改良极化液对心内直视手术心肌保护的初步研究
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摘要
目的研究改良极化液(GIK)对心内直视手术的心肌保护效果。方法 760例患者随机分为GIK组(n=379)和对照组(n=381),观察患者术后并发症发生率和死亡率,测定围术期血糖、乳酸及心肌酶学指标的变化。结果体外循环(CPB)后两组血糖水平均显著上升,在术后6 h达到峰值,但GIK组在术后6 h显著低于对照组(P<0.05);两组乳酸水平在CPB后均显著上升,GIK组在术后1 h﹑6 h和12 h显著低于对照组(P<0.05);两组血清钾离子浓度在各观察点均保持正常水平;两组术后谷草转氨酶(AST)、乳酸脱氢酶(LDH)、肌酸激酶(CK)、肌钙蛋白I(cTnI)均显著升高(P<0.05),GIK组患者AST、CK、LDH在术后24 h、48 h均低于对照组(P<0.05),cTnI在术后24 h低于对照组(P<0.05);术后一周左室射血分数明显高于对照组(P<0.01);术后突发休克、新发房颤比率显著低于对照组。结论 GIK对心内直视手术患者有明显的心肌保护作用。
Objective To investigate the effect of modified glucose-insulin-potassium solution( GIK) on the myocardial protection of the cardiac surgery patients. Methods 760 cases with the heart disease were divided randomly into two groups: modified GIK group( 379 cases) and control group( 381 cases). The early mortality and rate of complications were observed. The blood glucose,lactic acid and indexes of myocardial enzymes were measured in the perioperative period. Results The blood glucose after cardiopulmonary bypass( CPB) increased significantly in 2 groups,and reached to the peak at T5. But the level of blood glucose in GIK group was much lower than that in control group at T5( P <0.05). The lactic acid level rised dramatically after CPB,and it was markedly lower in GIK groupthan control group( P <0.05) at T4,T5 and T6. There were not significant differences of serum potassium ion in each observation point. Glutamic oxalacetic transaminase( AST),lactate dehydrogenase( LDH),creatine kinase( CK) and troponin I( CTnI) increased observably( P <0.05). But in the GIK group,the AST,CK and LDH were much lower than those in the control group at T6 and T7( P <0.05); the CTnI much less than control group at T7( P <0.05). The left ventricular ejection fraction of GIK group was much higher at 7th day after operation( P <0.01); Rates of postoperative sudden shock and atrial fibrillation( AF) of GIK group were much lower. Conclusion Modified GIK has the good myocardial protecting functions of myocardium during the open-heart surgery.
Objective To investigate the effect of modified glucose-insulin-potassium solution( GIK) on the myocardial protection of the cardiac surgery patients. Methods 760 cases with the heart disease were divided randomly into two groups: modified GIK group( 379 cases) and control group( 381 cases). The early mortality and rate of complications were observed. The blood glucose,lactic acid and indexes of myocardial enzymes were measured in the perioperative period. Results The blood glucose after cardiopulmonary bypass( CPB) increased significantly in 2 groups,and reached to the peak at T5. But the level of blood glucose in GIK group was much lower than that in control group at T5( P <0.05). The lactic acid level rised dramatically after CPB,and it was markedly lower in GIK groupthan control group( P <0.05) at T4,T5 and T6. There were not significant differences of serum potassium ion in each observation point. Glutamic oxalacetic transaminase( AST),lactate dehydrogenase( LDH),creatine kinase( CK) and troponin I( CTnI) increased observably( P <0.05). But in the GIK group,the AST,CK and LDH were much lower than those in the control group at T6 and T7( P <0.05); the CTnI much less than control group at T7( P <0.05). The left ventricular ejection fraction of GIK group was much higher at 7th day after operation( P <0.01); Rates of postoperative sudden shock and atrial fibrillation( AF) of GIK group were much lower. Conclusion Modified GIK has the good myocardial protecting functions of myocardium during the open-heart surgery.
引文
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[9]Li Y,Zhang L,Zhang L,et al.High-dose glucose-insulin-potassium has hemodynamic benefits and can improve cardiac remodeling in acute myocardial infarction treated with primary percutaneous coronary intervention:From a randomized controlled study[J].J Cardiovasc Dis Res,2010,1(3):104-109.
[10]Jovic M,Gradinac S,Lausevic-Vuk L,et al.Preconditioning with glucose-insulin-potassium solution and restoration of myocardial function during coronary surgery[J].Gen Physiol Biophys,2009,28 Spec No:262-270.
[11]Howell NJ,Ashrafian H,Drury NE,et al.Glucose-insulin-potassium reduces the incidence of low cardiac output episodes after aortic valve replacement for aortic stenosis in patients with left ventricular hypertrophy:results from the Hypertrophy,Insulin,Glucose,and Electrolytes(HINGE)trial[J].Circulation,2011,123(2):170-177.
[12]Groban L,Butterworth J,Legault C,et al.Intraoperative insulin therapy does not reduce the need for inotropic or antiarrhythmic therapy after cardiopulmonary bypass[J].J Cardiothorac Vasc Anesth,2002,16(4):405-412.
[13]Janiger JL,Cheng JW.Glucose-insulin-potassium solution for acute myocardial infarction[J].Ann Pharmacother,2002,36(6):1080-1084.
