不同剂量国产抑肽酶对体外循环中血小板的保护作用

目的：观察体外循环中应用抑肽酶对血小板数及功能的影响。方法：２９例心内直视手术患者，分为Ｉ观察组（ｎ＝１０）预充液中一次性加入国产抑肽酶５万单位／ｋｇ，Ｉ观察组（ｎ＝１０）一次性加入抑肽酶８～１０万单位／ｋｇ，对照组（ｎ＝９）常规预充。３组均观察血小板计数、血小板聚集功能、术后２４小时胸腔引流量和血红蛋白及输血量。结果：术后血小板计数在Ｉ观察组为（１２３．０±３．０）×１０９／Ｌ，显著高于对照组的（９１．５±４．０）×１０９／Ｌ（Ｐ＜０．０５）。血小板聚集功能体外循环中较体外循环前降低，在Ｉ观察组降低不明显与Ｉ观察组和对照组相比较差异显著（Ｐ＜０．０５），术后２４小时胸腔引流量及输血量在ＩＩ观察组较对照组分别减少４２．７％（Ｐ＜０．０５）和４８．１％（Ｐ＜０．０５）。结论：体外循环中应用大剂量国产抑肽酶对术后血小板数及功能均有良好的保护作用，明显减少术后出血及库血的应用。     

川芎嗪对体外循环中炎性因子IL-8、TNF-α的影响

在体外循环（CPB）预充液中加入川芎嗪注射液,分别于术前及心脏复跳后10、60、120 min抽取静脉血观察其对白介素8（IL-8）、肿瘤坏死因子α（TNF-α）的影响。发现川芎嗪可明显降低静脉血中IL-8、TNF-α的水平,提示川芎嗪能通过降低CPB过程中炎性因子IL-8、TNF-α的浓度而达到心肺保护目的。     

抑肽酶对体外循环下心脏直视术后血清细胞因子浓度的影响

随着体外循环技术的不断发展 ,心脏直视手术的安全性较前已有显著提高 ,但术后仍见“灌注后综合征”发生。目前认为灌注后综合征是 CPB引起的系统炎性反应综合征 ( SIRS) ,严重者可诱发多脏器功能衰竭( MODS)。近来发现 ,CPB过程中多伴有某些细胞因子的产生 ,它们在介导微血管损伤与脏器功能障碍方面起重要作用 [1] ,是 SIRS的病理基础。因此 ,有必要采取措施减少 CPB引起的细胞因子的过量产生。本研究观察抑肽酶对临床 CPB激发的肿瘤坏死因子 -α( TNF-α)、白细胞介素 - 6( IL- 6)、白细胞介素 - 8( IL- 8)分泌的影响的 ,并…     

细胞因子在急性心肌梗塞中的作用

为探讨细胞因子在急性心肌梗塞（AMI）中的作用，测定了28例AMI患者血清肿瘤坏死因子α（TNFα）和白细胞介素1β（IL－β）水平，并选择13例不稳定型心绞痛（UA）患者和15例健康人作为对照。结果表明：AMI组血清TNFα水平明显高于UA组及正常组（P＜0．01），UA组血清TNFα水平明显高于正常组（P＜0．01）；血清IL－1β水平在严重的AMI患者（心功能KillipⅢ、Ⅳ级）明显高于正常组（P＜0．01）。提示血清TNFα和IL-1β水平与心肌缺血的严重程度有关。     

抑肽酶对体外循环期间血小板保护作用的电镜观察

体外循环心内直视手术病人２０例，随机分为对照组和实验组，每组１０例。对照组行常规体外循环心脏手术，实验组给予抑肽酶处理。取围手术期２个时段血小板行电镜观察，并行统计学处理。结果表明：对照组血小板明显聚集、脱颗粒、破碎、微管扩张；实验组应用抑肽酶后血小板超微结构的变化显著优于对照组。作者认为抑肽酶是一个效果确切的体外循环期间血小板保护药物。     

平衡超滤加改良超滤对婴幼儿体外循环术后血清炎症介质水平的影响

目的观察平衡超滤加改良超滤对低体重婴幼儿体外循环术后血清炎症介质水平的影响。方法40例低体重先天性心脏病患儿,随机分为观察组和对照组,各20例。观察组在体外循环术中施行平衡超滤加改良超滤技术,对照组未应用超滤技术。测定两组患儿术前、体外循环术后即刻及3、6、24h血清肿瘤坏死因子（TNF）-α及白细胞介素（IL）-6、8水平。结果体外循环后各时点观察组患儿血清TNF—α、IL-6、IL-8水平均显著低于对照组。结论平衡超滤加改良超滤技术可显著降低体外循环术后患儿血清TNF—α、IL-6、IL-8的水平。     

