吗啡后处理对小儿心内直视手术损伤心肌的影响
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摘要
目的探讨不同剂量吗啡缺血后处理对小儿心内直视手术损伤心肌的影响及其可能机制。
方法45例单纯的房、室间隔缺损患儿随机分为3组(A组吗啡0.05㎎/㎏后处理组, B组吗啡0.1㎎/㎏后处理组,C组生理盐水对照组)。在常规体外循环主动脉阻断心内直视手术完成后,在主动脉开放前3min,3组分别将处理因素用生理盐水稀释至10ml经主动脉根部灌注。分别于麻醉后手术前(T1)、主动脉开放即刻(T2)、主动脉开放后1h(T3)、主动脉开放后3h(T4)、主动脉开放后24h(T5)、主动脉开放后72h(T6)各时点采集静脉血,测定红细胞压积(Hct)、心肌肌钙蛋白I(cTnI)、磷酸肌酸激酶同工酶(CK-MB)、丙二醛(MDA)、超氧化物歧化酶(SOD)、肿瘤坏死因子-a(TNF-a)。并比较三组术后心脏自动复跳率、心律失常发生率、正性肌力药物使用率、呼吸机应用时间(D1)、CICU病房驻留时间(D2)、术后住院时间(D3)。
结果和C组相比,(1)A、B组主动脉开放后各个时间点CK-MB、cTnI均较低(P<0.05);血清中SOD的含量较高,MDA、TNF-a的含量均较低(P<0.05)。(2)A、B组心脏自动复跳率高于C组(P<0.05);多巴胺等正性肌力药物使用率及D1、D2低于C组(P<0.05)。心律失常评分及D3无统计学意义。。
结论吗啡缺血后处理对小儿先心纠治术的心肌损伤具有一定保护作用,其作用机制可能与抗氧化及抗炎有关。
Objective : To investigate the effects and mechanism of ischemic postconditioning with morphine for myocardium preservation in children during open heart surgery.
Methods:Forty-five patients who confer congenital heart disease were randomly divided into three groups, group A(n=15, morphine 0.05mg/kg), group B (n=15, morphine 0.1mg/kg) and group C(n=15, saline).All patients’aortas were routinely clamped during cardiopulmonary bypass(CPB).3 minuts before open aorta , morphine 0.05mg/kg , morphine 0.1mg/kg and the same volume of saline were injected to patients in three groups respectively by aorta.The blood samples were taken from central venous catheter for detection of haematocrit (HCT),cardiac troponin I (cTnI), creatine kinase-MB(CK-MB),superoxide dismutase(SOD),macondialdehyde(MDA) and Tumor necrosis factor-a(TNF-a) at various time points,such as, before operation(T1),at aorta opening(T2) immediately, and at 1h (T3),3h(T4),24h(T5) , and 72h(T6) after aorta opening,respectively.We observed and recorded the rate of spontaneous resuscitation, the incidence of arrhythmia,the doses of inotropic agents,the duration of ventilation ,the days of staying in CICU and the hospitalization days after operation.
Results: The levels of cTnI,CK-MB,MDA and TNF-aat T2 and T6 (P<0.05) in group C were higher than those in group A and group B.Compared with group C,the doses of inotropic agents, the duration of ventilation ,the days of staying in CICU in group A and group B were lower and shorter (P<0.05,respectively).But the rate of spontaneous resuscitation was higher (P<0.05).The incidence of arrhythmia and the hospitalization days after operation in there groups were not different.
Conclusions: This study demonstrates that ischemic postconditioning with morphine could provide protection for injured myocardium in children during open heart surgery,and the mechanism may be associated with antioxidant and anti-inflammatory.
方法45例单纯的房、室间隔缺损患儿随机分为3组(A组吗啡0.05㎎/㎏后处理组, B组吗啡0.1㎎/㎏后处理组,C组生理盐水对照组)。在常规体外循环主动脉阻断心内直视手术完成后,在主动脉开放前3min,3组分别将处理因素用生理盐水稀释至10ml经主动脉根部灌注。分别于麻醉后手术前(T1)、主动脉开放即刻(T2)、主动脉开放后1h(T3)、主动脉开放后3h(T4)、主动脉开放后24h(T5)、主动脉开放后72h(T6)各时点采集静脉血,测定红细胞压积(Hct)、心肌肌钙蛋白I(cTnI)、磷酸肌酸激酶同工酶(CK-MB)、丙二醛(MDA)、超氧化物歧化酶(SOD)、肿瘤坏死因子-a(TNF-a)。并比较三组术后心脏自动复跳率、心律失常发生率、正性肌力药物使用率、呼吸机应用时间(D1)、CICU病房驻留时间(D2)、术后住院时间(D3)。
结果和C组相比,(1)A、B组主动脉开放后各个时间点CK-MB、cTnI均较低(P<0.05);血清中SOD的含量较高,MDA、TNF-a的含量均较低(P<0.05)。(2)A、B组心脏自动复跳率高于C组(P<0.05);多巴胺等正性肌力药物使用率及D1、D2低于C组(P<0.05)。心律失常评分及D3无统计学意义。。
结论吗啡缺血后处理对小儿先心纠治术的心肌损伤具有一定保护作用,其作用机制可能与抗氧化及抗炎有关。
Objective : To investigate the effects and mechanism of ischemic postconditioning with morphine for myocardium preservation in children during open heart surgery.
