不同瘤夾時(shí)間對(duì)顱內(nèi)動(dòng)脈瘤模型制作中失血性休克影響

方志成,張浩明,鄭　翔,閔　利,李海濤

(湖北醫(yī)藥學(xué)院附屬太和醫(yī)院， 湖北 十堰 442000)

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不同瘤夾時(shí)間對(duì)顱內(nèi)動(dòng)脈瘤模型制作中失血性休克影響

方志成,張浩明,鄭翔,閔利,李海濤

(湖北醫(yī)藥學(xué)院附屬太和醫(yī)院， 湖北 十堰 442000)

[摘要]目的觀察不同瘤夾時(shí)間對(duì)顱內(nèi)動(dòng)脈瘤模型制作期間失血性休克的影響。方法將80只日本大耳白兔隨機(jī)分為A、B、C、D 4組，每組20只，除A組外，B、C、D組采用改良胰彈性蛋白酶誘導(dǎo)動(dòng)脈瘤方法制作動(dòng)脈瘤模型，瘤夾時(shí)間分別為20，25，30 min，瘤夾松開(kāi)即刻和術(shù)后1 h監(jiān)測(cè)動(dòng)脈血?dú)夥治黾澳δ?，評(píng)估失血性休克和動(dòng)物自身凝血功能變化；頸總動(dòng)脈多普勒超聲觀察動(dòng)脈瘤形態(tài)，測(cè)定血流速度，評(píng)估不同瘤夾時(shí)間對(duì)動(dòng)脈瘤模型成瘤的影響。結(jié)果B、C組術(shù)中和術(shù)后血?dú)夥治鰌H值明顯低于A組和D組(P均<0.05 )，堿剩余和乳酸水平明顯高于A組和D組(P均<0.05 )。B、C、D組血漿凝血酶原時(shí)間、部分活化凝血酶原時(shí)間及凝血時(shí)間均明顯短于A組(P均<0.05 )，B、C組間比較差異無(wú)統(tǒng)計(jì)學(xué)意義，D組明顯短于B、C組(P均<0.05 )，各組組內(nèi)術(shù)中和術(shù)后比較差異無(wú)統(tǒng)計(jì)學(xué)意義。A、B、C、D 4組分別有0,8,6,2只兔發(fā)生失血性休克，D組失血性休克發(fā)生比例明顯低于B、C組(P均<0.05 )。3周后彩色多普勒超聲顯示B、C、D組頸總動(dòng)脈瘤夾部位血管內(nèi)徑均明顯大于A組(P均<0.05 )，近心端和遠(yuǎn)心端局部瘤樣擴(kuò)張血管血流速度均明顯高于A組(P均<0.05 )，且近心端局部瘤樣擴(kuò)張血管血流速度明顯高于遠(yuǎn)心端(P均<0.05 )；B、C、D組3組間比較差異均無(wú)統(tǒng)計(jì)學(xué)意義。結(jié)論延長(zhǎng)瘤夾時(shí)間可有效預(yù)防動(dòng)物動(dòng)脈瘤模型失血性休克發(fā)生，減少死亡，其機(jī)制可能與促進(jìn)血液高凝狀態(tài)有關(guān)。

[關(guān)鍵詞]顱內(nèi)動(dòng)脈瘤；失血性休克

改良胰彈性蛋白酶誘導(dǎo)顱內(nèi)動(dòng)脈瘤方法是制作顱內(nèi)動(dòng)脈瘤動(dòng)物模型的主要方法，組織學(xué)和病理學(xué)檢查結(jié)果已證明此種方法成瘤的成功率高，但創(chuàng)傷大、并發(fā)癥多，尤其是術(shù)中失血性休克發(fā)生率高，導(dǎo)致動(dòng)物死亡率高[1-3]。故如何采取正確措施預(yù)防和處理失血性休克是動(dòng)脈瘤模型制作的關(guān)鍵。本研究旨在探討不同瘤夾時(shí)間對(duì)動(dòng)脈瘤模型制作時(shí)失血性休克發(fā)生率的影響，以提高動(dòng)脈瘤模型制作的成功率，現(xiàn)報(bào)道如下。

1實(shí)驗(yàn)資料

1.1實(shí)驗(yàn)動(dòng)物日本大耳白兔80只，3～6月齡，體質(zhì)量2～2.5 kg，由湖北醫(yī)藥學(xué)院實(shí)驗(yàn)動(dòng)物中心提供，動(dòng)物合格證號(hào)：NO.42000900000184，雌雄不限，所有動(dòng)物自由飲水、進(jìn)食。