抑肽酶抑制体外循环的血小板活化

抑肽酶抑制体外循环的血小板活化南京铁道医学院附院马游，顾懋栋，吴熹体外循环导致血小板功能障碍，乃术后非外科性出血的重要原因。如何减轻体外循环对血小板的影响，减少术后出血，是一极待解决的课题，本实验于预充液中加入抑肽酶２×１０６ＫＩＵ，观察其对血小板和...     

缬沙坦对心力衰竭患者血浆细胞因子浓度的影响

目的 :探讨重度充血性心力衰竭 (CHF)患者血浆中细胞因子浓度的变化及其对缬沙坦干预的反应。方法 :选择CHF患者 80例 (CHF组 )和健康体检者 4 0例 (对照组 ) ,采用放免法测定血浆肿瘤坏死因子 (TNF α)、白细胞介素 1(IL 1)和白细胞介素 6 (IL 6 )的浓度 ;然后将CHF组随机分为常规治疗组和加用缬沙坦组各 4 0例 ,1个月后再测定上述指标。结果 :CHF组 3种细胞因子浓度均高于对照组 (P <0 .0 1) ;CHF越重 ,细胞因子的浓度越高 (P <0 .0 1) ;不同病种所致同级CHF的细胞因子浓度无明显差别 (P >0 .0 5 ) ;缬沙坦能改善心功能 ,降低上述细胞因子的浓度 (P <0 .0 1)。结论 :细胞因子在重度CHF的发展中起重要作用 ,而且与基础病无关 ;缬沙坦在改善心功能的同时 ,也降低细胞因子的血浆浓度。     

强化胰岛素治疗对体外循环炎症反应的影响

目的探讨强化胰岛素治疗对体外循环(CPB)下心脏瓣膜置换术炎性反应的影响。方法 30例CPB下行心脏瓣膜置换术患者随机分为强化胰岛素组(强化组,n=15)和对照组(n=15)。强化组术中血糖控制在3.9~10.0 mmol/L,术后控制在4.4~8.3 mmol/L;对照组血糖11.1 mmol/L时给予胰岛素治疗。分别于麻醉诱导后(T0)、CPB开始(T1)、CPB结束即刻(T2)、6 h(T3)、24 h(T4)和48 h(T5)时点测定血浆白细胞介素(IL)-6、肿瘤细胞坏死因子(TNF)-α浓度,并记录术后临床情况。结果两组TNF-α、IL-6浓度在T2、T3、T4时点均明显高于T0时点(P0.05);在T2、T3、T4时点,强化组TNF-α、IL-6浓度明显低于对照组(P0.05);强化组呼吸机支持时间明显短于对照组(P0.05)。结论强化胰岛素治疗能降低TNF-α、IL-6浓度表达,缩短呼吸机支持时间,减弱CPB引起的炎性反应。     

体外循环对血管内皮细胞的影响及干预性治疗的研究

目的研究体外循环(CPB)对血管内皮细胞的影响及参附注射液在CPB过程中对血管内皮细胞的保护作用。方法66例行心内畸形矫治术的先天性心脏病患者,随机分为实验组(n=33)与对照组(n=33),均在全麻低温体外循环下行心内直视手术,围术期对症支持处理;实验组在体外循环预充液中加入参附注射液2ml/kg,而对照组预充液中不用参附注射液,其他处理与实验组相同。分别于麻醉诱导后,体外循环30min,开放升主动脉5min、15min,停机2h,共5个时点抽取桡动脉血,检测肿瘤坏死因子(TNF-α)、血栓调节蛋白(sTM)、P选择素(sP-selectin)的表达值。结果两组患者TNF-"、sTM、sP-selectin水平在CPB后均显著升高,与麻醉诱导期比较差异有统计学意义(P<0.01);实验组上升幅度较对照组小(P<0.05或P<0.01)。结论CPB对血管内皮细胞有损伤作用,参附注射液对CPB所致的血管内皮细胞损伤有一定的保护作用。     

Comparison of inflammatory response following coronary revascularization with or without cardiopulmonary bypass

BACKGROUND:

It is well known that conventional coronary revascularization is associated with a pronounced systemic inflammatory response due to the application of cardiopulmonary bypass (CPB).

