KL-6与体外循环中行持续低潮气量通气的成年瓣膜患者围术期肺氧合功能改变的相关性研究
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摘要
目的初步探讨体外循环(CPB)术中持续低潮气量通气对成年瓣膜患者体内涎液化糖链抗原-6(KL-6)的表达水平及患者围术期肺氧合功能变化的影响,评估KL-6与此类患者围术期氧合功能改变的相关性。方法连续纳入2017年9月至2018年1月在我科接受心脏瓣膜手术的成年患者60例,随机分为对照组(n=30例,CPB期间未接受机械通气)和试验组(n=30例,CPB期间接受持续低潮气量通气)。动态监测患者围术期血清学指标及肺氧合功能变化情况,比较两组患者围术期临床结局,并分析KL-6表达水平与患者围术期肺氧合功能改变的相关性。结果对照组及试验组患者CPB术后血清及肺泡灌洗液中KL-6水平差异均有统计学意义(P<0.05)。两组患者CPB术后氧合指数随时间呈先升高后下降趋势(P<0.05),肺泡-动脉氧分压差随时间上下波动,差异均无统计学意义。直线相关分析发现,血清KL-6水平与氧合指数呈负相关(r=-0.525,P=0.003),与肺泡-动脉氧分压差呈正相关(r=0.489,P=0.006)。两组患者围术期临床结局均无明显差异(P>0.05)。结论术中持续低潮气量通气可有效抑制患者体内KL-6的表达,但对围术期临床结局无明显影响。KL-6表达水平可有效反映围术期肺氧合功能的改变。
Objective To investigate the influence of continuous low-volume ventilation in cardiopulmonary bypass(CPB) on the expression of krebs von den lungen-6(KL-6) and perioperative pulmonary function in adults undergoing valve surgery. Methods From 2017 Sept. to 2018 Jan., 60 patients who received valve replacement surgery were prospectively comprised in this study. We randomly allocated these patients into control group(n=30, non-ventilation) and experimental group(n=30, continuous low-volume ventilation during CPB). At different perioperative time points, we identified the dynamic changes of pulmonary function and biomarkers which expressed in serum and bronchoalveolar lavage fluid(BALF). Meanwhile, we also compared perioperative clinical outcomes of the two groups. Results The expression of serum KL-6 and BALF KL-6 in the two groups were both statistically significant(P<0.05). The oxygenation index increased with time and reached to the top point at T_1, then subsequently decreased with time(P<0.05). The alveolar-arterial oxygen tension difference(P_(A-a)O_2) in the two groups fluctuate with time, the differences have no statistical significance. According to linear correlation, the serum KL-6 level was negatively correlated with oxygenation indexes(r=-0.525, P=0.003), while it was positively correlated with P_(A-a)O_2(r=0.489, P=0.006). There were no significant differences between the two groups in clinical outcomes. Conclusion Continuing low-volume ventilation during CPB could decrease the expression level of KL-6, while it has no significant influence on perioperative outcomes.
Objective To investigate the influence of continuous low-volume ventilation in cardiopulmonary bypass(CPB) on the expression of krebs von den lungen-6(KL-6) and perioperative pulmonary function in adults undergoing valve surgery. Methods From 2017 Sept. to 2018 Jan., 60 patients who received valve replacement surgery were prospectively comprised in this study. We randomly allocated these patients into control group(n=30, non-ventilation) and experimental group(n=30, continuous low-volume ventilation during CPB). At different perioperative time points, we identified the dynamic changes of pulmonary function and biomarkers which expressed in serum and bronchoalveolar lavage fluid(BALF). Meanwhile, we also compared perioperative clinical outcomes of the two groups. Results The expression of serum KL-6 and BALF KL-6 in the two groups were both statistically significant(P<0.05). The oxygenation index increased with time and reached to the top point at T_1, then subsequently decreased with time(P<0.05). The alveolar-arterial oxygen tension difference(P_(A-a)O_2) in the two groups fluctuate with time, the differences have no statistical significance. According to linear correlation, the serum KL-6 level was negatively correlated with oxygenation indexes(r=-0.525, P=0.003), while it was positively correlated with P_(A-a)O_2(r=0.489, P=0.006). There were no significant differences between the two groups in clinical outcomes. Conclusion Continuing low-volume ventilation during CPB could decrease the expression level of KL-6, while it has no significant influence on perioperative outcomes.