Methods:Forty-five patients who confer congenital heart disease were randomly divided into three groups, group A(n=15, morphine 0.05mg/kg), group B (n=15, morphine 0.1mg/kg) and group C(n=15, saline).All patients’aortas were routinely clamped during cardiopulmonary bypass(CPB).3 minuts before open aorta , morphine 0.05mg/kg , morphine 0.1mg/kg and the same volume of saline were injected to patients in three groups respectively by aorta.The blood samples were taken from central venous catheter for detection of haematocrit (HCT),cardiac troponin I (cTnI), creatine kinase-MB(CK-MB),superoxide dismutase(SOD),macondialdehyde(MDA) and Tumor necrosis factor-a(TNF-a) at various time points,such as, before operation(T1),at aorta opening(T2) immediately, and at 1h (T3),3h(T4),24h(T5) , and 72h(T6) after aorta opening,respectively.We observed and recorded the rate of spontaneous resuscitation, the incidence of arrhythmia,the doses of inotropic agents,the duration of ventilation ,the days of staying in CICU and the hospitalization days after operation.
Results: The levels of cTnI,CK-MB,MDA and TNF-aat T2 and T6 (P<0.05) in group C were higher than those in group A and group B.Compared with group C,the doses of inotropic agents, the duration of ventilation ,the days of staying in CICU in group A and group B were lower and shorter (P<0.05,respectively).But the rate of spontaneous resuscitation was higher (P<0.05).The incidence of arrhythmia and the hospitalization days after operation in there groups were not different.
Conclusions: This study demonstrates that ischemic postconditioning with morphine could provide protection for injured myocardium in children during open heart surgery,and the mechanism may be associated with antioxidant and anti-inflammatory.
引文
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[14]毛张凡,杜心灵,等阿片受体参与大鼠缺血后处理的心肌保护作用华中科技大学学报2007,36(5):610-3
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[54]毛张凡,杜心灵,等阿片受体参与大鼠缺血后处理的心肌保护作用华中科技大学学报2007,36(5):610-3
[55]王珏,高琴,等δ-阿片受体在缺血后处理心肌保护中的作用中国应用生理学杂志,2008;24(2):184-8
[56]王珏,高琴,等κ-阿片受体介导缺血后处理的心肌保护作用及其受体后机制浙江大学学报2007,36(1)41-7 ????
[2] Jiang X,Shi E,Nakajima Y,et al,Inducible Nitric Oxide synthase Mediates Delayed Cardioprotection Induced by Morphine In Vivo[J].Anesthesiology,2004,101(1):82.
[3] Zhao ZQ, Corvera JS, Halkos ME,et al. Inhibition of myocardial injury by、、schemic postconditioning during reperfusion: comparison with ischemic preconditioning[J]. Am J Physiol Heart Circ Physiol,2003,285 (2): 579-88.
[4] Yang XM,Proctor JB,Cui L,et a1.Multiple,brief coronary occ]usions during early reperfusion pmteet rabbit hearts by targeting cell signaling pathways[J]. Am Coil Cardiol,2004,44(5):1103—10
[5] Staat P, Rioufol G, Piot C,et al. Postconditioning the human heart [J]. Circulation, 2005, 112 (14): 2143-8.
[6] Ma XJ,Zhang XH,Li CM,et al.Effect of postconditioning on coronary blood flow velocity and endothelial function in patients with acute myocardial infarction [J].Scand Cardiovasc 2006, 40(6):327-33
[7]张雷,刘学刚,唐震,等.先天性心脏病心内直视手术中改良缺血后处理对心肌的保护作用[J].解剖与临床2009,14(3):155-8
[8] Gross ER, Hsu AK, Gross GJ. Opioid-induced cardioprotection occursvia glycogen synthase kinase beta inhibition during reperfusion in intact rat hearts [J]. Circ Res, 2004, 94 (7): 960-6.
[9] Tessier-Vetzel D, Tissier R, Waintraub X,et al. Isoflurane inhaled at the onset of reperfusion potentiates the cardioprotective effect of ischemic postconditioning through a NO-dependent mechanism [J]. Cardiovasc Pharmacol, 2006, 47 (3): 487-92.
[10] Zhao ZQ,Jakob VJ.Postconditioning:reduction of reperfusion-inducedinjury[J]. Cardiovasc Res,2006,70(2):200-21.
[11] Kin H,Zatta AJ,Jiang R,et al.Activation of opioid receptors mediates the infarct postconditionging[J].J Mol cell Cardiol,2005,38:827.
[12] Rosa ER,Gross GJ.Ligand triggers of classical preconditioning and postconditioning [J].Cardiovasc Res,2006,34(4):364-6.
[13] Weihrauch D, Krolikowski JG, Bienengraeber M, et al. Morphine enhances isoflurane-induced postconditioning against myocardial infarction: the role of phosphatidylinositol-3-kinase and opioid receptors in rabbits[J]. Anesth Analg, 2005, 101 (4): 942-9.
[14]毛张凡,杜心灵,等阿片受体参与大鼠缺血后处理的心肌保护作用华中科技大学学报2007,36(5):610-3
[15]王珏,高琴,等κ-阿片受体介导缺血后处理的心肌保护作用及其受体后机制浙江大学学报2007,36(1)41-4
[16]王珏,高琴,等δ-阿片受体在缺血后处理心肌保护中的作用中国应用生理学杂志,2008;24(2):184-8
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