OBJECTIVE:

To compare the effects of coronary artery bypass grafting (CABG) with (on-pump) or without (off-pump) extra-corporeal circulation observing certain inflammatory response parameters.

METHODS:

Twenty patients undergoing CABG with (CPB group: 10 patients) or without (off-pump coronary artery bypass grafting [OPCAB] group: 10 patients) CPB were enrolled in this prospective, randomized study. Blood samples were collected three times during the operation and on postoperative days 1, 2, 3 and 7. The plasma level of proinflammatory cytokine tumor necrosis factor (TNF)-alpha was measured by enzyme-linked immunosorbent assay method following stimulation, and the expression of adhesion molecules (CD11, CD18) of leukocytes were determined by flow cytometry. Furthermore, white blood cell (WBC) and neutrophil count were carried out.

RESULTS:

The WBC and neutrophil counts rose markedly in both groups following the operation and remained at this increased level during the observation period. There was a significant difference in WBC and neutrophil counts between the two groups of patients on postoperative day 7. A significant difference in the level of TNF-alpha was found between the two groups on postoperative day 2 (P<0.05). An intense increase was observed with CPB, which significantly exceeded the values of the OPCAB group without extracorporeal circulation in the early postoperative period. The CD11a and CD18 expression of leukocytes decreased during the operation and on postoperative day 1; thereafter, it increased markedly. There was a significant difference in adhesion molecule expression between the two groups on postoperative day 2.

CONCLUSION:

The investigation revealed that inflammatory response reactions following extracorporeal circulation could be reduced significantly using the off-pump technique.     

体外循环肺肿瘤坏死因子表达与细胞凋亡的研究

目的：探讨肺组织肿瘤坏死因子-α（tumor necrosis factor-α,TNF-α）在体外循环（cardiopulmonary bypass,CPB）中的表达及其与细胞凋亡的关系。方法：选取健康新西兰大白兔20只,随机分为CPB组和Sham组（单纯开胸）。测定各组围CPB期左心房、右心房血液中中性粒细胞计数、TNF-α含量;取肺组织样本,动态观察肺组织TNF-αmRNA表达、细胞凋亡相关因子Bcl-2、Bax、Fasl的表达和Bcl-2/Bax及凋亡指数变化情况。结果：CPB后,中性粒细胞在肺内明显聚集,肺源性TNF-α的表达及释放显著增加。同时,肺组织细胞凋亡指数明显提高,肺泡上皮细胞Fasl、Bax蛋白表达增加,Bcl-2蛋白表达下降。结论：CPB可引起肺源性TNF-α表达增高并诱发细胞凋亡,从而导致肺损伤。     

Anti-inflammatory effects of propofol during cardiopulmonary bypass: A pilot study

Introduction:

Propofol has been suggested as a useful adjunct to cardiopulmonary bypass (CPB) because of its potential protective effect on the heart mediated by a decrease in ischemia-reperfusion injury and inflammation at clinically relevant concentrations. In view of these potentially protective properties, which modulate many of the deleterious mechanism of inflammation attributable to reperfusion injury and CPB, we sought to determine whether starting a low dose of propofol infusion at the beginning of CPB would decrease inflammation as measured by pro-inflammatory markers.

Materials and Methods:

We enrolled 24 patients undergoing elective coronary artery bypass graft (CABG). The study group received propofol at rate of 120 mcg/kg/min immediately after starting CPB and was maintained throughout the surgery and for the following 6 hours in the intensive care unit (ICU). The control group received propofol dose of 30-50 mcg/kg/min which was started at the time of chest closure with wires and continued for the next 6 hours in the ICU. Interleukins (IL) -6, -8 and -10 and tumor necrosis factor alpha (TNFalpha) were assayed.

Result:

The most significant difference was in the level of IL-6 which had a P value of less than 0.06. Starting a low dose propofol early during the CPB was not associated with significant hemodynamic instability in comparison with the control group.

Conclusion:

Our study shows that propofol may be suitable as an anti-inflammatory adjunct for patients undergoing CABG.     