[14]Shim YH,Kweon TD,Lee JH,et al.Intravenous glucose-insulin-potassium during off-pump coronary artery bypass surgery does not reduce myocardial injury[J].Acta Anaesthesiol Scand,2006,50(8):954-961.
[15]Lorenz RA,Lorenz RM,Codd JE.Perioperative blood glucose control during adult coronary artery bypass surgery[J].AORN J,2005,81(1):126-144,147-150;quiz 151-124.
[16]Gale SC,Sicoutris C,Reilly PM,et al.Poor glycemic control is associated with increased mortality in critically ill trauma patients[J].Am Surg,2007,73(5):454-460.
[17]Su H,Sun X,Ma H,et al.Acute hyperglycemia exacerbates myocardial ischemia/reperfusion injury and blunts cardioprotective effect of GIK[J].Am J Physiol Endocrinol Metab,2007,293(3):E629-635.
[18]Gao F,Gao E,Yue TL,et al.Nitric oxide mediates the antiapoptotic effect of insulin in myocardial ischemia-reperfusion:the roles of PI3-kinase,Akt,and endothelial nitric oxide synthase phosphorylation[J].Circulation,2002,105(12):1497-1502.
[19]Apstein CS,Taegtmeyer H.Glucose-insulin-potassium in acute myocardial infarction:the time has come for a large,prospective trial[J].Circulation,1997,96(4):1074-1077.
[2]Vlasselaers D.Glucose-insulin-potassium:much more than enriched myocardial fuel[J].Circulation,2011,123(2):129-130.
[3]王新利,陈文生,金振晓,等.改良极化液对体外循环二尖瓣置换患者心脏功能的作用及其机制[J].中国体外循环杂志,2012,10(1):20-24.
[4]Fan Y,Zhang AM,Xiao YB,et al.Glucose-insulin-potassium therapy in adult patients undergoing cardiac surgery:a meta-analysis[J].Eur J Cardiothorac Surg,2011,40(1):192-199.
[5]Lawrence H.Cohn LHE.Cardiac Surgery in the Adult[M].New York:McGraw-Hill Medical Publishing Division,2003.70-136.
[6]Schipke JD,Friebe R,Gams E.Forty years of glucose-insulinpotassium(GIK)in cardiac surgery:a review of randomized,controlled trials[J].Eur J Cardiothorac Surg,2006,29(4):479-485.
[7]Ebeling P,Koivisto VA.Glucose-insulin-potassium therapy for treatment of acute myocardial infarction[J].Circulation,1998,97(22):2278-2279.
[8]Bothe W,Olschewski M,Beyersdorf F,et al.Glucose-insulinpotassium in cardiac surgery:a meta-analysis[J].Ann Thorac Surg,2004,78(5):1650-1657.
[9]Li Y,Zhang L,Zhang L,et al.High-dose glucose-insulin-potassium has hemodynamic benefits and can improve cardiac remodeling in acute myocardial infarction treated with primary percutaneous coronary intervention:From a randomized controlled study[J].J Cardiovasc Dis Res,2010,1(3):104-109.
[10]Jovic M,Gradinac S,Lausevic-Vuk L,et al.Preconditioning with glucose-insulin-potassium solution and restoration of myocardial function during coronary surgery[J].Gen Physiol Biophys,2009,28 Spec No:262-270.
[11]Howell NJ,Ashrafian H,Drury NE,et al.Glucose-insulin-potassium reduces the incidence of low cardiac output episodes after aortic valve replacement for aortic stenosis in patients with left ventricular hypertrophy:results from the Hypertrophy,Insulin,Glucose,and Electrolytes(HINGE)trial[J].Circulation,2011,123(2):170-177.
[12]Groban L,Butterworth J,Legault C,et al.Intraoperative insulin therapy does not reduce the need for inotropic or antiarrhythmic therapy after cardiopulmonary bypass[J].J Cardiothorac Vasc Anesth,2002,16(4):405-412.
[13]Janiger JL,Cheng JW.Glucose-insulin-potassium solution for acute myocardial infarction[J].Ann Pharmacother,2002,36(6):1080-1084.
[14]Shim YH,Kweon TD,Lee JH,et al.Intravenous glucose-insulin-potassium during off-pump coronary artery bypass surgery does not reduce myocardial injury[J].Acta Anaesthesiol Scand,2006,50(8):954-961.
[15]Lorenz RA,Lorenz RM,Codd JE.Perioperative blood glucose control during adult coronary artery bypass surgery[J].AORN J,2005,81(1):126-144,147-150;quiz 151-124.
[16]Gale SC,Sicoutris C,Reilly PM,et al.Poor glycemic control is associated with increased mortality in critically ill trauma patients[J].Am Surg,2007,73(5):454-460.
[17]Su H,Sun X,Ma H,et al.Acute hyperglycemia exacerbates myocardial ischemia/reperfusion injury and blunts cardioprotective effect of GIK[J].Am J Physiol Endocrinol Metab,2007,293(3):E629-635.
[18]Gao F,Gao E,Yue TL,et al.Nitric oxide mediates the antiapoptotic effect of insulin in myocardial ischemia-reperfusion:the roles of PI3-kinase,Akt,and endothelial nitric oxide synthase phosphorylation[J].Circulation,2002,105(12):1497-1502.
[19]Apstein CS,Taegtmeyer H.Glucose-insulin-potassium in acute myocardial infarction:the time has come for a large,prospective trial[J].Circulation,1997,96(4):1074-1077.