多次缺血预处理对兔脊髓缺血性损伤时金属元素的影响

背景：缺血预处理对主动脉手术的脊髓缺血性损害有良好的保护作用，但是脊髓缺血预处理保护作用的机制尚未完全阐明。目的：探讨多次缺血预处理对兔脊髓缺血再灌注损伤的保护作用及其机制。设计：以实验动物为研究对象，完全随机对照实验研究。单位：一所大学医院的麻醉科。材料：实验于2002-09／12在武汉大学人民医院麻醉学研究室完成。24只日本大白兔随机双盲分为假手术组、缺血再灌注组和缺血预处理保护组，每组8只。干预：假手术组不阻断主动脉，缺血再灌注组阻断主动脉45min，缺血预处理保护组阻断主动脉5min，开放5min，反复4次之后再阻断45min。主要观察指标：术后第7天检测脊髓组织金属元素(钙，镁，铜，锌)的浓度。术后观察后肢神经功能的评分、后肢针电极肌电图和脊髓组织病理学的改变。结果：缺血再灌注组脊髓组织钙，铜的浓度较假手术组显著性升高(P&;lt;0．05或0．01)，镁，锌的浓度则显著性降低(P&;lt;0．05)。缺血再灌注组脊髓组织钙、锌的浓度分别较缺血预处理保护组显著性升高或降低(P&;lt;0．01)。缺血再灌注组后肢神经功能评分均显著性低于假手术组和缺血预处理保护组(P&;lt;0．05或0．01)，脊髓病理学和后肢肌电图亦较缺血预处理保护组有显著性病理改变(P&;lt;0．01)。结论：多次缺血预处理对兔脊髓缺血再灌注损伤具有显著而又快速的保护作用，其保护机制与维持缺血区域钙，镁，铜，锌离子的平衡有关。     

多次缺血预处理对兔脊髓缺血性损伤时金属元素的影响

背景缺血预处理对主动脉手术的脊髓缺血性损害有良好的保护作用,但是脊髓缺血预处理保护作用的机制尚未完全阐明.目的探讨多次缺血预处理对兔脊髓缺血再灌注损伤的保护作用及其机制.设计以实验动物为研究对象,完全随机对照实验研究.单位一所大学医院的麻醉科.材料实验于2002-09/12在武汉大学人民医院麻醉学研究室完成.24只日本大白兔随机双盲分为假手术组、缺血再灌注组和缺血预处理保护组,每组8只.干预假手术组不阻断主动脉,缺血再灌注组阻断主动脉45 min,缺血预处理保护组阻断主动脉5 min,开放5 min,反复4次之后再阻断45 min.主要观察指标术后第7天检测脊髓组织金属元素(钙,镁,铜,锌)的浓度.术后观察后肢神经功能的评分、后肢针电极肌电图和脊髓组织病理学的改变.结果缺血再灌注组脊髓组织钙,铜的浓度较假手术组显著性升高(P＜0.05或0.01),镁,锌的浓度则显著性降低(P＜0.05).缺血再灌注组脊髓组织钙、锌的浓度分别较缺血预处理保护组显著性升高或降低(P＜0.01).缺血再灌注组后肢神经功能评分均显著性低于假手术组和缺血预处理保护组(P＜0.05或0.01),脊髓病理学和后肢肌电图亦较缺血预处理保护组有显著性病理改变(P＜0.01).结论多次缺血预处理对兔脊髓缺血再灌注损伤具有显著而又快速的保护作用,其保护机制与维持缺血区域钙,镁,铜,锌离子的平衡有关.     

DSA引导下山羊缺血性脊髓损伤模型的建立及形态学实验研究

脊髓缺血性损伤在临床中较为常见,治疗花费高,预后差,给个人和社会带来巨大的经济负担,良好的动物模型是实验研究的基础[1-2],既往多采用经腹手术夹闭主动脉的方法建立缺血模型[3],操作复杂、动物损伤大。我们尝试采用DSA引导下栓塞相应节段腰动脉的方法建立脊髓缺血损伤模型,     