体外循环自体血预充技术对全身炎性反应的影响

目的 研究体外循环采用自体血预充技术对全身炎性反应相关指标的影响.方法 32例非急诊手术首次接受体外循环下心脏冠脉搭桥的患者,依性别（男女比例）、年龄、体重、身高、体表面积（BSA）和射血分数（EF）进行配对后分为两组：自体血预充组（16例）和经典预充组（16例）.自体血预充组：用1250 ml晶体液和8000 IU肝素预充,体外循环开始前先采用自体血预充技术置换出大部分最初预充液,置换过程中严密监视血流动力学变化,维持平均动脉压（MAP）在50 mm Hg以上.整个过程依患者血流动力学耐受程度决定.经典预充组：1250 ml晶体液和8000 IU肝素预充.两组患者心肌保护均采用Calafiore温血停跳液灌注,体外循环中保持温度35.0 ℃～35.5 ℃,流量 2.5～2.8 L·min-1·m-2.所有患者按标准手术步骤进行手术,先完成全部远端吻合口后,开放升主动脉再逐一完成近端吻合.平均体外循环时间64 min,阻断升主动脉时间37 min,平均每例搭桥3.0支.手术结束前将体外循环系统中余血全部回输给患者.结果 自体血预充组平均置换出（885±161）ml的最初预充液,患者体外循环中、手术结束时、术后6 h、术后1 d的HCT水平均明显高于经典预充组（P＜0.05）.90%自体血预充组患者围术期免于输血,而经典预充组患者未输血比例为68%.患者体外循环结束和体外循环后6 h动脉血IL-6水平低于经典体外循环组（P＜0.05）.经典预充组患者体外循环开始和结束时IL-8、TNF-α水平高于自体血预充组（P＜0.05）.结论 体外循环应用自体血预充技术能减少血液稀释,减少围术期输血量,一定程度地抑制IL-6、IL-8和TNF-α炎症介质的升高.     

体外循环缺血再灌注后心肌缺血胰岛素抵抗与相关因子变化关系的研究

目的:探讨体外循环(cardiopulmonary bypass,CPB)缺血再灌注后,冠状动脉血清胰高血糖素、生长激素及肿瘤坏死因子-α(tumor necrosis factor-α,TNF-α)的变化与心肌胰岛素抵抗(insulin resistance,IR)的关系及其作用。方法:选择近年在我院行体外循环手术患者48例分为两组:组1主动脉阻断时间≤30min(n=24);组2主动脉阻断时间30min(n=24)。于CPB转流3min(主动脉阻断前)、主动脉开放后15min、45min、75min、2h、4h及8h时分别采集桡动脉、冠状静脉窦血标本,比较对应时点血浆葡萄糖、胰岛素、胰高血糖素、生长激素、TNF-α及计算胰岛素抵抗指数(IRI)的变化。结果:血浆葡萄糖、胰岛素及胰岛素抵抗指数在缺血再灌注后显著不同程度增高,且于再灌注后15min达峰值,差异有统计学意义(P0.05);心肌对葡萄糖的摄取、利用发生严重障碍,与1组比较,组2上述指标增高程度更重、持续更久,差异有统计学意义(P0.05)。检测血清胰高血糖素、生长激素及TNF-α与血浆葡萄糖、胰岛素及胰岛素抵抗指数增高呈一致性,随主动脉阻断时间延长,其增高程度更重、持续更久,差异有统计学意义(P0.05)。结论:在人体外循环中心肌缺血再灌注后冠状动脉血清胰高血糖素、生长激素及TNF-α分泌增加可能是心肌IR的重要因素之一。     

咯利普兰对体外循环时炎症反应的影响

目的:探讨选择性磷酸二酯酶抑制剂(PDE4)咯利普兰对体外循环时炎症反应的影响。方法:将30只清洁级健康大鼠随机分为对照组和实验组。经腹主动脉逆行插入动脉灌注管,经下腔静脉穿刺静脉引流管直至右心房水平,建立体外循环(CPB)模型。术中转流灌注流量约为50～70ml.kg-1.min-1。实验组术前30min腹腔注射咯利普兰稀释液10ml/kg,术中经股静脉以40mg.kg-1.min-1持续滴入咯利普兰稀释液,对照组以同样的方法给予等量的5%乙醇生理盐水。于转流开始、转流20min、停CPB后5min和2h这4个时点分别取静脉血。测定血浆中肿瘤坏死因子(TNF-α)、内毒素(LPS)水平,采用免疫组织化学染色技术检测肺毛细血管内皮细胞P-选择素的表达。取肺组织标本制片进行HE染色,光镜下观察组织学改变,评估肺损伤的程度。结果:对照组血TNF-α及LPS水平在转流中及转流后均较CPB前明显升高;咯利普兰组在灌注20min、停CPB后5min和2h时,TNF-α和LPS水平较对照组明显减少。咯利普兰组肺毛细血管内皮细胞P-选择素表达明显低于对照组(P<0.05)。结论:选择性PDE4抑制剂咯利普兰能够抑制TNF-α,LPS和P-选择素表达,对抗CPB时的全身炎症反应,具有保护心肌的作用。     

