體外循環(huán)中梯度控制氧分壓對紫紺型先天性心臟病心肌保護(hù)的影響

1、體外循環(huán)中梯度控制氧分壓對紫紺型先天性心臟病心肌保護(hù)的影響         10-01-29 11:13:00     編輯：studa20                      作者：陳萍，黃勁松，郭陽嬌，宋興榮，黃克力【摘要】  目的 探討體外循環(huán)(C

2、PB)中梯度控制動(dòng)脈氧分壓(PaO2)對紫紺型先天性心臟病心肌保護(hù)的影響。方法 3歲以下經(jīng)皮血氧飽和度<85%、行根治術(shù)的法洛四聯(lián)癥患兒90例，隨機(jī)分為三組：實(shí)驗(yàn)1組(G1組，n=30)以接近患兒術(shù)前水平的低氧分壓啟動(dòng)CPB并控制CPB中血流復(fù)溫前的PaO2130 mmHg，CPB血流復(fù)溫后使PaO2逐漸升至250300 mmHg;實(shí)驗(yàn)2組(G2組，n=30)CPB中PaO2在250300 mmHg啟動(dòng)CPB，血流復(fù)溫后使PaO2逐漸升至450500 mmHg;對照組(G3組，n=30)CPB中PO2始終控制在450500 mmHg。觀察心肌生化改變：于CPB前、CPB 10 min、升

3、主動(dòng)脈開放(CCR)10 min、術(shù)后6 h、24 h抽外周血檢測心肌酶CKMB、LDH活性及cTnI濃度。結(jié)果 CKMB：CPB前及CPB 10 min 三組間無差異;CCR 10 min、術(shù)后6 h及24 h G1組顯著低于G3組(P<0.01);CCR 10 min G2組顯著低于G3組(P<0.05)。 LDH：CPB前及CPB 10 min 三組間無差異;CCR 10 min、術(shù)后6 h 和24 hG1組顯著低于G3組(P<0.01或P<0.05)。 cTnI：CPB前及CPB 10 min 三組間無差異;CCR 10 min、術(shù)后6 h、術(shù)后24 h G1組

4、顯著低于G3組(P<0.01);術(shù)后6 h G2組cTnI也顯著低于G3組(P<0.05)。結(jié)論 對于紫紺型先天性心臟病，CPB中PaO2控制在G1組的低水平能減少CKMB、LDH活性及cTnI的釋放，改善心肌保護(hù)效果。 【關(guān)鍵詞】  紫紺;先天性心臟病;體外循環(huán);氧分壓Abstract: OBJECTIVE To evaluate the effects of arterial oxygen partial pressure (PaO2) at the beginning and during cardiopulmonary bypass (CPB) on myocar

5、dial injury of cyanotic congenital heart diseas.METHODS 90 Children diagnosed Tetrallogy of Fallot (TOF) under 3 years of age with SpO2<85% underwent one stage repairing operations were divided into 3 groups: G1(n=30), experimental group 1, PaO2 at the beginning and during CPB was maintained belo

6、w 130 mmHg before CPB rewarming phase; G2(n=30), experimental group 2, PaO2 at the beginning and during CPB was controlled between 250-300 mmHg before CPB rewarming phase; G3(n=30), control group, PaO2 during CPB was maintained between 450-500 mmHg. Myocardial enzymes and cTnI were measured before C

7、PB, 10 min after CPB, 10 min after cross clamp releasing (CCR), 6 hrs and 24 hrs post operation with peripheral blood samples.RESULTS CKMB,LDH and cTnI had no significantly different between 3 groups preoperatively and 10 min after CPB among 3 group. At 10 min after CCR, 6 hrs and 24 hrs post operat

8、ion, KMB, LDH and cTnI in G1 were significantly lower than that in G3( P<0.01 or P<0.05). At 24 hrs post operation, also cTnI in G1 was significantly lower than that in G2(P<0.05). At 10min after CCR, CKMB in G2 was significantly lower than that in G3 (P<0.05). At 6hrs post operation, cT

