磷酸肌酸钠预处理对止血带诱发肺损伤的影响

发布时间：2018-10-23 14:48

【摘要】：目的:通过预先静注磷酸肌酸钠,观察止血带解除早期动脉血液中的肺表面活性蛋白D的变化情况,来评价磷酸肌酸钠预处理对止血带诱发肺损伤的防治作用。方法:本研究选取择期全麻下行下肢创伤性骨科手术,年龄30-40岁ASA分级为I-II级的30例患者,随机将患者分为两组,A组为对照组,B组为磷酸肌酸钠预处理组。患者进入手术室后均连接无创血压,心电图以及指脉氧饱和度,并开放外周静脉,在盐酸利多卡因局麻下行桡动脉穿刺置管用于监测有创动脉压及血样的采集。准备工作均完成后B组将磷酸肌酸钠2g溶于100ml0.9%氯化钠中通过外周静脉在30分钟内输注,而A组则用单纯的0.9%氯化钠100ml代替。待100ml液体输注完成后进行麻醉诱导:步骤为静脉注射咪达唑仑0.03mg/kg、顺苯磺酸阿曲库铵0.2mg/kg、依托咪酯0.25mg/kg、舒芬太尼0.6ug/kg。待肌松完全后插入喉罩,连接麻醉机进行机械通气,潮气量的设定为8ml/kg,呼吸频率的设定为12次/min,吸呼比的设定为1:2,并根据呼气末二氧化碳分压的数值来调整潮气量,使其维持在35-40mm Hg之间。患者术中麻醉维持均为输注丙泊酚与瑞芬太尼,并根据麻醉深度(BIS值维持在40-60)以及循环情况,来调整丙泊酚和瑞芬太尼的输注速度。术中监测并记录患者入手术室时(T0)、止血带充气即刻(T1)、止血带充气30分钟(T2)、止血带充气1小时(T3)、止血带放气后1分钟(T4)、止血带放气后30分钟(T5)以及拔除喉罩后出室前(T6)时患者的收缩压(SBP)、舒张压(DBP)、心率(HR)及平均动脉压(MAP)。同时在T0、T5、T6以上三个时间点抽取桡动脉血用于检测肺表面活性蛋白D(SP-D)和动脉血PH值、动脉血氧分压(Pa O 2)、动脉血二氧化碳分压(Pa CO 2)、并依此计算肺泡气动脉血氧分压差PO2(A-a)以及呼吸指数(RI)。结果:1、两组不同时间SP-D比较从组内看,A组、B组不同时点间差异有统计学意义(P0.05),表现为T5时明显高于T0时,T6时明显高于T5时。从组间来看,在T0时,两组差异无统计学意义(P0.05);在T5、T6时,两组差异有统计学意义(P0.05),结果显示A组明显高于B组。2、两组不同时间PH和Pa CO2比较A组、B组两组间和组内的PH和Pa CO2差异均无统计学意义。3、两组不同时间Pa O2比较从组间看,T0时,两组差异无统计学意义;T5、T6时,两组差异有统计学意义(P0.05),均表现为B组明显高于A组。从组内看,A组、B组不同时点间差异有统计学意义(P0.05),进一步互相比较,两组均表现T5时Pa O2明显高于T0、T6时,差异有统计学意义(P0.05),T0与T6差异无统计学意义。4、两组PO2(A-a)、RI比较从组间比较T0时,A组与B组PO2(A-a)、RI差异无统计学意义;T6时,A组PO2(A-a)、RI高于B组,差异有统计学意义(P0.05)。结论:在下肢创伤性骨科手术的患者中,磷酸肌酸钠预处理在一定程度上可以抑制缺血再灌注所引起的肺损伤,对止血带诱发的肺换气功能损伤起到保护作用。
[Abstract]:Aim: to observe the changes of pulmonary surfactant D in the early arterial blood of tourniquet after intravenous injection of creatine phosphate sodium in advance, and to evaluate the preventive and therapeutic effect of sodium phosphate on lung injury induced by tourniquet. Methods: 30 patients aged 30-40 years with ASA grade of I-II grade were randomly divided into two groups: group A (control group) and group B (pretreatment group with sodium phosphate creatine phosphate). After entering the operating room, the patients were connected with non-invasive blood pressure, electrocardiogram and finger oxygen saturation, and the peripheral vein was opened. The radial artery puncture catheter was used to monitor the invasive arterial pressure and blood sample collection under the local anesthesia of lidocaine hydrochloride. After all the preparations were completed, group B dissolved 2g creatine phosphate in 100ml 0.9% sodium chloride through peripheral vein for 30 minutes, while group A was replaced by a single 0.9% sodium chloride 100ml. Anesthesia induction was performed after 100ml infusion: intravenous midazolam 0.03 mg / kg, atracurium cisbenzenesulfonate 0.2 mg / kg, etomidate 0.25 mg / kg, sufentanil 0.6 ugg / kg. When the muscle release is complete, the laryngeal mask is inserted and the anesthetic machine is connected to perform mechanical ventilation. The tidal volume is set to 8 ml / kg, and the respiratory frequency is set to 12 times / min, breathing ratio of 1: 2, and the moisture volume is adjusted according to the value of the partial pressure of carbon dioxide at the end of the breath. Keep it between 35-40mm