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  本文選題：二尖瓣置換術　切入點：胰島素　出處：《新鄉(xiāng)醫(yī)學院》2014年碩士論文

【摘要】：背景體外循環(huán)下行二尖瓣置換術是最常見的心內(nèi)直視手術之一,是目前公認的治療二尖瓣膜病變最有效的方法。但是體外循環(huán)帶來的間質(zhì)體液增加、血小板減少、溶血、發(fā)熱、血管收縮、肺、腎功能異常,異常出血,易受感染等,尤其是心臟直視手術結束后開放主動脈帶來的心肌細胞缺血再灌注損傷。在整個手術及圍手術期過程中手術的創(chuàng)傷、術中的麻醉、體外循環(huán)中全身的肝素化、術中低溫、術后疼痛等,會導致機體在出現(xiàn)葡萄糖代謝紊亂,造成的應激性高血糖,這種機體應激性升高的血糖水平一方面進一步加劇了二尖瓣置換術中的心肌缺血再灌注損傷,近幾十年來,關于胰島素對心肌保護的話題一直備受關注。 目的1.研究胰島素對體外循環(huán)下二尖瓣置換術病人的心肌保護作用；2,探討其作用機制。 方法在新鄉(xiāng)市中心醫(yī)院倫理委員會批準的條件下,于2012年3月5日至2013年5月27日,選擇36例首次體外循環(huán)下行二尖瓣置換術的擇期手術患者,并在知情同意書上簽字。將36例病人隨機分為胰島素治療組(insulin,Ⅰ組)、對照組(control,C組),每組18例,Ⅰ組術中經(jīng)患者中心靜脈持續(xù)泵入胰島素,使術中血糖控制在3.9---11.0mmol/L,術后控制在4.0---12.0mmol/L;對照組C組不泵胰島素,術中血糖不處理,術后血糖控制在4.0---12.0mmol/,記錄血糖變化水平。并分別于切皮前(T1)、主動脈開放后5min(T2)、主動脈開放后4h(T3)、主動脈開放后12h(T4)、主動脈開放后24h(T5)抽取橈動脈血,檢測血漿乳酸脫氫酶(LDH)、肌酸激酶同工酶(CK-MB)、肌鈣蛋白I(cTnI)、血漿超氧化物歧化酶(SOD)水平,并在切開右心房和縫合右心房時取少許心肌組織,分別在光鏡、電鏡下觀察右心房心肌組織形態(tài)結構和超微結構的變化,記錄體外循環(huán)時間、主動脈阻斷時間、心臟復跳情況、輔助通氣時間、術后機械通氣時間及術后48h正性肌力藥物的應用情況。 結果 1.實驗組(Ⅰ組)與對照組(C組)兩組病人的輔助通氣時間、體外循環(huán)時間、主動脈阻斷時間均無顯著差異(P0.05)。 2.兩組血漿SOD含量術前無明顯差異(P0.05),術后各時間點均較術前顯著降低(P0.05),各個時刻：Ⅰ組SOD含量均顯著高于C組(P0.05)。 3.心肌酶血漿乳酸脫氫酶、肌酸激酶同工酶及肌鈣蛋白Ⅰ,術前,兩組無顯著差異(P0.05),術后各時間點均較術前顯著升高(P0.05),各個時刻：Ⅰ組LDH、CK-MB、cTnI含量均顯著低于C組(P0.05)。 4.開放主動脈后實驗組(Ⅰ組)心臟自動復跳率為74.37%,對照組(C組)為32.55%,Ⅰ組的心臟自動復跳率明顯高于C組(P0.05)。 5.術后48小時內(nèi)的正性肌力藥物應用,Ⅰ組與C組相比較,多巴胺、腎上腺素劑量有顯著性差異(P0.05) 6.電鏡、光鏡下可見兩組心肌組織術前無明顯差異,術后兩組心肌組織均有不同程度損傷,其損傷程度Ⅰ組明顯輕于C組。 結論本研究表明：1、在體外循環(huán)下二尖瓣置換術患者經(jīng)中心靜脈持續(xù)泵入胰島素能有效的保護心肌細胞,減輕體外循環(huán)后心肌缺血再灌注損傷,減少術后心律失常的發(fā)生率,減少術后血管活性藥物用量,改善心臟跳動的術后自然回復率,發(fā)揮心肌保護作用。 2、體外循環(huán)下非糖尿病患者二尖瓣置換術中持續(xù)泵入胰島素的心肌保護作用可能與胰島素具備促修復和增進心肌細胞生存、抑制炎性物質(zhì)、促活化心肌細胞、抗凋亡作用有關。另外可能與術中胰島素降低應急反應所產(chǎn)生的高血糖促進缺血心肌對葡萄糖的攝取代謝有關。
[Abstract]:The background of the cardiopulmonary bypass mitral valve replacement surgery is one of the most common heart, is currently the treatment of mitral valve disease is recognized as the most effective. But the cardiopulmonary bypass has increased interstitial fluid, thrombocytopenia, hemolytic anemia, fever, vasoconstriction, pulmonary, renal dysfunction, abnormal bleeding, vulnerable to infection. Especially after open heart surgery and opening after myocardial ischemia reperfusion injury caused by aortic surgery in the perioperative period. And the whole operation process of the trauma, anesthesia, cardiopulmonary bypass in systemic heparinization, intraoperative hypothermia and postoperative pain, can cause the body in glucose metabolism, stress high blood sugar caused by the stress of elevated blood sugar levels on the one hand, further exacerbating the mitral valve replacement in myocardial ischemia reperfusion injury, in recent decades, with insulin on myocardial protection The topic of protection has always been the focus of attention.
Objective 1. to study the myocardial protective effect of insulin on patients with mitral valve replacement under cardiopulmonary bypass (CPB) and 2 to explore the mechanism of its action.
In the method approved by the ethics committee of Xinxiang Central Hospital conditions, from March 5, 2012 to May 27, 2013, 36 cases of patients undergoing elective surgery for mitral valve replacement under extracorporeal circulation, and signed the informed consent. 