改良超滤联合平衡超滤对婴幼儿体外循环术后补体和炎性介质的血浆含量和肺功能影响

目的探讨婴幼儿体外循环术后肺损伤机制及平衡超滤联合改良超滤对肺功能的保护效果。方法 60例先天性心脏病患儿随机分为对照组(C)、改良超滤组(M)和平衡超滤联合改良超滤组(U)。M组在转流结束后应用改良超滤,U组在转流开始后进行平衡超滤,转流结束后进行改良超滤。分别在转流前(TI),转流结束后20 min(T2),术后2 h(T3),术后6 h(T4),术后12 h(T5)和术后24 h(T6)测定记录气道峰压(Ppeak)、呼吸停顿压(Ppause)、潮气量(TV)、呼吸频率(F)、吸入氧浓度(FiO2)和吸气比例(insp)并测量动脉血中C3a、C5a及白介素-6(IL-6)、肿瘤坏死因子-α(TNF-α)的浓度。结果各组体外循环术后较术前的肺静态顺应性(Cstat)、氧合指数(OI)明显降低,肺泡-动脉氧分压(AaD02)明显增加,在T4、T5时间U组的Cstat、OI明显高于M组和C组,M组高于C组;AaDO2明显低于M组和C组,M组低于C组。C3a、C5a术后浓度明显降低,各组差别不明显。IL-6、TNF-α术后浓度均明显升高。在T2、T3、T4、T5时间U组的IL-6、TNF-α浓度明显低于M组和C组。结论术后肺功能损害可能与CPB术后补体激活致细胞因子大量释放致肺毛细血管内皮损伤有关。血浆补体浓度减低可作为观察炎性反应及组织损害早期指标。联合应用平衡超滤和改良超滤可降低血浆中的炎性因子的浓度,减轻炎性反应,改善患儿肺的通气功能和换气功能,具有良好肺保护作用。

Effects of balanced ultrafiltration combined with modified ultrafiltration technique on plasma level of complement,inflammatory mediators and pulmonary function in infant open heart surgery

OBJECTIVE To study the mechanism of pulmonary injury and the effect of balanced ultrafiltration with modified ultrafiltration on pulmonary function in infant open heart surgery.METHODS 60 cases of congenita1 heart disease were divided into control group（C）,modified ultrafiltration group（M） and balanced ultrafiltration with modified ultrafihration group（U）.The cardiopulmonary bypass（CPB） was used with modified ultrafiltration in Group M and balanced ultrafiltration with modified ultrafiltration in Group U.The pneumodynamic parameters and inflammatory mediators were measured at certain specific time points.RESULTS The static pulmonary compliance（Cstat） and oxygen index（OI） were lower,and alveolar-arteria oxygen difference（AaDO2） was higher after CPB in all three groups.At T4 and T5 time points,the Cstat and OI in Group U was higher than that in the Groups M and C,and that in Group M was higher than in Group C;AaDO2 in Group U was lower than that in the Groups M and C,but that in Group M was lower than in Group C.The levels of C3a and C5a were lower after CPB in the three groups;levels of IL-6,TNF-α were higher after CPB in the three groups;however,the level of IL-6,TNF-α in Group U were lower than that in Groups M and C at T2,T3,T4 and T5 time points.CONCLUSION The pulmonary injury in infant open heart surgery may be concerned with the pulmonary capillaries endothelial damage due to the alexin（C3a,C5a）activation resulting in cytokine releasing.The level of C3a and C5a was considered as the earlier index of inflammatory reaction and pulmonary injury.Therefore,combined balanced ultrafiltration with modified ultrafiltration degrades plasma concentrations of IL-6 and TNF-α,also improves pulmonary ventilation and air exchange function.