-BNP levels of intraoperative body temperature≦ 28℃group was higher than> 28℃group at the end of CPB and after 24 hours of the surgery, the difference was significant (P <0.05). Comparing the cooling time of surgery, the plasma of BNP and NT-pro-BNP levels of≦40min group after 24 hours of the surgery was lower than>40min group,the difference was statistically significance (P<0.05); the difference was not statistically significant between two groups at the end of CPB. The plasma of BNP and NT-pro-BNP levels of CPB time≦60min group was lower than the CPB time>60min group at the end of CPB and after 24 hours of the surgery, the differences were significant (P<0.05).Conclusion:1.Using of the plasma of BNP or NT-pro-BNP levels to determine early cardiac function of children with congenital heart disease after cardiopulmonary bypass, it is timely to prevente heart failure and low cardiac output after surgery.2. The plasma of BNP and NT-pro-BNP levels were negatively correlation with operation temperature and the duration of intraoperative hypothermia, were positively correlation with CPB time.During the surgery, control the body temperature≧28℃(below 30℃), the cooling time≦40min and the CPB time≦60min have protective effect on cardiac function.更多还原