远程缺血预处理对全胸腔镜体外循环手术的肺保护作用

远程缺血预处理对全胸腔镜体外循环手术的肺保护作用

目的探讨直接阻断股动脉进行下肢缺血预处理对全胸腔镜体外循环手术患者术后肺功能的影响。方法选取2015年3月～2016年5月在本院实施胸腔镜下体外循环手术的60例先天性心脏病患者作为研究对象，随机分为研究组（R 组）和对照组（C组），各30例。游离股动、静脉后，C组直接插管建立体外循环；R组夹闭股动脉3 min，开放3 min，如此三个循环后与C组采用相同的方法建立体外循环。两组均采用右侧胸壁三孔入路，在第三、四和六肋间切取三个1.5～2.0 cm的孔状切口，在胸腔镜下显露术野完成手术。于麻醉诱导插管完毕5 min（T0）、体外循环停机2 h（T1）、体外循环停机12 h（T2）和体外循环停机24 h（T3）采集桡动脉血进行血气分析，记录氧合指数；采集外周静脉血以酶联免疫吸附法（ELISA）检测血浆可溶性晚期糖基化终末产物受体（RAGE）含量。结果60例患者均治愈出院，两组术后的机械通气时间比较，差异无统计学意义（P>0.05）。两组T0时的氧合指数比较，差异无统计学意义（P>0.05）。两组T1～T3时的氧合指数均降低，R组T1～T3时的氧合指数高于C组同时间段，差异有统计学意义（P＜0.05）。两组T0时的血浆RAGE水平比较，差异无统计学意义（P>0.05）。两组T1～T3时的血浆RAGE水平均增高，R组T1～T3时的血浆RAGE水平显著低于C组同时间段，差异有统计学意义（P＜0.05）。结论直接阻断股动脉进行下肢缺血预处理，可减轻全胸腔镜体外循环手术肺损伤程度，具有一定肺功能保护作用。

[Abstract]Objective To investigate the effects of remote ischemic preconditioning （RIPC）by direct femoral artery occlusion on lung function of patients undergoing totally thoracoscopic cardiac surgery with cardiopulmonary bypass（CPB）.Methods 60 patients with congenital heart disease underwent thoracoscopic cardiac surgery with CPB from March 2015 to May 2016 were selected and divided into the research group （group R）and the control group （group C），30 cases in each group.After the femoral artery and vein were dissociated，group C was established CPB through the intubation directly.Group R was clamped and closed femoral artery 3 min，then open 3 min，After three cycles，the same method in the group C was used to establish CPB.Through three hole shape incision at the right chest wall，that each was 1.5 to 2.0 cm long in the third，fourth and sixth intercostals surgical field was revealed totally by thoracoscope to complete the operation.The radial artery blood was collected after tracheal intubation for 5 min （T0），after cessation of CPB for 2 hours （T1），after cessation of CPB 12 hours （T2）and after cessation of CPB 24 hours （T3）.Oxygenation index was recorded by blood gas analysis.The receptor of advanced glycation end-products （RAGE）level was detected by enzyme linked immunosorbent assay （ELISA）.Results 60 patients were all cured.There was no significant difference in the mechanical ventilation time between the two groups （P>0.05）.There was no significant difference in oxygenation index between the two groups in T0 point （P>0.05）.The oxygenation index of the two groups of T1-T3 were all decreased.The oxygenation index of group R in T1-T3 points was higher than that of group C at the same time，with significant difference

（P＜0.05）.There was no significant difference in the level of RAGE between the two groups in T0 point （P>0.05）.The level of plasma RAGE were increased in the two groups in T1-T3 points.The level of plasma RAGE of group R in T1-T3 points was lower than that of group C at the same time，with significant difference （P＜0.05）.Conclusion RIPC by femoral artery occlusion can decrease the level of RAGE in patients underwent thoracoscopic cardiac surgery with CPB and has lung protective effects.[Key words]Remote ischemic preconditioning；Thoracoscope；Cardiopulmonary bypass；Lung protection

全胸腔镜体外循环手术无需正中开胸，仅在右胸肋间隙打孔，通过股动静脉插管建立体外循环（cardiopulmonary bypass，CPB），在电视胸腔镜下显露术野完成手术操作，是心脏外科手术微创化发展的重要方向，在临床中的应用也越来越多。术后肺功能不全是CPB心脏手术死亡率增加的主要原因之一[1]，CPB相关炎症反应与术后肺损伤关系密切。适当的肺保护措施，对于改善术后肺功能，减少术后肺部并发症十分必要。本研究利用胸腔镜心脏手术需游离股动静脉建立CPB的特点，通过直接阻断股动脉，进行下肢缺血预处理，观察其对术后机械通气、氧合指数（PaO2/FiO2）和血浆晚期糖基化终末产物受体（the receptor of advanced glycation end-products，RAGE）的影响，探讨下肢远程缺血预处理（remote ischemia pre-conditioning，RIPC）对全胸腔镜体外循环术后肺功能的影响。

1资料与方法

1.1一般资料

选取2015年3月～2016年5月在我院实施胸腔镜下体外循环手术的60例先天性心脏病患者作为研究对象，其中男15例，女45例；年龄14～50岁；体重39～67 kg；左心室射血分数60%～70%；心功能均为Ⅰ级；房间隔缺损修补43例，室间隔缺损修补14例，部分型房室隔缺损矫治2例，三尖瓣成形1例。所有患者均签署知情同意书。排除标准：年龄50岁、射血分数0.05）（表1），具有可比性。本研究经我院医学伦理委员会审核批准。

1.2手术方法

两组的麻醉和体外循环方法相同，均采用单腔气管插管，静吸复合麻醉，并行循环期间低潮气量通气。麻醉达成后，患者取仰卧位，右侧胸壁垫高15°，右臂抬高，右前臂悬吊于麻醉头架。于右肩胛角和心尖部胸壁粘贴除颤电极片，接除颤仪备用。经右侧胸壁三孔入路，在胸骨旁第三肋间、腋中线第四肋间和腋前线第六肋间切取三个1.5～2.0 cm大小的孔状切口，分别为右手操作孔、左手操作孔和胸腔镜孔。解剖游离股动静脉，C组直接股动、静脉插管建立CPB，R组以血管阻断钳夹闭股动脉3 min，然后开放3 min，如此三个循环后再插管建立CPB。采用双级股静脉插管（康心，16～26Fr），头端位于上腔静脉内，第二级侧孔位于下腔静脉。上、下腔静脉套10号线（慕丝）阻断。主动脉根部缝荷包，安放加长灌注针，经左手操作孔安放Chitwood主动脉阻断钳，主动脉根部灌注