卡托普利局部灌注对脊髓缺血损伤的保护作用

目的观察局部灌注卡托普利低温溶液对阻断兔主动脉致脊髓缺血损伤的保护作用。方法 3 2只成年新西兰白兔随机分成假手术组 (A组 )、缺血对照组 (B组 )、低温生理盐水局部灌注组 (C组 )和低温生理盐水 +卡托普利 (4mg/kg)局部灌注组 (D组 ) ,每组 8只。阻断肾动脉水平和主动脉分叉上方的腹主动脉上下两端 40min ,建立兔脊髓缺血损伤模型 ,经主动脉阻断段灌注保护液 ,观察 4组动物的血流动力学指标、再灌注后后肢神经功能Tarlov评分和脊髓组织病理学改变。结果 4组动物的心率、血压均无显著性差异 ;B组 8只兔子发生瘫痪 ,C组 3只瘫痪 ,D组仅 1只瘫痪 ,3组间的差异有显著性意义 (P <0 .0 5 ) ;光镜下 ,C、D组兔子脊髓前角正常神经细胞数较B组明显增多 (P <0 .0 1)。结论卡托普利低温溶液局部灌注对脊髓缺血损伤有较好的保护作用。     

缺血前和缺血后联合应用丙泊酚对兔脊髓缺血再灌注损伤的保护作用

目的探讨缺血前和缺血后联合应用丙泊酚对兔主动脉阻断脊髓缺血性损伤的影响。方法 24只日本大白兔随机双盲均分为三组:假手术组、缺血再灌注组、丙泊酚保护组。缺血再灌注组采取主动脉阻断40min建立脊髓缺血损伤模型,丙泊酚保护组于主动脉阻断前10min及再灌注即刻分别以微量输液泵持续静脉输注丙泊酚(30mg/kg溶于30ml0.9%氯化钠注射液,以3ml/min的速度泵注),另外两组以同样方法静脉泵注等容量0.9%氯化钠溶液作对照。术后行后肢神经功能评分、脊髓组织病理学改变检测、丙二醛(MDA)含量和超氧化物歧化酶(SOD)活性测定。结果与假手术组、丙泊酚保护组比较,缺血再灌注组日本大白兔后肢神经功能评分和脊髓组织病理学有显著改变(P<0.01);缺血再灌注组脊髓中MDA水平显著高于假手术组,丙泊酚保护组脊髓中MDA水平显著低于缺血再灌注组(P<0.01);与假手术组比较,缺血再灌注组脊髓中SOD活性明显减弱(P<0.01),丙泊酚保护组脊髓中SOD活性明显强于缺血再灌注组;假手术组与丙泊酚保护组的所有参数均无统计学差异。结论丙泊酚缺血前和缺血后联合应用对兔脊髓缺血再灌注损伤有良好的保护作用,并可能与其具有较强的抗过氧化反应作用有关。     

主动脉阻断所致脊髓缺血再灌注损伤的监测与处理的研究进展

目前主动脉阻断技术在临床中的应用日趋广泛,然而,主动脉阻断的同时也对有关脏器的正常功能造成一定影响。笔者主要针对主动脉阻断时脊髓缺血再灌注损伤的监测途径与处理措施进行研究和思考。一、主动脉阻断技术的运用与脊髓缺血再灌注损伤的发生临床上,在行胸/腹主动脉瘤、主动脉缩窄、脊柱以及骶骨、骨盆肿瘤等外科手术中,由于出血量较大而风险较高,常采用主动脉阻断以控制术中出血,提高手术的成功率,但长时间的主动脉阻断极易造成腹部重要脏器的缺血再灌注损伤和脊髓缺血再灌注损伤,严重者甚至死亡。     

多次缺血预处理对兔脊髓缺血性损伤后脊髓功能和形态学的影响

目的 观察多次缺血预处理（IPC）对兔脊髓缺血再灌注损伤的保护作用。方法 24只日本大白兔随机分为假手术组（A组）、缺血再灌注组（B组）和IPC保护组（C组），各组均为8只。A组不阻断主动脉，B组左肾下阻断主动脉45min，C组左肾下阻断主动脉5min，开放5min，反复4次后再阻断主动脉45min。术后进行后肢神经功能评分和针电极肌电图（EMG）的描记及脊髓组织形态学改变的观察。结果 B组同A、C组相比，后肢EMG亦有显性病理改变（P＜0．01）。结论 多次IPC对家兔脊髓缺血再灌注损伤具有快速保护作用。     

