肢体缺血预处理对肺叶切除术患者肺的保护作用

摘要

目的 评价肢体缺血预处理对肺叶切除术患者的肺保护作用,并进一步探讨其可能存在的相关机制.方法 择期行胸腔镜肺叶切除术患者40例,男26例,女14例,年龄45~64岁, BMI 20~28 kg/m2,ASAⅠ或Ⅱ级.随机分为两组:肢体缺血预处理组(P组),左下肢根部绑止血带,充气阻断下肢血流5 min,再放气恢复血流5 min,如此循环3次;对照组(C组),左下肢绑止血带未充气30 min.所有患者均采用静-吸复合麻醉.分别于入室时、术后6、12、24 h采集静脉血样检测Toll 样受体4(TLR4)的表达,并于上述各时点采集动脉血样,计算肺泡-动脉氧分压差(PA-aO2)、呼吸指数(RI)和氧合指数(OI),记录术后48 h内肺部并发症和P组左下肢不良反应.结果 与入室时比较,术后6、12、24 h两组TLR4表达均明显上升,但 P组明显低于 C组(P<0.05);与入室时比较,术后6、12、24 h两组PA-aO2、RI明显升高,OI明显降低(P<0.05);与C组比较,P组PA-aO2、RI明显降低,OI明显升高(P<0.05).术后两组患者肺炎和肺不张发生率差异无统计学意义,两组均未见呼吸衰竭.P组患者左下肢无皮肤破溃、血栓栓塞、神经损伤等不良反应.结论 肢体缺血预处理对肺叶切除术患者肺具有保护作用,与下调血液单核细胞TLR4的表达、减轻全身炎症反应有关.%Objective To evaluate the effect of extremity ischemia preconditioning on lung protection in patients undergoing pulmonary lobectomy,and to further explore its possible mecha-nisms.Methods Forty patients (male 26 and female 14,BMI 20-28 kg/m2,ASA Ⅰ or Ⅱ,aged 45-64 years old)scheduled for elective pulmonary lobectomy via a thoracoscope,were randomly divided into two groups:extremity ischemic preconditioning group (group P)had the left leg roots tied with a tourniquet,lower extremity blood flow aerated blocked for 5 min,then deflated to restore blood flow for 5 min,the cycle was repeated three times;control group (group C)had the left lower extremity tied but not charged for 30 min.All the patients underwent intravenous-inhaled composite anesthesia. Arterial and venous blood samples were taken after admission to the operating room,at 6 h,12 h and 24 h after operation.The alveolar-arterial oxygen pressure difference (PA-aO2),respiratory index(RI) and oxygenation index (OI)were calculated.The level of TLR4 was measured.The pulmonary com-plications within 48 h after operation were recorded.The adverse reactions of the left lower extremity of the group P were recorded.Results Compared with the admission to the operating room,the ex-pression of TLR4 was significantly increased in the two groups at 6 h,12 h and 24 h after operation, but the expression of the group P was significantly lower than that of group C (P<0.05).Compared with the admission to the operating room,PA-aO2and RI were significantly increased,and OI was sig-nificantly decreased in the two groups at 6 h,12 h and 24 h after operation (P<0.05).Compared with group C,PA-aO2and RI were significantly decreased,and OI was significantly increased in group P (P<0.05).There was no statistically significant difference in the incidence of pneumonia and ate-lectasis in the two groups after operation,and no respiratory failure was observed in both groups.The left lower extremity of the group P had no adverse reactions,such as rupture of skin,thromboembo-lism,and nerve injury.Conclusion Extremity ischemic preconditioning has protective effect on pul-monary function in the patients undergoing pulmonary lobectomy,which may be related to down-reg-ulation of TLR4 expression in monocytes of blood and inhibition of the systemic inflammatory re-sponse.