【作者】 孙霞；

【导师】 缪长虹； 方浩；

【作者基本信息】 复旦大学 ， 麻醉学， 2008， 硕士

【摘要】 目的:研究不同麻醉方法对单核细胞mCD14、TLR4表达的影响。方法:选择择期行结、直肠癌根治术患者24例,年龄18-65岁,性别不限,BMI 18-23kg/m²,ASAⅠ-Ⅱ级,无传染性疾病,无代谢性功能障碍,并且近期未服用任何药物者,随机分为两组:单纯全麻组（G组）和全麻加硬膜外阻滞组（G+E组）各12例。G组以6μg/kg芬太尼、1.5-2mg/kg丙泊酚和0.6-0.8mg/kg罗库溴铵行全麻诱导,术中呼气末七氟醚浓度维持在1.0-1.3MAC,术中酌情追加罗库溴铵,每次10-20mg。G+E组病人入手术室时于T₁₂-L₁穿刺并放置硬膜外导管,并给予2%利多卡因3ml试验剂量,以确定硬膜外阻滞效果后开始全麻诱导,全麻诱导方法和药物同G组,气管插管后硬膜外分次给予1%利多卡因+0.2%丁卡因混合液9-12ml,并维持呼气末七氟醚浓度在0.6-0.8MAC,术中每小时追加1%利多卡因+0.2%丁卡因混合液3-4ml,并按需酌情追加罗库溴铵。分别于手术前、手术开始时、术中2小时及术后24小时采血测定单核细胞mCD14、TLR4及进行中性粒细胞计数。结果:两组患者年龄、性别比、BMI指数和ASA分级比较差异均无统计学意义（P＞0.05）。G组单核细胞mCD14数值术前、手术开始、术中2h及术后24h分别为829.1±48.19MFI、783.2±39.33MFI、695.2±42.69MFI、815.6±57.11MFI,各时点之间统计均无显著差异（P＞0.05）,G+E组单核细胞mCD14数值在术前（791.1±75.44MFI）、手术开始时（770.4±71.78MFI）、术中2h（756.9±90.48MFI）及术后24h（760.8±50.15MFI）各时点与G组相比均无统计学差异（P＞0.05）。G组单核细胞TLR4数值在手术开始时（50.8±3.0MFI）与术前（52.9±2.8MFI）无显著差异（P＞0.05）,但术中2h（41.4±2.8MFI）明显降低（P＜0.003）,至术后24 h（58.1±5.0MFI）恢复至术前水平。G+E组单核细胞TLR4数值术前、手术开始、术中2h、术后24h分别为64.5±6.6MFI、57.1±8.3MFI、52.4±6.6MFI、66.4±10.2MFI,各时点间均无统计学差异（P＞0.05）。G组中性粒细胞计数在手术开始时（3.5±0.7×10⁹/L）与术前（4.7±0.8×10⁹/L）相比无显著差异（P＞0.05）,但术中2h（8.9±1.0×10⁹/L）比术前明显升高（P＜0.005）,术后24h（10.4±1.1×10⁹/L）中性粒细胞计数比术前明显增高（P＜0.001）,但与手术开始2h无明显差异。G+E组中性粒细胞计数在术前（4.1±0.3×10⁹/L）、手术开始时（3.7±0.3×10⁹/L）、术中2h（7.5±0.7×10⁹/L）及术后24h（9.6±0.6×10⁹/L）各时点与单纯全麻组相比均无显著差异（P＞0.05）。结论:全麻加硬膜外阻滞和单纯全麻相比,患者单核细胞mCD14数值无明显变化,中性粒细胞计数亦无显著差异。单纯全麻组术中单核细胞TLR4较术前明显下降,而全麻加硬膜外阻滞组围术期单核细胞TLR4无明显变化,提示硬膜外阻滞可能通过影响TLR4的表达从而对手术应激、全身性炎性反应综合征（SIRS）等方面产生一系列影响。更多还原