赛庚啶对家兔主动脉阻断所致脊髓损伤的保护作用

目的：探讨赛庚啶对家兔肾下腹主动脉阻断所致脊髓缺血性损伤的保护作用。方法：24只家兔随机分为假手术组(A组)、缺血组(B组)和赛庚啶组(C组)，每组8只。肾下阻断腹主动脉40min后松开，C组于阻断前10min静注赛庚啶2mg／ks，继以2mg／(kg&;#183;h)持续输注至松开前10min。测定给药前、松开前及松开后60min兔血中丙二醛(MDA)含量。术后观察动物后肢神经功能、肌电图(EMG)和脊髓形态学变化。结果：B组主动脉阻断及再通后血中MDA含量明显升高(P&;lt;0．01)，C组动物阻断及再通后无明显变化。C组动物术后瘫痪数低于B组，术后神经功能评分及EMG检查显示C组脊髓功能损伤明显轻于B组。B组脊髓病理变化明显，可见大量神经元坏死，C组偶见神经元变性，病理学评分两组有明显差异。结论：赛庚啶对家兔主动脉阻断导致的脊髓缺血性损害有一定的保护作用，这一作用与赛庚啶抗过氧化反应及其他多种药理作用有关。     

多次缺血预处理对兔脊髓缺血性损伤后脊髓功能和形态学的影响

目的观察多次缺血预处理(IPC)对兔脊髓缺血再灌注损伤的保护作用。方法24只日本大白兔随机分为假手术组(A组)、缺血再灌注组(B组)和IPC保护组(C组),各组均为8只。A组不阻断主动脉,B组左肾下阻断主动脉45min,C组左肾下阻断主动脉5min,开放5min,反复4次后再阻断主动脉45min。术后进行后肢神经功能评分和针电极肌电图(EMG)的描记及脊髓组织形态学改变的观察。结果B组同A、C组相比,后肢EMG亦有显著性病理改变(P<0.01)。结论多次IPC对家兔脊髓缺血再灌注损伤具有快速保护作用。     

主动脉术后脊髓缺血相关截瘫的治疗与预防

手术治疗是主动脉疾病治疗的主要方式。截瘫作为主动脉术后严重的并发症之一,有着不低的发生率。因此如何降低术后截瘫的发生,一直是大血管外科医师所关注的问题。脊髓缺血是主动脉术后截瘫发生的主要原因。本综述通过检索国内外相关研究进展,对主动脉术后脊髓缺血所致脊髓损伤的机制、治疗及如何进行预防进行总结,为临床医师提供参考。     

胸腹主动脉夹层手术脊髓损伤标记物临床研究

目的探讨脑脊液生化指标监测对胸腹主动脉夹层术后脊髓缺血损害判断的临床意义。方法将50例胸腹主动脉夹层手术患者根据术后是否发生脊髓缺血损害并发症分成损伤组（SCI组,n=5）和无损伤组（NSCI组,n=45）。术前、术后分7个时点对脑脊液取样,对胶质纤维酸蛋白（GFAP）、S100β蛋白以及神经丝蛋白亚单位（NFL）等3个生化指标进行测定。比较分析上述3个生化指标在2组之间的变化。将无脊髓损伤患者据术式分为血管置换手术组（AR组,n=9）和腔内隔绝术组（EVGE组,n=36）,同样比较分析上述3个生化指标在2组之间的差异。结果 SCI组术后6 h各项生化指标开始升高,48-72 h各项指标明显高于NSCI组（P〈0.01）。术后6 h以后GFAP、S100β蛋白测定数值在2组之间数值无重叠。腔内隔绝术后各项指标无明显升高,血管置换术后6 h起GFAP、S100β开始升高,术后24 h达到峰值,较术前相比差异有统计学意义（P〈0.05）,同时高于腔内隔绝术后对应时点。血管置换术后（第24h4、8 h）时点NFL高于腔内隔绝术后对应时点（P〈0.05）。结论脑脊液生化指标持续监测可以预判迟发性脊髓损害。GFAP、S100β蛋白比NFL诊断脊髓损伤有更高的预测价值。     

Use of lumbar cerebrospinal fluid drainage in thoracoabdominal aortic aneurysm repairs.