Pharmacological intervention for renal protection during cardiopulmonary bypass

Summary The possibility of minimizing organ damage following cardiopulmonary bypass (CPB) was examined. In the control group,n = 21, upon completion of CPB, elevation of the lysosomal enzyme -glucuronidase, which is a sensitive indicator of cellular damage, was affected by the concentration of granulocyte elastase (r = 0.59) or the endothelial-derived constricting factor, endothelin, (r = 0.8). Renal damage, which was detected by an increase in renal tubular enzymes (N-acetyl--D-glucosaminidase and -glutamyltranspeptidase) in urine, was also affected by endothelin (r = 0.79, r = 0.56), elastase (r = 0.6, r = 0.71), and by free hemoglobin levels (r = 0.76, r = 0.82). Next, the efficacy of pharmacological intervention for the prevention of renal damage was evaluated. During CPB, the administration of an elastase inhibitor (ulinastatin, 3 × 10⁵IU),n = 8, or a calcium antagonist (nicaldipine HCl, elastase release inhibitor; 5 /kg per min),n = 8, significantly reduced the elevation of -glucuronidase and renal tubular enzymes (p < 0.05). Although the ulinastatin and nicardipine groups demonstrated low values of elastase in the Intensive Care Unit (ICU), only the values of the nicardipine group reached statistical significance (p < 0.05). A reduction in endothelin levels compared to the control group was observed in the nicardipine group. However, preventive and counteractive effects of nicardipine against vasoconstriction caused by endothelin were also considered to play an important role in the prevention of renal damage. The addition of haptoglobin (4,000 IU) to the priming solution of the CPB also reduced levels of renal tubular enzymes (p < 0.05). We concluded that elastase, endothelin, and free hemoglobin were causes of renal damage during CPB. The administration of ulinastatin, nicardipine, or haptoglobin possibly prevent apparent renal dysfunction after CPB.     

乌司他丁和地塞米松对心肺脑复苏早期大鼠脑组织含水量及IL-1β水平等的影响

目的探讨乌司他丁、地塞米松以及两者联合应用对心肺脑复苏早期大鼠脑组织含水量及脑组织IL-1β、外周血肿瘤坏死因子α（TNF-α）含量的影响。方法将40只SD大鼠随机分为假手术对照组、心肺脑复苏（CPCR）组、地塞米松组、乌司他丁组、乌司他丁＋地塞米松组，每组各8只大鼠。采用夹闭气管法建立大鼠心肺脑复苏模型。于自主呼吸循环恢复后2h，采用干湿法检测各组大鼠脑组织含水量，采用放射免疫法检测大鼠脑组织IL-1β和外周血TNF-α水平。结果①脑组织含水量：CPCR组为（80．4±2．0）％，较对照组（76．7±1．3）％显著增加（P〈0．01）；乌司他丁组、地塞米松组、乌司他丁＋地塞米松组，3组间差异无统计学意义（P〉0．05），但均较CPCR组显著减少（P〈0．01）。②脑组织IL-1β含量：CPCR组为（0．235±0．051）ng／mg，较对照组（0．108±0．020）ng／mg明显增高（P〈0．01）；地塞米松组、乌司他丁组与CPCR组比较，差异无统计学意义；乌司他丁＋地塞米松组IL-1β含量为（Q（365±Q021）ng／mg，明显低于CPCR组（0．235±0．051）ng／mg（P〈0．001）。③外周血TNF-α水平：CPCR组为（3．07±0．74）ng／ml，较对照组（1．03±0．51）ng／ml明显增高（P〈0．01）；乌司他丁组、地塞米松组、乌司他丁＋地塞米松组均比CPCR组显著降低（P〈0．01），但3组间差异无统计学意义（P〉0．05）。结论CPCR早期即可发生脑水肿，脑组织IL-1β及外周血TNF-α水平显著增加；应用乌司他丁、地塞米松能有效降低脑组织含水量、IL-1β和外周血中TNF-α水平。