1.2分組與造模將80只大耳白兔隨機(jī)分為A、B、C、D 4組，每組20只。B、C、D組采用改良胰彈性蛋白酶誘導(dǎo)方法制作顱內(nèi)動(dòng)脈瘤模型，經(jīng)兔耳緣靜脈給予10%烏拉坦行靜脈麻醉，沿頸部正中切口，分離筋膜，暴露氣管，在氣管右側(cè)游離出右頸總動(dòng)脈，繼續(xù)向近心端方向游離直至右頸總動(dòng)脈與右鎖骨下動(dòng)脈分叉處，在距右頸總動(dòng)脈與右鎖骨下動(dòng)脈分叉上方2.5 cm處，結(jié)扎右頸總動(dòng)脈，然后以動(dòng)脈瘤夾夾閉右頸總動(dòng)脈與右鎖骨下動(dòng)脈分叉，瘤夾時(shí)間分別為20，25，30 min，A組不夾閉。在距右頸總動(dòng)脈與右鎖骨下動(dòng)脈分叉上方1.5 cm處，用26 G靜脈留置針(內(nèi)徑0.6 mm，長(zhǎng)度1.5 cm，流量15 mL/min)穿刺右頸總動(dòng)脈并注入75 IU豬胰彈性蛋白酶，最后松開(kāi)右頸總動(dòng)脈遠(yuǎn)心端結(jié)扎，并移除動(dòng)脈瘤夾。

1.3動(dòng)脈血?dú)夥治鼋?jīng)右股動(dòng)脈抽取動(dòng)脈血2 mL，測(cè)定瘤夾松開(kāi)即刻及術(shù)后1 h的pH值、堿剩余(BE)和血乳酸(LA)水平，計(jì)算平均值，評(píng)估術(shù)中失血、組織灌注情況。失血性休克診斷標(biāo)準(zhǔn)：動(dòng)物模型制作中出現(xiàn)大失血，血?dú)夥治鲇袊?yán)重代謝性酸中毒，血LA水平高于2 mmol/L。

1.4凝血功能檢測(cè)經(jīng)右股動(dòng)脈抽取動(dòng)脈血2 mL，測(cè)定瘤夾松開(kāi)即刻及術(shù)后1 h 血漿凝血酶原時(shí)間(PT)、部分活化凝血酶原時(shí)間(APTT)及凝血時(shí)間(TT)，計(jì)算平均值，評(píng)估凝血功能情況。

1.5動(dòng)脈瘤形成評(píng)估實(shí)驗(yàn)后3周行彩色多普勒超聲檢查，評(píng)估右頸總動(dòng)脈動(dòng)脈瘤形成情況及血流速度。

2結(jié)果

2.1失血性休克發(fā)生情況A組無(wú)一只實(shí)驗(yàn)動(dòng)物發(fā)生失血性休克，B、C、D組分別發(fā)生失血性休克8，6，2只，經(jīng)過(guò)局部加壓止血、持續(xù)靜脈輸注生理鹽水等搶救措施，3組分別有2,3,1只死亡，其余全部存活。D組失血性休克發(fā)生比例明顯低于B、C組(P均<0.05)。所有發(fā)生失血性休克實(shí)驗(yàn)動(dòng)物術(shù)后進(jìn)食、自由活動(dòng)需2 ～ 3 d完全恢復(fù)，較未發(fā)生失血性休克動(dòng)物恢復(fù)稍慢。

2.2動(dòng)脈血?dú)夥治龀鼳組外，動(dòng)物模型制作期間，B、C組術(shù)中和術(shù)后血?dú)夥治鰌H值明顯低于A組和D組(P均<0.05)，BE和血LA水平明顯高于A組和D組(P均<0.05)，D組和A組比較差異無(wú)統(tǒng)計(jì)學(xué)意義(P均>0.05)。見(jiàn)表1。

2.3凝血功能B、C、D組血漿PT、 APTT及TT均明顯短于A組(P均<0.05 )，B、C組間比較差異無(wú)統(tǒng)計(jì)學(xué)意義，D組明顯短于B、C組(P均<0.05 )，各組組內(nèi)以上指標(biāo)術(shù)中和術(shù)后比較差異均無(wú)統(tǒng)計(jì)學(xué)意義(P均>0.05)。見(jiàn)表2。

表1　各組動(dòng)脈血?dú)夥治霰容^±s)