Hg. Anesthesia was maintained by infusion of propofol and remifentanil during the operation. The infusion rate of propofol and remifentanil was adjusted according to the depth of anesthesia (BIS) and circulation. Intraoperative monitoring and recording of patients entering the operating room (T0), tourniquet inflating instant (T1), tourniquet inflating 30 minutes (T2), tourniquet inflating 1 hour (T3), tourniquet exhaling 1 minute (T4), tourniquet exhaling 30 minutes (T5) and removing larynx hood out of the room Systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR) and mean arterial pressure (MAP).) in patients with anterior (T6) At the same time, radial artery blood was extracted at three time points above T0 T5 and T6 to detect pulmonary surfactant protein D (SP-D) and arterial blood PH. Arterial partial pressure of oxygen (Pa O _ 2) and arterial partial pressure of carbon dioxide (Pa CO _ 2) were used to calculate PO2 (A-a) and respiratory index (RI). Results: 1. There were significant differences in SP-D between groups A and B at different time points (P0.05), showing that T5 was significantly higher than T0 and T6 was significantly higher than T5. At T0, there was no significant difference between the two groups (P0.05), but at T5 / T6, there was no significant difference between the two groups. The difference between the two groups was statistically significant (P0.05). The results showed that group A was significantly higher than group B. 2. PH and Pa CO2 in two groups were higher than those in group A at different time. There was no significant difference in PH and Pa CO2 between and within group B. 3. The Pa O 2 ratio of two groups at different time was higher than that in group B. When T0 is compared with other groups, There was no significant difference between the two groups. At T5 and T6, the difference between the two groups was statistically significant (P0.05), which showed that group B was significantly higher than group A. From the point of view of group A and group B, there was significant difference at different time points (P0.05). Further comparison between the two groups showed that Pa O 2 was significantly higher at T5 than that at T0 T6, and there was no significant difference between group A and group B at different time points (P0.05). The difference was statistically significant (P0.05), but there was no significant difference between T0 and T6. 4The PO2 (A-a), RI) was not significantly different between group A and group B when compared with T0 (P 0.05); at T6, PO2 (A-a), RI) in group A was higher than that in group B. the difference was statistically significant (P0.05). Conclusion: in the patients with traumatic orthopedic surgery of lower extremity, the pretreatment with creatine phosphate can inhibit the lung injury induced by ischemia and reperfusion to some extent, and protect the lung ventilation injury induced by tourniquet.
【学位授予单位】：大连医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R614

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