肺動(dòng)脈灌注肺保護(hù)液對(duì)體外循環(huán)相關(guān)性炎癥反應(yīng)影響的實(shí)驗(yàn)研究

林柏松,張秀和,張柏民,姜亦忠,李 哲

(吉林大學(xué)中日聯(lián)誼醫(yī)院心臟外科,吉林長(zhǎng)春 130033)

肺動(dòng)脈灌注肺保護(hù)液對(duì)體外循環(huán)相關(guān)性炎癥反應(yīng)影響的實(shí)驗(yàn)研究

林柏松,張秀和,張柏民,姜亦忠,李 哲

(吉林大學(xué)中日聯(lián)誼醫(yī)院心臟外科,吉林長(zhǎng)春 130033)

目的探討肺動(dòng)脈灌注低溫肺保護(hù)液對(duì)體外循環(huán)相關(guān)性炎癥反應(yīng)的影響。方法將20只雜種犬隨機(jī)分為對(duì)照組和實(shí)驗(yàn)組。實(shí)驗(yàn)組在阻斷升主動(dòng)脈后經(jīng)肺動(dòng)脈灌注低溫肺保護(hù)液,對(duì)照組則行常規(guī)體外循環(huán)、不灌注肺保護(hù)液,分別于誘導(dǎo)前(T1),轉(zhuǎn)流1h(T2),停機(jī)1h(T3),停機(jī)2h(T4)抽取動(dòng)脈血,測(cè)定血漿腫瘤壞死因子α(TNF-α)、白細(xì)胞介素-6(IL-6)和白細(xì)胞介素-10(IL-10)濃度。結(jié)果兩組實(shí)驗(yàn)犬血漿TNF-α、IL-6和IL-10的濃度,在T2-T4各時(shí)點(diǎn)與體外循環(huán)前比較均明顯增加(P＜0.05);T2-T4時(shí)點(diǎn)實(shí)驗(yàn)組血漿TNF-α和IL-6濃度明顯低于對(duì)照組(P＜0.01),IL-10濃度明顯高于對(duì)照組(P＜0.05)。結(jié)論體外循環(huán)期間經(jīng)肺動(dòng)脈灌注低溫肺保護(hù)液可抑制體外循環(huán)過(guò)程中促炎細(xì)胞因子TNF-α和IL-6的釋放,促進(jìn)抗炎細(xì)胞因子IL-10的釋放,從而減輕體外循環(huán)引起的全身炎癥反應(yīng)。

肺保護(hù)液;體外循環(huán);炎癥反應(yīng)

(Chin J Lab Diagn,2010,14:0194)

體外循環(huán)的機(jī)械剪切、血液與體外循環(huán)的人工材料表面接觸,可啟動(dòng)并激活中性粒細(xì)胞,引起全身炎癥反應(yīng)綜合征[1-4],進(jìn)一步引起心、肺等重要器官的損傷,其已成為術(shù)后死亡的主要原因之一。本研究使用含抗炎劑及肺保護(hù)劑的低溫肺動(dòng)脈灌注液,觀察其對(duì)體外循環(huán)相關(guān)性炎癥反應(yīng)的抑制作用。

1 材料與方法

1.1 實(shí)驗(yàn)分組 雜種犬20只,體重17-22 kg(19.8±0.7 kg),隨機(jī)分為 2組,每組10只,實(shí)驗(yàn)組:肺動(dòng)脈灌注低溫肺保護(hù)液,對(duì)照組不經(jīng)肺動(dòng)脈灌注肺保護(hù)液。

1.2 材料 冷晶體心肌保護(hù)液為St.ThomasⅡ停跳液。肺保護(hù)液:氧合機(jī)器血250 ml,葡萄糖25 g,胰島素4 U,氯化鉀0.75 g,甘露醇1.25 g,NaH2PO40.3 g,低分子右旋糖苷15 g,還原型谷胱苷肽200 mg,L-精氨酸1.25 g,山莨菪堿30 mg,抑肽酶500 000 kIU,沐舒坦30 mg,加乳酸林格氏液至500 ml。