注：①與A組和D組比較，P<0.05。

2.4顱內(nèi)動(dòng)脈瘤制作情況A組無(wú)死亡動(dòng)物，B、C、D組實(shí)驗(yàn)動(dòng)物分別死亡2,3,1只，其余全部存活。3周后彩色多普勒超聲顯示B、C、D組頸總動(dòng)脈瘤夾部位血管內(nèi)徑均明顯大于A組(P均<0.05)，近心端和遠(yuǎn)心端局部瘤樣擴(kuò)張血管血流速度均明顯高于A組(P均<0.05 )，且近心端局部瘤樣擴(kuò)張血管血流速度明顯高于遠(yuǎn)心端(P均<0.05 )；B、C、D組3組間比較差異均無(wú)統(tǒng)計(jì)學(xué)意義。見(jiàn)表3。各組頸總動(dòng)脈瘤夾部位彩色多普勒超聲表現(xiàn)見(jiàn)圖1～4。

3討論

顱內(nèi)動(dòng)脈瘤動(dòng)物模型是研究顱內(nèi)動(dòng)脈瘤基礎(chǔ)與臨床診療的基礎(chǔ)。動(dòng)脈瘤模型制作因需在距右頸總動(dòng)脈與右鎖骨下動(dòng)脈分叉部位上方約1.5 cm穿刺右頸總動(dòng)脈，注射胰蛋白酶破壞動(dòng)脈彈力層，在拔出穿刺針后，穿刺口極易發(fā)生大失血而導(dǎo)致失血性休克,加上兔對(duì)失血耐受性很差，故動(dòng)物死亡率極高，影響模型制作成功率。盡管有研究者采取最小號(hào)穿刺針、穿刺口局部顯微鏡下縫合血管，但并不能降低失血性休克發(fā)生率[4-5]。本研究從增加瘤夾時(shí)間加強(qiáng)實(shí)驗(yàn)動(dòng)物自身凝血功能角度探討了該方法對(duì)失血性休克發(fā)生的影響。

表2　各組凝血功能比較

注：①與A組比較，P<0.05；②與D組比較，P<0.05。

表3　4組頸總動(dòng)脈瘤夾部位血管內(nèi)徑、近心端和遠(yuǎn)心端

注：①與A組比較，P<0.05。

圖1　A組頸總動(dòng)脈瘤夾部位超聲表現(xiàn)

圖2　B組頸總動(dòng)脈瘤夾部位超聲表現(xiàn)

圖3　C組頸總動(dòng)脈瘤夾部位超聲表現(xiàn)

圖4　D組頸總動(dòng)脈瘤夾部位超聲表現(xiàn)

本研究結(jié)果顯示，B、C組術(shù)中和術(shù)后血?dú)夥治鰌H值明顯低于A組和D組，堿剩余和乳酸水平明顯高于A組和D組。B、C、D組血漿凝血酶原時(shí)間、部分活化凝血酶原時(shí)間及凝血時(shí)間均明顯短于A組，B、C組間比較差異無(wú)統(tǒng)計(jì)學(xué)意義，D組明顯短于B、C組，各組組間上述指標(biāo)術(shù)中和術(shù)后比較差異無(wú)統(tǒng)計(jì)學(xué)意義。A、B、C、D 4組分別有0,8,6,2只兔發(fā)生失血性休克，D組失血性休克發(fā)生比例明顯低于B、C組。3周后彩色多普勒超聲顯示B、C、D組頸總動(dòng)脈瘤夾部位血管內(nèi)徑均明顯大于A組，近心端和遠(yuǎn)心端局部瘤樣擴(kuò)張血管血流速度均明顯高于A組，且近心端局部瘤樣擴(kuò)張血管血流速度明顯高于遠(yuǎn)心端；B、C、D組3組間比較差異均無(wú)統(tǒng)計(jì)學(xué)意義。提示延長(zhǎng)瘤夾時(shí)間短期內(nèi)對(duì)顱內(nèi)動(dòng)脈瘤形成無(wú)明顯不良影響，而失血性休克發(fā)生率明顯降低，實(shí)驗(yàn)動(dòng)物自身凝血功能呈現(xiàn)高凝狀態(tài)。分析原因可能在于：①調(diào)節(jié)自身凝血功能。穿刺口存在、局部血管壁損傷激發(fā)體內(nèi)凝血功能，加上瘤夾期間，右頸總動(dòng)脈遠(yuǎn)心端血流量急劇減少，血流緩慢，凝血功能亢進(jìn)，且瘤夾時(shí)間長(zhǎng)，右頸總動(dòng)脈遠(yuǎn)心端血流量、局部血流速度異常情況更為突出，凝血功能亢進(jìn)更明顯，故可降低失血性休克發(fā)生率[6-8]。②促進(jìn)自身穿刺口愈合。延長(zhǎng)瘤夾時(shí)間，夾閉遠(yuǎn)端血流減少，血流速度減慢，對(duì)靜脈留置針穿刺口沖擊力量減小，加上凝血物質(zhì)激活，局部凝血酶原形成，十分有利于穿刺口愈合[9-10]。

