不同灌注液对人离体小动脉保护作用的超微观察

目的 研究不同灌注液对离体小动脉超微结构的影响.方法 对手指近端毁损伤,缺乏再植条件或患者放弃再植的18指近节离断手指(热缺血时间＜2 h),分成3组,每组6指,分别在指动脉内灌注能量合剂(A组)、肝素钠+1%利多卡因(B组)和生理盐水(C组),4℃保存.分别于灌注后2、4 6 8、12、16、24 h切取指动脉3 mm,固定后切片电镜下观察小动脉在不同时间段超微结构的变化.另取离断指体近端未缺血的健康指动脉3 mm直接固定,为对照组.结果 电镜下观察:A组灌注8 h后,小动脉平滑肌细胞线粒体仅轻度肿胀,嵴变短.B组灌注4 h后,线粒体明显肿胀和内质网扩张;8 h后,血管平滑肌细胞内线粒体进一步肿大,嵴稀疏.C组灌注2 h后,内皮细胞轻度肿胀,少数脱落;4 h后,内皮细胞肿胀,部分脱落,血管平滑肌细胞内线粒体开始肿大;8 h后,血管平滑肌细胞内线粒体进一步肿大,部分出现空泡,嵴减少,基质变淡.与A组和C组比较,小动脉经肝素钠+利多卡因灌注后内皮细胞脱落延迟至16 h.结论 能量合剂灌注液对离体小动脉的超微结构有保护作用,能够减轻肢体缺血再灌注损伤的程度.     

参附对肢体缺血再灌注损伤保护作用的时效及量效关系探讨

目的探讨参附注射液对肢体缺血再灌注损伤保护作用的机制、时效及量效关系。方法选择合适病例如断肢再植、皮瓣移植、四肢大血管损伤、骨筋膜室综合征等或四肢手术需用止血带1～1．5h的男性患者45例,随机分为A,B,C,D和E（空白对照组）五组,A,B组在手术前30min、术后30min分别以参附注射液10ml／kg加入5％糖盐水（GNS）静脉滴注,C,D组在手术前30min、术后30min分别以参附注射液20ml／kg加入5％GNS静脉滴注,E组单纯静脉滴入5％GNS,每组分别在术前1h、术后6h抽取静脉血,测定丙二醛（MDA）、血浆超氧化物歧化酶（SOD）含量。结果各治疗组中SOD明显增高,MDA明显降低。结论参附注射液对缺血再灌注肢体具有保护作用,且术前治疗效果更佳。     

断肢保护及再植后防治缺血再灌注损伤的研究进展

随着显微外科技术及设备的迅速发展,断肢再植成活率不断提高,但是如何保存离断肢体并延长再植时限,更好地恢复再植后肢体功能,仍是显微外科有待解决的问题。断肢缺血损伤和再植后的再灌注损伤是一个连续的过程,研究断肢保护是再植的基础,研究再灌注损伤是断肢保护的延续,两者不可分离。     

川芎嗪联合乌司他丁对断肢再植缺血再灌注损伤的保护作用

目的：评价川芎嗪和乌司他丁对断肢再植缺血再灌注损伤的保护作用。方法：40例上肢离断再植病人,随机分为4组,A组为对照组,围手术期不接受川芎嗪和乌司他丁。B组为乌司他丁组,于再植后动脉开放前给予乌司他丁0.5万U/kg。C组为川芎嗪组,于再植后动脉开放前给予川芎嗪2.5 mg/kg。D组为联合组,于再植后动脉开放前分别给予乌司他丁0.5万U/kg、川芎嗪2.5 mg/kg。分别于术前（T1）、术中再灌注后30 min（T2）,术后3 h（T3）、24 h（T4）、72 h（T5）共5个时点采集中心静脉血,测定患者血清天冬氨酸氨基转移酶（AST）、肌酸激酶（CK）、乳酸脱氢酶（LDH）、丙二醛（MDA）和超氧化歧化酶（SOD）的含量在该过程中的变化。结果：血清AST、CK、MDA的含量在A组、B组、C组有升高趋势,与A组比较,B、C组的AST、CK在不同时点上升幅度较小,有显著性差异（P〈0.05）。D组无明显上升,有非常显著性差异（P〈0.01）。血清LDH的含量在A组有上升趋势,B、C、D组无明显上升,与A组比较在T2时点有显著性差异（P〈0.05）。血清SOD的含量在A、B、C组有降低趋势,B、C组下降幅度较小,与A组比较有显著性差异（P〈0.05）。D组无明显下降,与A组比较有非常显著性差异（P〈0.01）。结论：川芎嗪和乌司他丁对断肢再植缺血再灌注损伤具有一定的保护作用,联合使用效果更佳。     