1.3 方法 實(shí)驗(yàn)犬以苯巴比妥鈉25 mg?kg-1誘導(dǎo)麻醉后,氣管內(nèi)插管,人工呼吸機(jī)容量控制模式輔助呼吸,吸入氧濃度100%(FiO2=1.0),靜注潘可羅寧0.3 μ g?kg-1,芬太尼 100 μ g?kg-1,靜點(diǎn)芬太尼(50 μ g?kg-1?h-1)維持麻醉。心電監(jiān)護(hù),右側(cè)股動(dòng)脈置入測(cè)壓管,股靜脈置入Swan-ganz導(dǎo)管。胸部正中切口,顯露心臟。肝素化,經(jīng)升主動(dòng)脈插入動(dòng)脈管,經(jīng)上、下腔靜脈插入靜脈管,建立體外循環(huán)。在鼻溫降至25℃時(shí)阻斷上、下腔靜脈及升主動(dòng)脈,經(jīng)主動(dòng)脈根部灌注冷晶體心肌停跳液,實(shí)驗(yàn)組同時(shí)經(jīng)肺動(dòng)脈根部灌注肺保護(hù)液,首次30 ml?kg-1體重,灌注壓30 mmHg(4.0kPa),每30 min以首量的1/2重復(fù)灌注,灌注液通過(guò)左心房回收,對(duì)照組未行肺灌注。心臟阻斷90 min,開放上、下腔靜脈、升主動(dòng)脈、左肺動(dòng)脈。當(dāng)鼻溫達(dá)到36.5℃、心跳有力、平均動(dòng)脈壓在60 mmHg(8.0 kPa)時(shí),停體外循環(huán)機(jī)。

1.4 檢測(cè)指標(biāo)

分別于誘導(dǎo)前(T1),轉(zhuǎn)流1 h(T2),停機(jī)1 h(T3),停機(jī)2 h(T4)四個(gè)時(shí)點(diǎn)抽取動(dòng)脈血3 ml,用酶聯(lián)免疫吸附(ELISA)法測(cè)定血漿TNF-α、IL-6及IL-10的濃度。為排除體外循環(huán)時(shí)血液稀釋對(duì)測(cè)定值的影響,所有數(shù)據(jù)都按下列公式進(jìn)行矯正,矯正值=實(shí)測(cè)值×(術(shù)前HCT/采樣時(shí)HCT)。

1.5 統(tǒng)計(jì)學(xué)分析

以SPSS11.0軟件對(duì)兩組所有數(shù)據(jù)均進(jìn)行統(tǒng)計(jì)學(xué)處理,組間比較使用 t檢驗(yàn),結(jié)果以±s表示,P＜0.05時(shí)認(rèn)為有顯著性差異。

2 結(jié)果

實(shí)驗(yàn)組與對(duì)照組的組內(nèi)比較TNF-α、IL-6和IL-10的濃度在 T2、T3、T4時(shí)點(diǎn)均明顯高于T1時(shí)點(diǎn)(P＜0.05);其中實(shí)驗(yàn)組的TNF-α和IL-6的濃度在T4時(shí)點(diǎn)明顯回落但仍高于手術(shù)前水平(P＜0.05)。兩組間比較,TNF-α、IL-6和IL-10的濃度在麻醉前無(wú)明顯差異,但在T2、T3、T4各時(shí)點(diǎn)實(shí)驗(yàn)組TNF-α和IL-6的濃度明顯低于對(duì)照組(P＜0.01),而IL-10濃度明顯高于對(duì)照組(P＜0.05),見表1。

表1 實(shí)驗(yàn)組與對(duì)照組的不同時(shí)間點(diǎn)TNF-α IL-6、IL-10結(jié)果

3 討論

體外循環(huán)(CPB)經(jīng)數(shù)十年的探索與改進(jìn),技術(shù)日益成熟,其安全性得以明顯增加,使得重癥和復(fù)雜心臟直視手術(shù)死亡率和并發(fā)癥明顯下降。但CPB后的全身炎癥反應(yīng)仍然是心血管外科患者的一個(gè)主要并發(fā)癥,已成為目前心血管外科的重要研究課題。