Thoracoabdominal aortic aneurysm repairs present many challenges, and the complication of paraplegia remains a concern for both the surgeon and the nurse caring for the patient in the postoperative period. Paraplegia can occur secondary to spinal cord ischemia from prolonged aortic clamping during the repair of the descending thoracic aorta. Paraplegia is a devastating complication for the patient and family. Multiple adjunct techniques have been instituted to prevent reduced spinal cord perfusion during and after the operation, including the use of shunts and cardiopulmonary bypass, femoral artery-femoral vein bypass, left atrial-femoral artery bypass, and selective revascularization of the dominant intercostal artery. Other methods, such as somatosensory evoked potential monitoring during the operation and regional spinal hypothermia techniques, have not reduced the incidence of paraplegia. Improved outcomes have been seen with the use of methods to reduce cerebrospinal fluid (CSF) pressure. One such method is the use of external CSF drainage during the operation, followed by use of a lumbar drain system for as long as 72 hours after the operation. This system setup uses a transducer to monitor CSF pressure and a drip chamber to drain CSF to maintain a normal pressure. This article describes thoracoabdominal aneurysms, surgical techniques to repair the aneurysm, and the use of external CSF drainage and related nursing care measures.     

Transcutaneous near-infrared spectroscopy for monitoring spinal cord ischemia: an experimental study in swine

We aimed to assess the ability of near-infrared spectroscopy (NIRS) to detect spinal cord ischemia, and to evaluate changes in regional oxygen saturation (rSO₂) following recovery of spinal cord circulation and cerebrospinal fluid drainage. Four 12-month-old female swine weighing 28.7–29.5 kg were acquired for this study. NIRS probes were placed along the midline of the upper (T6/7) and lower (T9/T10) thoracic vertebrae. The thoracic aorta was clamped distal of the left subclavian artery to induce spinal ischemia. Aortic cross-clamping was maintained for 30 min. Fifteen minutes after aortic de-clamping, the cerebrospinal fluid drainage catheter was opened to air, and cerebrospinal fluid drainage was initiated. Following aortic clamping, rSO₂ in both upper and lower regions of the spinal cord decreased by 15 % within 5 min and by 20 % within 10 min (relative change). After aortic de-clamping, rSO₂ values in both regions returned to baseline within 5 min. No changes in rSO₂ in either the upper or lower vertebrae were observed following initiation of cerebrospinal fluid drainage. Histological analysis revealed that ischemic changes had occurred in all spinal levels. NIRS may be used to detect decreases in and recovery of spinal cord circulation following aortic clamping and de-clamping, whereas it may not reflect minor changes in spinal cord circulation due to cerebrospinal fluid drainage. Further clinical studies are required to investigate the potential for NIRS as an index of spinal cord circulation.     

Epidural cooling for spinal cord protection during thoracoabdominal aortic aneurysm repair (a case study)

Aneurysms result from damage to artery walls as a result of underlying athrosclerotic and/or thromboembolic disorders. A thoracoabdominal aortic aneurysm involves vessel damage and wall weakening in the thoracic and abdominal segments of the aorta. Thoracoabdominal aortic aneurysm repair is considered to be high risk due to the nature of the intervention that requires an extensive incision with clamping of the thoracic aorta above the renal arteries. Clamping of the aorta renders all areas distal to the clamp at high risk for ischemic trauma especially to the spinal cord where the risk of neurological deficits postoperatively is 7-16% (Cambria, et al., 1997; Davison, et al., 1997). Several adjunct interventions have been tried to reduce the risk of spinal cord injury associated with the ischemia of cross clamping. Epidural cooling has been successful as an adjunct in reducing the neurological deficits. A preoperative nursing assessment indicating the appropriate nursing diagnoses and nursing care required for this patient, allowed for individualization of the plan needed to include this new procedure and plan for best patient outcomes and practices.     

