【作者】 方能新；

【导师】 汪思应；

【作者基本信息】 安徽医科大学 ， 病理学与病理生理学， 2003， 硕士

【摘要】 目的 比较心肺转流心脏手术与心脏不停跳心肺转流技术对围术期患者血浆C-反应蛋白（CRP）、细胞因子TNF-α、IL-8、IL-10水平的影响，以及米力农和不同剂量芬太尼对其调理作用。方法 临床试验采用随机、双盲法。将择期CPB心脏手术患者88例分为5组10亚组，即心肺转流心脏手术组的成人组（adults group，A组）和小儿组（children group，B组）、采用心脏不停跳心肺转流技术组（C组）和其对照组即采用CPB下心脏停跳技术组（D组）、小儿F₄米力农组（M组）和其对照组即小儿F₄非米力农组（N组）、瓣膜置换术米力农成人组（O组）和其对照组即成人瓣膜置换术非米力农组（P组）、大剂量芬太尼组(0.025 mg·kg^-1，R组)和其对照组即较小剂量芬太尼组(0.010 mg·kg^-1，S组)。除R和S组病例数各为12例外，其它各组均为8例。分别于全麻诱导前（基础，T₀）、主动脉开放后（T₁）、心肺转流停机后（T₂）、术毕（T₃）、术后24H（T₄）、术后48H（T₅）抽取患者中心静脉血，采用酶联免疫法定量测定TNF-α、IL-8、IL-10的血浆水平；采用放射免疫分析法定量测定CRP血浆水平。结果 TNF-α在各组及各时段均能检测到，且变化不显著。CRP峰值出现在术后24小时及48小时，且较术前增幅为数十倍。CPB小儿和成人相比，IL-8血浆浓度增幅大，而CRP回落快。不停跳CPB心脏手术组IL-8增高持续时间远短于停跳组（P＜0.05）。在米力农小儿F₄组对照组，IL-8出现早，持续时间长，而米力农组IL-10有明显增高（P＜0.05）。在米力农瓣膜置换成人组，米力农对CRP血浆浓度的增加影响更大，安徽医科大学硕士学位论文且IL一10增幅远大一于对照组。大剂量芬太尼组的CRP在术后24小时较对照组有显一著增高，且IL一10增高持续时间长（尸<0.盯）。结论心肺转流心脏手术所诱发的组织炎性反应小儿强一于成少、;采用心脏不停跳心肺转流技术，可能在围术期减轻患者机体组织炎性反应方面起积极作用。对于心肺转流心脏手术患者，米力农和较大剂准芬太尼可能在围术期减轻机体急性组织炎性反应方面起积极作用，更多还原

【Abstract】 Objective To compare effects of cardiac surgery with cardiopulmonary bypass (CPB) or an arresting heart on serum level of C-reactive protein (CRP) and cytokines in patients and observe the modulation effects of milrinone and high-doses Fentanyl. Methods Prospective, randomized, double-blind study. 88 patients scheduled for cardiac surgery with CPB divided into 5 groups and 10 subgroup: CPB adult group(group A) and children group(B), CPB with a beating heart group (C) and CPB with a non-beating heart group (as controlled group, D), milrinone F4 children group with milrinone (M) and. F4 children group with milrinone free(as controlled group, N), cardiac valve replacement group with milrinone (R) and cardiac valve replacement group with milrinone free(as controlled group, S) and high-dose fentanyl group (0.025 mg’kg-1h-1 of fentanyl, group R) and 0.010 mg’kg-1h-1 of fentanyl group (as controlled group, S). The standardized anaesthetic included fentanyl, vecuronium and midazolam. Blood samples for cytokines and CRP measurements were collected into EDTA-Vacutainers from central vein at the following time: just prior to induction of anesthesia (baseline, T0), 5 min after aortic cross-clamp release (T1), 5 min after weaning from CPB (end-CPB, T2), on completion of surgery (T3), 24 hours (T4) and 48 hours(T5) after the operation. Concentrations of TNF- a , IL-8, and IL-10 were measured using a quantitative sandwich enzyme linked-immunosorbent assay (ELISA). The concentration of CRP on blood serum was measured by radioimmunoassay (RIA). Results No significant rise of TNF- a was found almost in all groups. The peak of CRP emerged on T4 and T5 and increased nearly ten times as much as the value of baseline. Patients in the group A had significant rises in T5 CRP and significant reduces in T3, T4IL-8 compared with group B (P < 0.05). In group C vs group D a significant increase of CRPwas detected on T5. On T2 in group D, IL-8 levels were higher than the one in group C and the opposite result was got on T3. Compared with baseline value TNF- a was lower at T,. IL-10 level was seen in the group M at T2, T3, T4 and T5 (P<0.05). On the contrary, IL-8 was higher in group N at T1, T3, T4 than in group M (P<0.05). IL-10 was increased significantly in group M at T2, T3, T4 and T5 (P<0.05). TNF- a increased significantly at T2 compared with T0 in group O. Compared with baseline a significant increase of CRP in the group O and P at T4 and T5 each was emerged and the value in group O at the same time points was much higher than the one in P (P<0.05).A more increased IL-10 level was detected in the group O than group P at T4 and T5 (P<0.05}. Patients in the group R had significant rises in T4, T5 CRP, T2-5 IL-8 and T1-5 IL-10 (P < 0.05) and patients in the group S had significantly higher in T4, T5 CRP, T1-5 IL-8 and T5 IL-10 compared with the baseline of each (P < 0.05). Conclusions Systemic inflammatory response in children underwent cardiac surgery with CPB was more severe than the one in adults. In patients who underwent CPB without cardiocirculatory arrest CRP and cytokine production seems be an adaptive response for attenuating the CPB-induced inflammatory response. Milrinone and high-dose fentanyl inhibited systemic inflammation induced by CPB and the cardiac surgery.更多还原