断肢再植肌组织缺血再灌注损伤的细胞凋亡表达

目的研究断肢再植过程中缺血性损伤和缺血再灌注损伤的发生情况和病理改变，探讨细胞凋亡表达规律。方法建立大鼠后肢断肢实验模型，以光镜观察缺血和缺血再灌注早期的骨骼肌组织病理变化，以TUNEL（POD法）检测缺血和缺血再灌注过程中细胞凋亡现象的发生。结果缺血5h的大鼠断肢再植全部存活，而缺血9h者未存活。大鼠断肢再植过程中，缺血性和缺血再灌注性损伤引起骨骼肌细胞水肿、坏死和细胞凋亡，并于再灌注过程观察到微循环障碍和中性粒细胞趋化浸润现象，缺血7h凋亡率最高。结论骨骼肌存在缺血性和缺血再灌注性损伤，细胞凋亡是缺血和缺血再灌注损伤的重要病理改变。骨骼肌缺血再灌注过程存在微循环障碍和中性粒细胞趋化浸润，它们是缺血再灌注损伤的重要原因之一。     

血必净联合维拉帕米对大鼠小肠缺血再灌注损伤的实验研究

目的探讨血必净联合维拉帕米对大鼠小肠缺血再灌注（I／R）损伤的保护作用及其可能机制。方法制作小肠缺血再灌注模型,SD大鼠50只随机分为假手术组（A组）、缺血再灌注组（B组）、血必净组（c组）、维拉帕米组（D组）及血必净和维拉帕米联合治疗组（E组）,各10只。分别检测各组大鼠小肠缺血45min再灌注0h、2h时血清中肿瘤坏死因子α（TNF—α）、白细胞介素1β（IL-1β）、丙二醛（MDA）的含量;同时观察小肠黏膜组织病理学变化。结果缺血再灌注组小肠组织病理学改变较其他组明显;在再灌注0h、2h时B、C、D、E组血清中TNF—α、IL-1β、MDA含量均较A组显著升高（P〈0．05）;再灌注2h时C、D、E组血清中TNF—α、IL-1β、MDA含量均较B组明显降低（P〈0．05）,但C、D两组间差异无统计学意义;C、D组血清中TNF—α、IL-1β、MDA含量均较E组明显升高（P〈0．05）。结论血必净、维拉帕米能减轻大鼠小肠缺血再灌注损伤,二者联合用药有协同保护作用,效果更明昴。     

丹酚酸B联合高氧液对兔肢体再灌注损伤保护作用

[目的]探讨高氧液和丹酚酸B对兔肢体再灌注损伤的保护作用.[方法]选用健康新西兰家兔24只,随机分为4组,在缺血前从耳缘静脉推注等虽的生理盐水(A组)、高氧液(B组)、丹酚酸B(C组)或高氧液加丹酚酸B(D组),夹阻股动静脉,建立肢体缺血再灌注损伤模型,在缺血前和再灌注4 h抽血检测丙二醛(MDA)和超氧化物岐化酶(SOD),取腓肠肌作病理检测.[结果]再灌注损伤后血清丙二醛浓度较前明显升高,丹酚酸B组、高氧液组以及丹酚酸B联合高氧液组的MDA升高均受到抑制(P<0.01),以丹酚酸B联合高氧液组最为明显;血清超氧化物岐化酶活性较前明显降低,丹酚酸B组、高氧液组以及丹酚酸B联合高氧液组的SOD降低均受到抑制(P<0.01),以丹酚酸B联合高氧液组最为显著.骨骼肌HE染色见丹酚酸B联合高氧液组骨骼肌损伤程度最轻.[结论]丹酚酸B联合高氧液和对兔肢体缺血再灌注损伤具有一定的保护作用,且两者有协同作用.     

