【作者】 贾立峰；

【导师】 张连阳；

【作者基本信息】 第三军医大学 ， 外科学， 2010， 硕士

【摘要】 目的近年来，腔镜技术由于其各种优点在外科领域应用日益广泛。而失血性休克复苏后行腹腔镜手术时COB2B气腹对机体影响的基础性研究还很少。我们前期的研究提示：中度及重度创伤失血性休克未复苏情况下建立COB2B气腹，当气腹压力为10 mmHg和15mmHg时实验动物死亡率高，且较高腹内压、长时间气腹对实验动物心、肺、脑血流量及生理功能影响较大。本课题通过建立失血性休克复苏兔模型，旨在探讨在循环血流量减少复苏情况下COB2B气腹对肝、肾和心肌血流量及功能的影响，以期为腔镜技术在创伤失血性休克患者的应用进一步提供理论依据。方法根据休克程度[中度休克(失血量20％～40％)和重度休克(失血量>40％) ]和气腹压力(5 mmHg，10 mmHg和15 mmHg)将实验动物随机分为6组(中度休克/5 mmHg，中度休克/10 mmHg，中度休克/15 mmHg，重度休克/5 mmHg，重度休克/10 mmHg，重度休克/15 mmHg)，若有死亡则补充，保证每组有效数量8只。制作失血性休克复苏兔模型，分别于气腹前、气腹0.5 h、气腹2 h以及撤去气腹后0.5 h四个时相点检测以下指标：1.谷草转氨酶(aspartate aminotransferase,AST)、谷丙转氨酶(alanine aminotransferase,ALT)、肌酐(serum creatinine,Cr)和尿素氮(Blood urea nitrogen,BUN)用全自动生化仪进行指标检测；乳酸脱氢酶(lactic dehydrogenase,LDH)、肌酸激酶同工酶MB(isoenzyme activity of creatine kinase,CK-MB)和肌钙蛋白(cardiac troponin T,cTnT)则用试剂盒进行检测。2.肝血流量(hepatic blood flow, HBF)、肾血流量(the blood flow of renal, RBF)和心肌血流量(myocardial blood flow，MBF)用彩色微球法检测。结果1.肝功能(1)AST：COB2B气腹前和撤去气腹后：AST与失血量呈正比。气腹后：气腹0.5 h时AST即明显升高(P<0.05),重度休克组同中度休克组相比有显著性差异(P<0.05)。(2)ALT：COB2B气腹前和撤去气腹后：重度休克组较中度休克组的ALT上升显著(P<0.05)。气腹后：中度休克、5 mmHg气腹压时，气腹2 h时ALT才显著增加，气腹压增加至10 mmHg，气腹0.5 h时即明显上升(P<0.05)；重度休克组较中度休克组ALT升高显著，组间比较也有显著性差异(P<0.05)。(3)HBF：COB2B气腹前和撤去气腹后：HBF随失血量的增加而减少。气腹后：5 mmHg和10 mmHg气腹时，中度休克组HBF 2h时才明显下降(P<0.05)；而15 mmHg气腹时，0.5 h即显著减少(P<0.05)；重度休克组气腹0.5 h HBF即明显减少，与中度休克组比较下降明显，且组内比较也有显著性差异(P<0.05)。2.肾功能(1)Cr：COB2B气腹前和撤去气腹后：重度休克组较中度休克组的Cr上升。气腹后：中度休克、5 mmHg气腹压时，气腹2 h时Cr才显著增加，气腹压增加至10mmHg，气腹0.5 h时即明显上升(P<0.05)；重度休克组较中度休克组Cr升高显著，组间比较也有显著性差异(P<0.05)。(2)BUN：COB2B气腹前和撤去气腹后：BUN随失血量的增加而增加。气腹后：中度休克、5 mmHg气腹压时BUN无明显变化，而10 mmHg气腹2 h时方明显升高，当压力升至15 mmHg，气腹0.5 h即显著升高(P<0.05)；重度休克气腹后各时相点的BUN明显增高，且与中度休克组相比也有显著性差异(P<0.05)。(3)RBF：COB2B气腹前和撤去气腹后：RBF随失血量的增加而下降。气腹后：5 mmHg、10 mmHg气腹时，中度休克组RBF 2 h时才明显下降(P<0.05)；15 mmHg气腹时0.5 h即显著减少(P<0.05)；重度休克组气腹0.5 h RBF即明显减少，与中度休克组比较有显著性差异(P<0.05)。3.心功能(1)LDH：气腹前和撤去气腹后，LDH随着失血量增加呈上升趋势；气腹后：中度休克组LDH无明显改变，重度休克组，在5 mmHg和10 mmHg气腹压时无显著变化，气腹压升至15 mmHg、气腹2 h时LDH才明显升高(P<0.05)。(2)CK-MB：气腹前和撤去气腹后，CK-MB随失血量的增加而增加；CK-MB中度休克组无明显升高，重度休克组在压力为5 mmHg及10 mmHg，气腹2 h时方发生显著改变，而较高的15 mmHg气腹压，气腹0.5 h CK-MB即明显升高，且相同的气腹压组间比较有显著性差异(P<0.05)。(3)cTnT：气腹前和撤去气腹后，重度休克组较中度休克组的cTnT上升显著(P<0.05)；cTnT中度休克组5 mmHg、10 mmHg气腹时无显著上升，但15mmHg气腹压、气腹2 h时增加明显，重度休克组气腹2 h时cTnT亦显著升高，中度和重度休克相同气腹压组间比较有显著性差异(P<0.05)。(4)MBF：COB2B气腹前和撤去气腹后：MBF随失血量的上升而降低。气腹后：中度休克组在5 mmHg时和10 mmHg气腹压时MBF无明显变化，当压力升至15 mmHg、气腹2 h时则显著下降(P<0.05)；重度休克组在5 mmHg气腹压气腹2 h时MBF才明显减少，而10 mmHg、15 mmHg气腹压时，气腹0.5 h时即明显下降(P<0.05)；不同失血量组间比较均有显著性差异，且重度休克时组间比较也有显著性差异(P<0.05)。结论1．结合本单位前期研究结果，复苏后建立气腹较未复苏可显著降低失血性休克实验动物的死亡率。2．中度及重度失血性休克复苏后建立COB2B气腹可导致肝、肾和心功能损害及器官血流量减少。休克程度越重、气腹时间越长、气腹压力越高，脏器功能障碍越明显；相反，休克程度较轻、短时间的低气腹压对机体脏器功能影响较小。3．中度及重度失血性休克复苏后建立COB2B气腹，肝、肾和心功能障碍程度与失血量、复苏、COB2B气腹、气腹压力和气腹时间关系密切。更多还原