36 patients were randomly divided into the insulin treatment group (insulin, group), control group (control group, C). Each group of 18 cases, group I patients by intraoperative central venous continuous infusion of insulin, the intraoperative blood glucose control in 3.9---11.0mmol/L, postoperative control in the 4.0---12.0mmol/L control group; group C blood glucose insulin pump, not in operation, postoperative blood glucose control in 4.0---12.0mmol/, the level of blood glucose change records. And respectively before skin incision (T1), 5min after aortic opening (T2), 4h after aortic opening (T3), 12h after aortic opening (T4), 24h after aortic opening (T5) from the radial artery blood, detection of plasma lactate dehydrogenase (LDH), creatine kinase isoenzyme ( CK-MB), troponin I (cTnI), plasma superoxide dismutase (SOD) levels, and the myocardium a little in the right atrium and right atrium incision suture, respectively in the light microscope, changes of right atrial myocardial tissue morphology and ultrastructure were observed under the electron microscope, record the cardiopulmonary bypass time, aortic clamping time. The heart Rebeating, ventilation time, postoperative mechanical ventilation time and postoperative 48h positive inotropic drug application.
Result
1. the time of auxiliary ventilation, the time of extracorporeal circulation and the interruption time of the aorta in the two groups of the experimental group (group I) and the control group (group C) had no significant difference (P0.05).
2., there was no significant difference in plasma SOD content between the two groups before operation (P0.05), which was significantly lower than those before operation (P0.05) at all time points after operation. The SOD contents in group I were significantly higher than those in C group at all times (P0.05).
3., there was no significant difference in plasma lactate dehydrogenase, creatine kinase isoenzyme and troponin I before operation between the two groups (P0.05), and the time points were significantly higher than those before operation (P0.05). The LDH, CK-MB and cTnI contents in group I were significantly lower than those in C group (P0.05).
4. the spontaneous cardiac recovery rate of the open aorta group (group I) was 74.37%, the control group (group C) was 32.55%, and the cardiac auto recovery rate in group I was significantly higher than that of the C group (P0.05).
5. the positive inotropic drug use within 48 hours after the operation. Compared with the C group, the dose of dopamine and adrenaline was significantly different (P0.05).
6. electron microscope. Under the light microscope, there was no significant difference in the two groups of myocardial tissue before operation. After operation, there were different degrees of injury in the two groups of myocardial tissue, and the degree of injury in group I was significantly lighter than that in group C.
Conclusion this study shows that: 1, under extracorporeal circulation of mitral valve replacement in patients with central venous continuous infusion of insulin can protect myocardial cells effectively, alleviate after CPB myocardial ischemia reperfusion injury, reduce the incidence of postoperative arrhythmia rate, reduce the dosage of vasoactive drugs after surgery, improve the heart beat after the natural recovery that play a role in myocardial protection.
2, the myocardial protection effect of extracorporeal circulation in non-diabetic patients with mitral valve replacement in continuous pump into insulin and insulin may have promoting rehabilitation and improving myocardial cell survival, inhibition of inflammatory substances, promoting the activation of myocardial cells, the anti apoptosis effect of pancreatic island. In addition with operation by reducing emergency response caused by high glucose promote the metabolism of glucose uptake in ischemic myocardium.

【學位授予單位】：新鄉(xiāng)醫(yī)學院
【學位級別】：碩士
【學位授予年份】：2014
【分類號】：R654.2

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