硬脊膜完整性可影响脑脊液中细胞因子的水平

背景：脊髓损伤后的病理生理机制非常复杂,人们对此认识还很不全面、深入。目的：观察脊髓损伤动物模型中硬脊膜完整性对脑脊液内细胞因子水平的影响。方法：采用钳夹压迫法建立新西兰大白兔脊髓损伤模型,随机分为无硬脊膜缺损组、硬脊膜缺损组、硬脊膜缺损复合膜修复组、硬脊膜缺损自体筋膜修复组。术后 30 min、1 h、3 h、6 h、12 h、36 h 采用酶联免疫吸附实验方法检测各组脑脊液中细胞因子白细胞介素 6、白细胞介素 10、肿瘤坏死因子α的变化。结果与结论：无硬脊膜缺损组、硬脊膜缺损复合膜修复组和硬脊膜缺损自体筋膜修复组术后 6 h 脑脊液中白细胞介素 6、白细胞介素 10、肿瘤坏死因子α水平均显著低于硬脊膜缺损组（P 〈 0.05）。其余时间点 4 组间各因子水平差异无显著性意义（P 〉 0.05）。说明维护脊髓损伤模型中硬脊膜的完整性可影响脑脊液中白细胞介素6、白细胞介素 10、肿瘤坏死因子α水平,抑制炎症反应。     

Thoracoabdominal aortic aneurysm repair: historical review and description of a re-engineered technique

Most complications related to thoracoabdominal aortic reconstruction stem from ischemia-induced injury to the viscera, kidneys, and spinal cord. Pioneers in the treatment of thoracoabdominal aortic aneurysms recognized the danger of producing ischemic damage to these vital organs. In addition to adjunctive methods designed to minimize metabolic demands of the spinal cord during aortic cross-clamping, a variety of extracorporeal techniques have been developed that provide supplemental blood flow to vital end organs during the period of clamp-induced ischemia. This article reviews these extracorporeal methods and provides a historical perspective of thoracoabdominal aortic aneurysm repair. In addition, a reengineered technique for thoracoabdominal aortic aneurysm repair is highlighted.     

局部低温程度与大鼠脊髓缺血损伤保护的相关性

背景脊髓的局部低温保护减轻了创伤性脊髓损伤后的二次损伤,但是低温深度与保护程度是否具有相关性目前尚不清楚. 目的研究局部低温的程度与大鼠脊髓缺血损伤保护的相关性. 设计完全随机对照实验. 地点和对象实验在中国医科大学普外三科实验室完成,采用雄性 Wistar大鼠. 干预模拟制作大鼠脊髓缺血动物模型,对 L5～ L10行逆行蛛网膜下腔低温生理盐水灌注,控制脊髓核心温度在 38℃, 34℃, 30℃, 18℃ 4个水平,近端动脉压控制在 5.3～ 6.6 kPa,阻断时间分别为 12, 16 min. 主要观察指标观察动物截瘫数及截瘫指数并作组织学检查. 结果实验动物的截瘫数及截瘫指数随着温度的降低而降低. 38℃, 34℃, 30℃, 18℃各组阻断 12 min后,截瘫数分别为 6, 3, 0, 0;阻断 16 min后分别为 8, 6, 5, 0.截瘫指数 0- 4评定结果为,阻断 12 min, 38℃分别为 2, 1, 2, 3, 0; 34℃分别为 4, 1, 2, 1, 0; 30℃和 18℃ 8只截瘫指数均为 0;阻断 16 min, 38℃分别为 0, 0, 1, 4, 3只; 34℃分别为 2, 1, 3, 2, 0只; 30℃分别为 4, 2, 2, 0, 0只; 18℃ 8只截瘫指数均为 0.组织学检查显示随着温度降低,脊髓缺血损伤逐渐减轻. 结论与轻、中度低温相比,深度低温对脊髓缺血损伤的保护作用更显著,局部低温的深度与大鼠脊髓缺血损伤保护程度呈正相关.     

Anesthesia, changes in hemodynamics and metabolism in surgical treatment of thoracic and abdominal aortic aneurysms

45 patients aged 32-63 years operated on for dissecting aneurysm of the thoracoabdominal part of the aorta were divided into 2 groups. Group 1 patients (n = 36) were operated on with application of the bypass using centrifuge pump. Group 2 patients (n = 9) were operated on without the bypass. The results evidence that the employed anesthesia and infusion therapy in combination with the bypass maintained by the pump provide stable intraoperative hemodynamics and prevent renal failure. Usage of the bypass in combination with liquor drainage reliably protects spinal cord from ischemia, especially in patients with long-term aortic ligature.