引文
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[16] SCHREIBER JU,LANC MD,DE KM,et al.The effect of different lung-protective strategies in patients during cardiopulmonary bypass:a meta-analysis and semiquantitative review of randomized trials.J Cardiothorac Vasc Anesth,2012,26(3):448-454.
[2] RANUCCI M,BALLOTTA A,LA ROVERE MT,et al.Postoperative hypoxia and length of intensive care unit stay after cardiac surgery:the underweight paradox?PloS One,2014,9(4):e93992 [2018-06-15].https://doi.org/10.1371/journal.pone.0093992.
[3] LANDIS RC,BROWN JR,FITZGERALD D,et al.Attenuating the systemic inflammatory response to adult cardiopulmonary bypass:a critical review of the evidence base.J Extra Corpor Technol,2014,46(3):197-211.
[4] BEER L,WARSZAWSKA JM,SCHENK P,et al.Intraoperative ventilation strategy during cardiopulmonary bypass attenuates the release of matrix metalloproteinases and improves oxygenation.J Surg Res,2015,195(1):294-302.
[5] ZHANG Y,Kaminski N.Biomarkers in idiopathic pulmonary fibrosis.Curr Opin Pulm Med,2012,18(5):441-446.
[6] TERPSTRA ML,AMAN J,VAN NIEUW AMERONGEN GP,et al.Plasma biomarkers for acute respiratory distress syndrome:a systematic review and meta-analysis.Crit Care Med,2014,42(3):691-700.
[7] 罗臻,钱何布,沈浩.血清 Kerbs von Lungren 6 水平对创伤性急性呼吸窘迫综合征诊断价值的研究.东南大学学报(医学版),2015,34(6):1001-1004.
[8] BROWER RG,MATTHAY MA,MORRIS A,et al.Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome.N Engl J Med,2000,342(18):1301-1308.
[9] DEBLIER I,SADOWSKA AM,JANSSENS A,et al.Markers of inflammation and oxidative stress in patients undergoing CABG with CPB with and without ventilation of the lungs:a pilot study.Interact Cardiovasc Thorac Surg,2006,5(4):387-391.
[10] BEER L,SZERAFIN T,MITTERBAUER A,et al.Continued mechanical ventilation during coronary artery bypass graft operation attenuates the systemic immune response.Eur J Cardiothorac Surg,2013,44(2):282-287.
[11] NG CS,ARIFI AA,WAN S,et al.Ventilation during cardiopulmonary bypass:impact on cytokine response and cardiopulmonary function.Ann Thorac Surg,2008,85(1):154-162.
[12] RICHTER JA,MEISNER H,TASSANI P,et al.Drew-Anderson technique attenuates systemic inflammatory response syndrome and improves respiratory function after coronary artery bypass grafting.Ann Thorac Surg,2000,69(1):77-83.
[13] LOER SA,KALWEIT G,TARNOW J.Effects of ventilation and nonventilation on pulmonary venous blood gases and markers of lung hypoxia in humans undergoing total cardiopulmonary bypass.Crit Care Med,2000,28(5):1336-1340.
[14] FREITAS CR,MALBOUISSON LM,BENICIO A,et al.Lung perfusion and ventilation during cardiopulmonary bypass reduces early structural damage to pulmonary parenchyma.Anesth Analg,2016,122(4):943-952.
[15] CHEN H,CHENG ZB,YU RG.Procalcitonin as a predictor of moderate to severe acute respiratory distress syndrome after cardiac surgery with cardiopulmonary bypass:a study protocol for a prospective cohort study.BMJ Open,2014,4(10):e006344 [2018-06-15].http://dx.doi.org/10.1136/bmjopen-2014-006344.
[16] SCHREIBER JU,LANC MD,DE KM,et al.The effect of different lung-protective strategies in patients during cardiopulmonary bypass:a meta-analysis and semiquantitative review of randomized trials.J Cardiothorac Vasc Anesth,2012,26(3):448-454.