胰岛素治疗对体外循环手术患者心功能的作用

目的探讨胰岛素治疗对体外循环（extracorporeal circulation,ECC）心脏手术患者心功能的作用及其机制。方法ECC下心脏手术患者按年龄（≥18岁为成人,〈18岁为儿童）和是否接受胰岛素治疗分为4组：成人常规治疗组（ART,n=8）,成人胰岛素治疗组（AIT,n=8）,儿童常规治疗组（CRT,n=8）,儿童胰岛素治疗组（CIT,n=8）。分别于术前、麻醉诱导、ECC开始后、ECC结束即刻及ECC结束4 h、12 h、24 h、48 h测定患者血浆胰岛素水平。ECC前和ECC后在右心耳切口缘取心肌,Western blot测定InsRβ、pP38-MAPK、pERK、pJNK、GLUT-4表达。ECC后24 h、48 h、72h经胸超声心动图检测心功能。结果与ART组和CRT组相比,AIT组和CIT组在ECC术后的左室压力上升最大速率（dp/dtmax）、左心室射血分数（LVEF）和短轴缩短率（FS）明显增加（P〈0.05）,同时InsR表达、pP38-MAPK表达及GLUT-4表达也显著增加（P〈0.05或P〈0.01）。结论胰岛素治疗对心肌有明显的正性变力作用。年龄增长是胰岛素抵抗的影响因素。ERK和pP38的活化受抑制是ECC后心肌胰岛素抵抗的重要环节。ECC刺激及胰岛素对心肌JNK的活化无明显影响。

Effects of Insulin Therapy on Heart Function in Patients Undergoing Cardiac Surgery with Extracorporeal Circulation

OBJECTIVE To investigate the effects of insulin therapy on heart function in patients undergoing cardiac surgery with extracorporeal circuation（ECC）.METHODS 32 patients were randomly assigned to 4 groups according to the age（adult≥18y,child〈18y） and whether recieving insulin therapy： adult routine therapy（ART） group,adult insulin therapy（AIT） group,child routine therapy（CRT） group and child insulin therapy（CIT） group.Levels of insulin in all the groups were respectively measured before surgical anesthesia,0 h after the initiation of ECC,and 0,4 h,12 h,24 h,48 h after the termination of ECC.Used western blot analysis to examine InsRβ,pP38-MAPK,pERK,pJNK and GLUT-4 expression in cardiomyocytes pro-and post-ECC.RESULTS Compared with ART and CRT groups, dp/dtmax,LVEF and FS were higher in AIT and CIT groups（P〈0.05）.After insulin therapy,InsRβ expression in cardiomyocytes was significantly higher post-ECC（compared with ART and CRT groups,P〈0.05）.Compared with ART and CRT groups,post-ECC pP38-MAPK expression levels were higher in AIT and CIT groups（P〈0.05）.GLUT-4 expression in cardiomyocytes was increased post-ECC in AIT and CIT groups（compared with ART and CIT groups,P〈0.05 or P〈0.01）.CONCLUSION Insulin therapy has positive inotropic action on myocardial.Ageing is a reason of insulin resistance.ERK and p38 activation inhibition are the key of insulin resistance post-ECC.JNK activation is no association with insulin and ECC.