鑒于肺臟缺血-再灌注損傷和CPB觸發(fā)的炎癥反應(yīng)是造成CPB后肺功能嚴(yán)重受損的主要原因,本研究經(jīng)肺動(dòng)脈灌注含氧合血及抗炎劑的保護(hù)液,理論上既減輕了肺臟缺血-再灌注損傷又減輕了肺臟的局部炎癥反應(yīng)。本研究觀察到實(shí)驗(yàn)組TNF-α和IL-6雖然在體外循環(huán)期間及體外循環(huán)后都有明顯增加,但各時(shí)點(diǎn)值均明顯低于對(duì)照組(P＜0.01);實(shí)驗(yàn)組抗炎細(xì)胞因子IL-10的值在體外循環(huán)期間及體外循環(huán)后各時(shí)點(diǎn)明顯高于對(duì)照組(P＜0.05),這說(shuō)明經(jīng)肺動(dòng)脈灌注低溫肺保護(hù)液不僅可以有效抑制體外循環(huán)期間促炎細(xì)胞因子TNF-α和IL-6的釋放,還促進(jìn)抗炎細(xì)胞因子IL-10的釋放,從而起到調(diào)節(jié)促炎因子和抗炎因子間的平衡的作用,可以下調(diào)體外循環(huán)期間的急性期反應(yīng),有效降低由體外循環(huán)引發(fā)的全身炎癥反應(yīng)。經(jīng)肺動(dòng)脈灌注低溫肺保護(hù)液在體外循環(huán)中調(diào)節(jié)炎性細(xì)胞因子釋放的作用可能與其抑制體內(nèi)廣泛分布的絲氨酸蛋白酶活性、抑制血細(xì)胞激活和白細(xì)胞跨內(nèi)皮遷移、減少炎細(xì)胞浸潤(rùn)及組織毒性物質(zhì)釋放等作用有關(guān)。

總之,本研究結(jié)果提示,經(jīng)肺動(dòng)脈灌注低溫肺保護(hù)液能夠抑制體外循環(huán)手術(shù)引起的促炎細(xì)胞因子TNF-α和IL-6以及促進(jìn)抗炎細(xì)胞因子IL-10的釋放,調(diào)節(jié)促炎因子和抗炎因子之間的平衡,減輕體外循環(huán)引起的炎癥反應(yīng)。

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The effect of pulmonary artery perfusion with hypothermic lung-protective solution on cardio-pulmonary bypass relative in-flammatory response

LIN Bai-song,ZHANG Xiu-he,ZHANG Bai-min,et al.(China-Japan Union Hospital of Jilin University,Changchun130033,China)

ObjectiveTo determine the effect of pulmonary perfusion with hypothermic protective solution on inflammatory response during cardiopulmonary bypass(CPB).MethodsTwenty adult mongrel dogs were randomly divided into two groups.During CPB,the study groupwere perfused with4℃protective solution,control groupwere not.The blood samples were collected at the same time point of preoperation(T1),60 min of cardiopulmonary bypass(T2),and 1 hour(T3),2 hour(T4)after cardiopulmonary bypass.Plasma concentration of IL-6,IL-10,TNF-αwere detected with ELISA.ResultsThe plasma levels of IL-6,IL-10,TNF-α in each group were significantly increased at T2,T3,T4.The plasma levels of IL-6 and TNF-α in study groupwere significantly lower than control group atT2,T3,T4.The plasma levels of IL-10were significantly higher than control group at T2,T3,T4.ConclusionThis study demonstrated that pulmonary artery perfusion with the hypothermic protective solution can obviously reduce cardio-pulmonary bypass relative inflammatory response.

Pulmonary artery Perfusion;Cardiopulmonary bypass;Inflammatory response

R332;R654.1

A

1007-4287(2010)02-0194-02

吉林省科技廳科技發(fā)展計(jì)劃基金資助課題(200505157)

2009-05-17)