【Abstract】 ObjectiveLaparoscopic surgery is rapidly replacing the open approach in many areas of surgeryand has been gaining in popularity in recent years. In previous experiment,we found under10mmHg and 15 mmHg intraabdominal pressure (IAP), experimental animals(withoutresuscitation) with intermediate and severe hemorrhagic shockh had a high mortality. Wealso found that there may be helpful with low COB2B pneumoperitoneum pressure whenlaparoscope used in patients with trauma and hemorrhagic shock condition，and thereshould be careful under no resuscitation when using laparoscope. However, during theprocedure of laparoscopic surgery，the impacts of COB2B pneumoperitoneum on splanchnicfunction to hemorrhagic shock resuscitation are not well clear. In this study we aimed toinvestigate the alterations in hepatic function,renal function and cardiac function bydifferent IAP during COB2B pneumoperitoneum to hemorrhagic shock resuscitation in rabbits。MethodsFifty New Zealand rabbits were randomized into 6 groups(intermediate hemorrhagicshock/5 mmHg,intermediate hemorrhagic shock /10 mmHg,intermediate hemorrhagicshock /15 mmHg，severe hemorrhagic shock /5 mmHg，severe hemorrhagic shock /10mmHg，severe hemorrhagic shock /15 mmHg) according to the volume of blood loss andthe intraabdominal pressure．After model was established successfully,venous bloodsamples were collected for measurement of items below at time of prepneumoperitoneum,0.5 h under pneumoperitoneum, 2 h under pneumoperitoneum and 0.5 hafter desufflation．1. Hepatic function: aminotransferase(AST),alanine aminotransferase(ALT) andhepatic blood flow(HBF).2. Renal function:aspartate serum creatinine(Cr), blood urea nitrogen (BUN) and renal blood flow (RBF).3. Cardiac function: lactic dehydrogenase(LDH), isoenzyme activity of creatinekinase(CK-MB),cardiac troponinT(cTnT),and myocardial blood flow(MBF).Results1. Hepatic function: (1)AST: With increase of volume of blood loss, AST had aelevation at time of no insuffflation.AST of intermediate hemorrhagic shock statisticallyincreased even at 0.5 h under 5 mmHg IAP(P <0.05). AST of intermediate hemorrhagic hada change significantly compared with severe hemorrhagic shock after ifsufflation (P <0.05).(2)ALT: Compared with severe hemorrhagic shock,cTnT of intermediate hemorrhagic hada significant increase at the time of no pneumoperitoneum(P <0.05). ALT of intermediatehemorrhagic shock were stable until 2 h under 5 mmHg IAP,but ALT statistically increasedeven at 0.5 h under 5 mmHg IAP(P <0.05). Statistical change in ALT of severehemorrhagic shock were observed even at 0.5 h after pneumoperitoneum (P <0.05). ALT ofintermediate hemorrhagic shock had a significant increase compared with severehemorrhagic shock after ifsufflation (P <0.05). (3) HBF: With increase of volume of bloodloss, HBF got down significantly at time of no insuffflation(P <0.05). Compare withpre-insuffflation,HBF of intermediate hemorrhagic shock decrease statistically at 2 h under5 mmHg and10 mmHg IAP,but it increased remarkably even at 0.5 h with 15 mmHg (P<0.05). HBF of severe hemorrhagic shock had a statistical increase even at 0.5 h afterpneumoperitoneum(P <0.05). Compared with intermediate hemorrhagic shock, HBFofsevere hemorrhagic increased significantly after insufflation (P <0.05).2. Renal function: (1)Cr: Compared with severe hemorrhagic shock, Cr of intermediatehemorrhagic had a significant change at the time of pre-insuffflation and post-suffflation (P<0.05). Cr of intermediate hemorrhagic shock elevated statistically at 2 h under 5 mmHgIAP,however,when IAP increase to 10 mmHg, Cr remarkably increased even at 0.5 h (P<0.05). Significant elevation in Cr of severe hemorrhagic shock were seen even at 0.5 hafter insuffflation (P <0.05).