高能灌注液对断肢再植术后肢体保护作用的实验研究

[目的]探讨高能灌注液对断肢再植术后肢体保护作用。[方法]选用健康SD兔18只,根据干预方法的不同将18只SD兔随机分为3组,每组6只,为空白对照组、缺血再灌注组(IR组)、高能灌注液保护组(高能组)。建立左后离断肢体模型,高能组于缺血时、再灌注时给予高能灌注液灌注,于2、4、8、12 h于胫骨前肌取材,测定骨骼肌超氧化物歧化酶(SOD)、丙二醛(MDA)、髓过氧化物酶(MPO)、Na+-K+-ATP酶、Ca2+-ATP酶,湿重/干重比值,光镜下观察大体结构变化。[结果]各项指标经过统计学处理后,发现三组间有着显著性差异(P<0.05),高能组明显优于缺血再灌注组,并且随着时间的延长差异更加明显。[结论]高能灌注液能够有效地预防骨骼肌的缺血再灌注损伤,从不同环节进行多种药物联合应用是对断肢再植术后肢体保护的有效方法。     

地塞米松对肢体缺血再灌注时白细胞介素—8和过氧化脂质的影响

目的 研究地塞米松对肢体缺血再灌注时白细胞介素－8（IL－8）和过氧化脂质（LPO）的影响。方法 35例择期手术病人随机分为缺血再灌注组（A组）、地塞米松治疗组（B组）和非缺血对照组（C组）。以ELISA法和硫代巴比妥法分别测定IL－8和LPO的值。结果 A组病人IL－8在缺血再灌注后20分钟显著升高;B组和C组则无显著变化。A组LPO在缺血再灌注后10分钟、20分钟均显著升高;B组和C组均无显著变化。结论 肢体缺血再灌注可使IL－8和LPO显著增高。地塞米松对肢体缺血再灌注引起的IL－8和LPO升高有显著的抑制作用。     

缺血后处理和预处理对大鼠骨骼肌缺血-再灌注损伤的作用

目的 探讨缺血后处理( IPost)和缺血预处理(IPC)对大鼠骨骼肌缺血再灌注(IR)损伤的影响.方法 将40只大鼠随机分成缺血再灌注组(A组)、缺血后处理组(B组)、缺血预处理组(C组)、缺血预处理加缺血后处理组(D组)以及对照组(E组),采用切断患肢全部皮肤、肌肉和神经,保留患肢股动、静脉的动物模型,通过夹闭和开放股动、静脉造成骨骼肌缺血再灌注损伤,通过测定骨骼肌缺血4h、再灌注1h后血清丙二醛(MDA)和骨骼肌髓过氧化物酶(MPO),以及再灌注6h后骨骼肌的坏死程度来观察缺血后处理.缺血预处理及缺血预处理加缺血后处理对大鼠骨骼肌缺血再灌注损伤的影响.结果 B组、C组和D组再灌注1 h MDA和MPO水平以及再灌注6h骨骼肌坏死程度均低于A组(P＜ 0.05),但是高于E组(P＜0.05);B组和D组再灌注1 h MDA和MPO水平以及再灌注6h骨骼肌坏死程度基本相同(P＞0.05);B组和D组再灌注1 h MDA和MPO水平低于C组(P＜0.05),但再灌注6h骨骼肌坏死程度基本相同(P＞0.05).结论 应用缺血后处理和缺血预处理对大鼠骨骼肌缺血再灌注损伤有一定的保护效果,联合应用缺血后处理和缺血预处理,对骨骼肌缺血再灌注损伤的保护作用并没有明显增强.     