9、nI in G2 was significantly lower than that in G3 (P<0.05).CONCLUSION During CPB controlling PaO2 to a preoperative low level would reduce releasing enzymes of myocardial and cTnI in cyanotic congenital heart disease.Key words： Cyanotic; Congenital heart disease;Cardiopulmonary bypass;Oxygen parti

10、al pressure紫紺型先天性心臟病(cyanotic congenital heart disease,CCHD)手術(shù)后低心排出量綜合征仍是術(shù)后主要的并發(fā)癥及死亡原因。有學(xué)者認(rèn)為這與體外循環(huán)(cardiopulmonary bypass,CPB)中長期缺氧的心臟接受突然、大量的氧導(dǎo)致的再氧合損傷有關(guān)1。我們選擇CCHD患兒來研究CPB中控制動(dòng)脈氧分壓(PaO2)對心肌酶及心肌肌鈣蛋白I(cTnI)的影響。1 臨床資料與方法1.1 病例的選擇與分組 選擇3歲以下、經(jīng)皮血氧飽和度 (SpO2)<85%、行根治術(shù)的法洛四聯(lián)癥(tetralogy of Fallot,TOF)患兒90例，隨

11、機(jī)分為三組：實(shí)驗(yàn)1組(G1組，n=30)以接近患兒術(shù)前水平的低氧分壓啟動(dòng)CPB;實(shí)驗(yàn)2組(G2組，n=30)啟動(dòng)CPB時(shí)PaO2在250300 mmHg;對照組(G3組，n=30)CPB中PaO2始終控制在450500 mmHg。分組及臨床資料見表1。1.2 CPB的建立及管理 氣管插管，靜吸復(fù)合麻醉。正中開胸行主動(dòng)脈及上、下腔靜脈插管建立CPB。采用Stockert 人工心肺機(jī)，Dideco 901或902膜式氧合器。預(yù)充液為：勃脈力A 200500 ml，20%白蛋白50 ml，紅細(xì)胞懸液01.5 U，肝素1520 mg，甲潑尼龍2030 mg/kg等。CPB血流降溫，阻斷升主動(dòng)脈(aor

12、tic cross clamp,ACC)，主動(dòng)脈根部插針一次性順行灌注冷改良St.Thomas晶體停搏液20 ml/kg。CPB中鼻咽溫降至2225。開放升主動(dòng)脈(cross clamp releasing,CCR)后并行循環(huán)時(shí)間為ACC時(shí)間的1/41/3，然后撤離CPB。1.3 PaO2的控制 采用SECHRIST空氧混合器、通過調(diào)節(jié)吸氧濃度(FiO2)來調(diào)節(jié)PaO2，應(yīng)用TERUMO公司CDI 500行持續(xù)監(jiān)測PaO2。G1組啟動(dòng)CPB時(shí)PaO2接近患兒麻醉前動(dòng)脈血?dú)夥治龅腜aO2水平，在4080 mmHg，隨著CPB的進(jìn)行逐漸增加FiO2，至CPB 15 min PaO2上升到130 mmHg，并維持一段時(shí)間。在CPB開始血流復(fù)溫時(shí)增加FiO2，使PaO2逐漸升至250300 mmHg至CPB結(jié)束。G2組啟動(dòng)CPB時(shí)PaO2在250300 mmHg，血流復(fù)溫后使PaO2逐漸升至450500 mmHg至CPB結(jié)束。G3 組啟動(dòng)CPB及CPB整個(gè)過程中PaO2始終控制在450500 mmHg。1.4 觀察指標(biāo) 于CPB前(T1)、CPB 10 min(T2)、CCR后10 min(T3)、術(shù)后6 h(T4)、術(shù)后24 h(T5)抽外周血檢測心肌肌酸激酶同工酶