綜上所述，延長(zhǎng)瘤夾時(shí)間，通過(guò)促進(jìn)自身凝血功能，可有效預(yù)防動(dòng)脈瘤模型制作期間失血性休克發(fā)生，降低死亡率，同時(shí)不影響動(dòng)脈瘤成瘤成功率，術(shù)后動(dòng)物恢復(fù)良好，未遺留肢體癱瘓等并發(fā)癥，可在臨床推廣應(yīng)用。但本研究有一定局限性：①盡管采取統(tǒng)一、內(nèi)徑最小的靜脈留置針穿刺右頸總動(dòng)脈，但穿刺角度不能完全一致，這可能會(huì)導(dǎo)致穿刺口大小不一，失血量多少不一，穿刺針與右頸總動(dòng)脈之間夾角越大，失血越多，失血性休克的發(fā)生概率也越大。②同一哺乳動(dòng)物物種，動(dòng)物自身凝血功能差異性比較大，可能會(huì)干擾研究結(jié)果。③研究動(dòng)物數(shù)量少，瘤夾時(shí)間多長(zhǎng)失血性休克的發(fā)生率最低有待確定。④發(fā)生失血性休克時(shí)，也采用局部加壓止血方法，因此，傷口止血不單純依靠動(dòng)物自身凝血，機(jī)械性外力作用也能發(fā)揮一定作用，而這種機(jī)械性力量大小、壓迫時(shí)間長(zhǎng)短無(wú)法做到一致[11-12]，是否也會(huì)影響實(shí)驗(yàn)結(jié)果需要進(jìn)一步研究。

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Influence of different tumor clipping time on the hemorrhagic shock in the production of intracranial aneurysm model

FANG Zhicheng, ZHANG Haoming, ZHENG Xiang, MIN Li, LI Haitao

(Taihe Hospital Affiliated to Hubei University of Medicine, Shiyan 442000, Hubei, China)

Abstract:Objective It is to observe the influence of different tumor clipping time on the hemorrhagic shock during the production of intracranial aneurysm model. Methods 80 Japanese big ear rabbits were randomly divided into group A, group B, group C and group D, 20 cases in each group. Except group A, the aneurysm model were produced by modified pancreatic elastase induced aneurysm model method with tumor clipping time as 20, 25, 30 min in group B, C, D respectively. The arterial blood gas analysis and blood coagulation function were observed at tumor clamp loosen immediate and postoperative 1 h, the changes of hemorrhagic shock and animal blood coagulation function were evaluated; the aneurysm shape was observed and the blood flow velocity was detected by carotid artery Doppler ultrasound, the influence of different tumor clipping time on aneurysm model into a tumor was evaluated. Results The blood gas analysis of pH values of intraoperative and postoperative in Group B and C were lower than those in group A and D (all P<0.05), the residual alkali and lactic acid level were significantly higher than those in group A and D (all P<0.05). The plasma prothrombin time, partial activation prothrombin time and clotting time in group B, C, D were significantly shorter than those in group A (all P<0.05), there was no significant difference between group B and C, and which in group D was obviously shorter than those in group B and C (all P<0.05); there was no significant difference between intraoperative and postoperative in all groups. There were 0, 8, 6, 2 rabbits with hemorrhagic shock in group A, B, C and D respectively, the incidence of hemorrhagic shock in group D were significantly lower than those in group B and C (all P<0.05). After three weeks, color Doppler ultrasonography showed that the blood vessel diameter of carotid aneurysm clip part in group B, C and D were significantly greater than that in group A (all P<0.05); the blood flow velocity in blood vessels of local tumor like dilation in group B, C and D were significantly higher than those in group A (all P<0.05), and which of near heart side was significantly higher than that of far heart side (P<0.05), there was no significant difference among 3 groups. Conclusion Extension of tumor clipping time can effectively prevent the occurrence of hemorrhagic shock in aneurysm model and reduce the mortality rate, which may be related to the promotion of the high blood coagulation state.

Key words:intracranial aneurysm; hemorrhagic shock

[收稿日期]2015-07-14

[中圖分類號(hào)]R-332

[文獻(xiàn)標(biāo)識(shí)碼]A

[文章編號(hào)]1008-8849(2016)06-0574-04

doi:10.3969/j.issn.1008-8849.2016.06.002

[基金項(xiàng)目]湖北省自然科學(xué)基金面上項(xiàng)目(2014CFB314)

[通信作者]張浩明，E-mial：13593751009@163.com

[作者簡(jiǎn)介]方志成，男，主任醫(yī)師，主要從事危重病研究工作。