An experimental study of the effect of fluorocarbon perfusion for amputated limb preservation. The effect of inhibition for replantation toxemia and muscle tissue destruction

In replantation surgery, it is widely accepted that replantation toxemia or muscle destruction in replanted limbs might occur after a long time of ischemia. Their possibilities are particularly high after replantation of the amputated limbs which contain more muscle tissue than tendon and bones. The present study was performed to investigate the efficacy of fluorocarbon (FC: artificial blood) perfusion to the amputated limbs in preventing these problems after replantation. The hind limbs of dogs were completely amputated at mid-thigh. Amputated limbs were divided into two groups. One was stored in ice water and the other at room temperature for six hours. Each group was furthermore divided into four subgroups. The amputated limbs were perfused with oxygenated FC or Hartmann's solution before replantation and remaining limbs were not perfused. All of them were replanted under an operating microscope. The results were as follows: Perfusion with FC had an inhibiting effect on the anaerobic metabolism in an amputated limb and also decreased the rate of death due to replantation toxemia. Perfusion with FC was effective for inhibiting leakage of creatine phosphokinase from the replanted limb and preventing muscle destruction. Both these effects were detected biochemically and histologically. The reactive hyperemia of the replanted limb usually occurred after replantation. This rate, however, was significantly decreased after replantation of the amputated limb perfusion with FC. These effects described above were more remarkable when the amputated limb was perfused continuously rather than intermittently. It is therefore reasonable to conclude that for prevention of systemic ill effect after replantation and for preservation of function of the amputated limb, continuous perfusion with FC in ice water is more effective than ice water cooling alone.     

An ischemia-induced model of revascularization failure of replanted limbs

Twenty-five amputated rat hindlimbs were replanted after various periods of warm ischemia. The incidence of limb failure that was due to the no-reflow phenomenon was found to be 0% after 2 or 3 hours of warm ischemia, 50% after 4 hours, and 80% after 5 hours of ischemia. Predictors of the occurrence of no-reflow were the presence of an increased number of venous red blood cell aggregates 5 minutes after replantation, the slope of the tissue pH curve that was recorded for 1 hour after replantation, and assessment of hydrogen washout flow to the foot pad. All limbs had excellent flow immediately after revascularization. The marked difference in flow that was detected 1 hour after replantation between the limb survival group (n = 16) and the limb failure group (n = 9) suggests an ongoing obstructive process. In those limbs that were successfully replanted, an 18% increase in femoral artery flow was found after revascularization compared with a 20% decrease in flow to the muscle and a 3% decrease to the foot pad. This supports the concept that arteriovenous shunting occurs after replantation. The presence of microthrombi that adhere to the vessel wall after replantation correlated well with limb failure. Our observations support ongoing arterial obstruction, arteriovenous shunting, and an altered thrombogenic-fibrinolytic system as factors that may be responsible for the no-reflow phenomenon.     

肝素对顿抑心肌功能影响的实验研究

目的：探讨肝素化剂量肝素对在体家兔短暂缺血－再灌注顿抑心肌的功能的影响。方法：23只雄性家兔，分为实验（A）组和对照（B）组，建立在体心肌短暂缺血（15min）－再灌主（60min）损伤模型。A组于前降支阻断前20min给予肝素（700U／kg）。分别于给药前、缺血前、再灌注期间，检测2组NO、ET－1、MDA、SOD水平，测定血流动力学指标变化，对心肌超微结构做定性观察。结果：A组在给药后20min，NO含量即较给药前明显升高（P＜0．05），且在整个再灌注期较B组有显著性差别（P＜0．05），心功能、超微结构明显改善。结论：肝素参与短暂缺血－再灌注顿抑心肌功能的保护，机制可能是通过药物性预适应，增强内皮源性NO的产生，从而减轻心肌缺血－再灌注损伤。     