(2)BUN: BUN had a statistical increase at time ofpre-insuffflation and post-suffflation with increase of volume of blood loss (P <0.05). BUNof intermediate hemorrhagic shock did not change significantly under 5 mmHgIAP(P>0.05),but statistically increased at 2 h with 10 mmHg IAP(P <0.05).Under 15mmHg IAP,BUN had a remarkabl increase even 0.5 h(P <0.05). Compared with intermediate hemorrhagic shock, BUN of severe hemorrhagic increased significantly afterinsufflation (P <0.05). (3) RBF: RBF had a no statistical decreasing trendline at time ofpre-insuffflation and post-insuffflation(p>0.05). RBF of intermediate hemorrhagic shockwere stable until 2 h with 5 mmHg and10 mmHg IAP(P <0.05). Under 15 mmHg IAP, RBFhad a remarkabl decrease even 0.5 h(P <0.05). Statistical change in RBF of severehemorrhagic shock were observed even at 0.5 h after pneumoperitoneum (P <0.05).3. Cardiac function: (1)LDH:LDH had a no-statistical increase at time ofpre-insuffflation and post-suffflation with increase of volume of blood loss.Compare withpre-pneumoperitoneum,under the IAP of 5 mmHg for 2 h,the change of LDH ofintermediate hemorrhagic shock was no statistical significance (p>0.05). LDH of severehemorrhagic shock elevated statistically at 2 h with 15 mmHg IAP(p>0.05).(2)CK-MB:Compare with pre-insuffflation, CK-MB were stable until 2 h under 5 mmHgand 10 mmHg IAP, however, under 15 mmHg,significant increase in CK-MB of severehemorrhagic shock were seen even at 0.5 h after insuffflation (P <0.05). (3)cTnT:At thetime of no pneumoperitoneum, cTnT of intermediate hemorrhagic had a changesignificantly compared with severe hemorrhagic shock(P <0.05). cTnT of intermediatehemorrhagic shock elevated statistically at 2 h under 15 mmHg IAP(P <0.05).Under 5mmHg, 10 mmHg and 15 mmHg IAP, cTnT of severe hemorrhagic shock increasedremarkably at 2 h (P<0.05).(4)MBF: MBF had a no statistical decrease at time ofpre-insuffflation and post -suffflation with increase of volume of blood loss(p>0.05). MBFof intermediate hemorrhagic shock did not change were seen with 5 mmHg and 10 mmHgIAP compare with pre-insufflation, but under15 mmHg IAP, MBF had a significantdecrease at time 2 h(P <0.05). Although statistical decrease in MBF of severe hemorrhagicshock were calculated until 2 h under 5 mmHg, MBF had a remarkabl decline even 0.5 hunder 10 mmHg,15 mmHg IAP(P <0.05).Conclusions1. Compare with the results of previous study,we found the resuscitation tohemorrhagic shock in rabbits may decrease remarkably the mortality of the animal.2. The disturbance of the cardiac, hepatic, renal physiological function caused byreduction of MBF,HBF and RBF to hemorrhagic shock resuscitation in rabbits may berelated to volume of blood loss,COB2Bpneumoperitoneum,the intra-abdominal pressure and the pneumoperitoneum duration.3. When the Laparoscopic surgery is to be performed for the patients withhemorrhagic shock resuscitation, it should be sure to improve effective blood volumepromptly,choose lower pressure of pneumoperitoneum and shorten the pneumoperitoneumduration.更多还原