乌司他丁对老年骨科患者止血带性肺损伤的保护作用

目的探讨乌司他丁对老年骨科患者止血带性肺损伤的影响及相关作用机制。方法28例年龄≥65岁，对拟行单侧膝关节置换的骨科手术患者随机数字表法分为两组：对照组（L组）15例和乌司他丁组（U组）13例。U组在上止血带前15min静脉滴注乌司他丁1万U／kg，第1次松止血带前5min再次静脉推注20万U，第2次松止血带前5min再次静脉推注20万U。L组以等量乳酸林格液代替。并分别于术前面罩给氧前（T0）、松止血带后5min（T1）、30min（T2）、4h（T3）采桡动脉、颈内静脉血行动静脉血气分析，计算肺泡动脉氧分压差（A—aDO2）、氧合指数（OI）、肺内分流率（QS／QT）值，并检测血清内肿瘤坏死因子（TNF—α）、丙二醛（MDA）含量。结果与T0时点比较，L组患者T1、T2时点血A—aDO2明显增加（P〈0．05），OI明显下降（P〈0．01）；T1、T2、T3时点血浆MDA、TNF—OC浓度显著升高（P〈0．01）；但T1、T2、T3时点QS／QT值差异无统计学意义（P〉0.05）。U组患者T1、T2、T3时点血A—aDO2、OI及QS／QT值与该组T0时点比较差异无统计学意义（P〉0．05）；与L组比较，T1、T2时点血A—aDO2明显降低、OI明显增高（P〈0．05）：T1、T2、T3时点血浆MDA及TNF—α浓度显著降低（P〈0．01）；但两组间各时点QS／QT值差异无统计学意义（P〉0．05）。结论止血带性再灌注后早期老年患者的肺换气功能降低，氧合功能下降，肺内分流率无明显影响。乌司他丁可以减轻再灌注对肺换气功能和氧合功能的影响，与抑制TNF-α炎症因子的产生，减少氧自由基的释放有关。

Ulinastatin reduces lung injury induced by tourniquets in orthopedic operations of elderly patients

Objective To investigate the protective effect of ulinastatin on lung injury induced by tourniquets in elderly patients undergoing orthopedic operations. Methods Twenty eight elderly patients who underwent total knee replacement operations were randomly divided into two groups. In group U （n=13）, patients were given with ulinastatin 10,000 I.V when the operation began; then 200,000 U/kg 5min before the first and second release of tourniquets respectively. In control group （group L, n=15） equal volume of normal saline was infused at the same time points. Blood samples were taken from jugular vein and radial artery before mask oxygenation （T0）, then 5 min（T1）, 30 rain（T2） and 4h（T3） after reperfusion of the leg. Plasma TNF-α, MDA levels were determined, arterial and mixed venous blood gas analysis was performed. A-aDO2,oxygenation index and QS/QT were calculated. Results In group L,A- aDO2 was higher（ P〈0.05）and oxygenation index was lower（ P〈0.01 ）at T1 and T2 than those at T0;plasma MDA was higher at T1, T2 and T3, TNF- α was higher at T1 and T2 than those at To （ P〈0.01 ）; but there was no difference in QS/QT at all time points （P〉0.05）. In group U,there were no differences in A-aDO2, oxygenation index and QS/QT at all time points （ P〉0.05 ）; however, A-aDO2 was significantly lower at T1 and T2 than that in group L （ P〈0.05 ）and oxygenation index was significantly higher than that in group L （P〈0.05）. Plasma MDA and TNF- α in group U were significantly lower at T1, T2 and T3than those in group L （ P〈0.05 ）. But there was not significantly different in QS/QT between two groups at all time points （P〉0.05）. Conclusion For elderly patients undergoing knee replacement operations pulmonary gas exchange and oxygenation index are damaged in the early stage of reperfusion, but intrapulmonary shunt fraction is not affected. Ulinastatin can effectively attenuate the damage of lung function, which might be attributed to its anti-inflammatory effects and reduced release of MDA.