缺血预处理对肢体缺血再灌注损伤的影响

目的　观察缺血预处理 (IPC)对肢体缺血再灌注损伤的影响。方法　选择 2 0例需充气止血带止血进行手术的患者 ,随机分为对照组 (n =10 )和IPC组 (n =10 )。IPC组患者术前应用 3次 5min循环缺血 ,间隔 5min再灌注预处理后在止血带下进行手术 ;对照组直接在止血带下进行手术。在肢体缺血前和再灌注 30min、90min、180min分别取静脉血检测血清肌酸磷酸激酶 (CPK)、谷草转氨酶(AST)、乳酸脱氢酶 (LDH)、丙二醛 (MDA)和过氧化物歧化酶 (SOD)水平。结果　随着肢体缺血再灌注时间的延长 ,血中CPK、AST、LDH、MDA含量逐渐升高 ,而SOD活性逐渐降低。IPC组在缺血前及再灌注同时间 ,血中CPK、AST、LDH、MDA含量低于对照组 (P <0 0 5 ,P <0 0 1) ;而SOD活性高于对照组 (P <0 0 5 ,P <0 0 1)。结论　IPC能有效地减轻肢体缺血再灌注损伤程度 ,减轻脂质过氧化反应 ,提高肢体缺血耐受性     

Experimental evaluation of oxygen free radical scavengers in the prevention of reperfusion injury to skeletal muscle

A prolonged preoperative ischemic interval decreases the chances for successful replantation of an amputated limb. Skeletal muscle is especially sensitive to periods of prolonged ischemia. It is now hypothesized that significant tissue injury occurs during reperfusion, when oxygen-rich blood contacts anaerobic metabolites forming toxic oxygen free radicals. A replantation model, using the rabbit hind limb tibialis anterior muscle, was developed to assess muscle function and histological appearance following ischemic intervals of five and eight hours. Muscle strength five weeks after injury was used as a functional measurement of tissue damage. The effects of the superoxide free radical scavenger superoxide dismutase (SOD) and the hydroxyl radical scavenger dimethylsulfoxide (DMSO), administered systemically just before reperfusion, were studied. Muscle treated with SOD following five hours of ischemia had essentially normal strength and histological appearance; however, there was no protective effect after eight hours. DMSO treatment had no beneficial effects after five hours of ischemia, but after eight hours DMSO-treated muscle had significantly better function than untreated muscle. Histological examination confirmed the functional results. Clinical treatment of ischemic limbs with free radical scavengers before revascularization may aid in avoiding reperfusion injury and may improve survival and later muscle function.     

The beneficial effect of heparin in preischemic perfusion solutions for cold-stored skin flaps

Storage of skin flaps in the cold before replantation increases their tolerance to ischemic damage. Rat epigastric skin flaps were perfused immediately before 2 days of cold ischemia with 3 ml of normal saline containing either 10 U per milliliter of heparin (group 1, N = 11) or normal saline (group 2, N = 10), or stored without perfusion (group 3, N = 6), and replanted. Flap viability was assessed 7 days later. The mean flap survival in groups 1, 2, and 3 was 73% (p<0.01 compared with group 2), 10%, and 33% respectively. Intravascular fibrin deposits were detected histochemically 5 minutes before reperfusion in nonperfused flaps and 5 minutes after reperfusion in saline-perfused flaps, but not in flaps perfused with heparinized saline. Angiography revealed evidence of no reflow in the first 5 minutes of reperfusion in saline-perfused flaps, but normal blood flow in heparinized saline-perfused flaps. Tissue water content, myeloperoxidase activity, and hydroperoxide levels after 1 and 24 hours of reperfusion were not significantly different in flaps perfused with heparinized saline and normal saline. These findings indicate that in skin flaps perfused before ischemia, flaps perfused with heparinized saline survive significantly better than flaps perfused with normal saline. They also survive better than nonperfused flaps but the improvement is not significant.     

Effect of fluorocarbon perfusion upon the preservation of amputated limbs. An experimental study

The present study was undertaken to investigate the effect of fluorocarbon on the preservation of an amputated limb. The hind limbs of dogs were completely amputated through the mid-thigh; some were perfused with fluorocarbon, others with lactated Ringer's solution and some were not perfused at all. After six hours of ischaemia, all the limbs were replanted. Perfusion with fluorocarbon had an inhibitory effect on the anaerobic metabolism of an amputated limb, thus increasing the survival rate. Leakage of creatine phosphokinase from the replanted limb also was inhibited by perfusion with fluorocarbon. These effects were more striking when the amputated limb was perfused continuously rather than intermittently and when it was preserved in iced water rather than at room temperature; these measures helped to prevent replantation toxaemia and to preserve muscle function.