【Abstract】 [Objective]:This study was designed to investigate the effects of different anaesthesia methods on expression of monocyte mCD14 and TLR4.[Methods]:We obtained informed consent from 24 ASAⅠorⅡ,BMI 18～23kg/m²,18～65 year-old patients,who were scheduled for radical treatment of colon cancer and carcinoma of rectum,to participate in this study.None of the patients had any infectious diseases or metabolic disturbances and none were taking any medication recently.They were randomly allocated to receive general anaesthesia（Group G,n=12） or general anaesthesia with epidural anaesthesia（Group G+E,n=12）.Patients in Group G were induced with propofol 1.5-2 mg/kg and fentanyl 6μg/kg,and tracheal intubation was accomplished with rocuronium 0.6-0.8mg/kg.The anaesthesia was maintained with sevoflurane（end-tidal concentration 1.0-1.3MAC）.Patients in Group G+E were placed an epidural catheter at a vertebral interspace between T₁₂ and L₁,and advanced 5 cm in the cephalad direction into the epidural space.After administering 3ml lidocaine 2%to the epidural space and identifying the level of analgesia by pinprick perception,general anaesthesia was induced with propofol 1.5-2 mg/kg and fentanyl 6μg/kg.Tracheal intubation was accomplished with rocuronium 0.6-0.8mg/kg.After administering 1% lidocaine + 0.2%tetracaine 9-12ml,anaesthesia was maintained with sevoflurane （end-tidal concentration 0.6-0.8MAC）,and epidural infusion of 1%lidocaine+0.2% tetracaine 3-4ml/h.Every patient was colleted 2ml peripheral vein blood before operation,at the beginning of operation,2 hours after the beginning of operation and 24 hours after the end of operation,respectively.Perioperative changes in neutrophil counts and monocyte mCD14 and TLR4 expression were measured. [Results]:There is no significant difference on the age,gender,BMI index and ASA between two groups（P＞0.05）.Monocyte mCD14 before operation,at the beginning of operation,2 hours after the beginning of operation and 24 hours after the end of operation was 829.1±48.19MFI,783.2±39.33MFI,695.2±42.69MFI and 815.6±57.11MFI in Group G and 791.1±75.44MFI,770.4±71.78MFI, 756.9±90.48MFI and 760.8±50.15MFI in Group G+E.The expression of monocyte mCD14 did not change during the operation in either group.There is no statistic difference on four times between two groups（P＞0.05）.Monocyte TLR4 at the beginning of operation was 50.8±3.0MFI in Group G,which got close to the number before operation（52.9±2.8MFI）（P＞0.05）,but that was 41.4±2.8MFI 2h after the beginning of operation,which was lower than the number before operation （P＜0.003）.And in Group G+E,monocyte TLR4 before operation,at the beginning of operation,2 hours after the beginning of operation and 24 hours after the end of operation was 64.5±6.6MFI,57.1±8.3MFI,52.4±6.6MFI and 66.4±10.2MFI.There is no significant difference on four times in Group G+E（P＞0.05）.Surgical stress rapidly depressed TLR4 expression（P＜0.003 vs preoperation） in Group G,but there were no significant changes in Group G+E.The leukocyte amount of 24 hours after operation（10.4±1.1×10⁹/L） is obviously higher than which of before operation（3.5±0.7×10⁹/L） in Group G（P＜0.001）.And in Group G+E,the leukocyte amount of 24 hours after operation（9.6±0.6×10⁹/L） is also great higher than which of before operation（4.1±0.3×10⁹/L）.But there is no significant difference on four times between two groups（P＞0.05）.[Conclusions]:General anesthesia combined with epidural block compared to general anesthesia has no influence on the expression of monocyte mCD14 and perioperative changes in neutrophil counts.But data indicate that epidural anesthesia can prevent the depression of monocyte TLR4 expression.Subgroup analysis suggested that epidural anaesthesia may has advantageous effects on the immune reaction and stress response to surgical stress,and may protect patients from SIRS, which is one of the complications of stress response.更多还原