体外循环自体血预充技术对全身炎性反应的影响

Study on inflammatory response about using the autologous priming technique in cardiopulmonary bypass

目的 研究体外循环采用自体血预充技术对全身炎性反应相关指标的影响.方法 32例非急诊手术首次接受体外循环下心脏冠脉搭桥的患者,依性别（男女比例）、年龄、体重、身高、体表面积（BSA）和射血分数（EF）进行配对后分为两组：自体血预充组（16例）和经典预充组（16例）.自体血预充组：用1250 ml晶体液和8000 IU肝素预充,体外循环开始前先采用自体血预充技术置换出大部分最初预充液,置换过程中严密监视血流动力学变化,维持平均动脉压（MAP）在50 mm Hg以上.整个过程依患者血流动力学耐受程度决定.经典预充组：1250 ml晶体液和8000 IU肝素预充.两组患者心肌保护均采用Calafiore温血停跳液灌注,体外循环中保持温度35.0 ℃～35.5 ℃,流量 2.5～2.8 L·min-1·m-2.所有患者按标准手术步骤进行手术,先完成全部远端吻合口后,开放升主动脉再逐一完成近端吻合.平均体外循环时间64 min,阻断升主动脉时间37 min,平均每例搭桥3.0支.手术结束前将体外循环系统中余血全部回输给患者.结果 自体血预充组平均置换出（885±161）ml的最初预充液,患者体外循环中、手术结束时、术后6 h、术后1 d的HCT水平均明显高于经典预充组（P＜0.05）.90%自体血预充组患者围术期免于输血,而经典预充组患者未输血比例为68%.患者体外循环结束和体外循环后6 h动脉血IL-6水平低于经典体外循环组（P＜0.05）.经典预充组患者体外循环开始和结束时IL-8、TNF-α水平高于自体血预充组（P＜0.05）.结论 体外循环应用自体血预充技术能减少血液稀释,减少围术期输血量,一定程度地抑制IL-6、IL-8和TNF-α炎症介质的升高.

Objective A prospective study has been conducted to evaluate the effects with autologous blood priming compared with standard priming in cardiopulmonary bypass （CPB） on systemic inflammatory response. Methods 32 patients undergoing elective coronary artery bypass surgery were matched assigned to CPB with autologous blood priming （A group, n=16） or standard priming （B group, n=16）. The groups were matched for patient＇s sex （male/female）, age, weight, height, body surface area （BSA） and ejection fraction （EF）. A group： This group use the technique of autologous blood priming. The priming of the extraeorporeal circuit was crystalloid priming （1250 ml ） with heparin （8000 IU ）. Before connection to the intracardiac cannulae, some initial priming volume was withdrawn from the hard-shell reservoir. The procedure was performed while the patient＇s hemodynamics is carefully monitored. The mean arterial blood pressure was maintained above 50 mm Hg. B group： The priming of the extracorporeal circuit was crystalloid priming （1250 ml） with heparin （8000 IU ）. Myocardial protection was achieved with normothermic intermittent blood cardioplegia according to Calafiore et al by application to the aortic root. Cardiopulmonary bypass was performed with a temperature of 35.0 ℃-35.5 ℃ and flow of 2.5- 2.8 L·min^-1·m^-2. All the patients were operated on according to a standardized surgical protocol： distal anastomoses first, proximal anastomosis after release of aortic cross-clamp. Blood from the bypass circuit was returned to all patients upon the completion of the operation. Specific evaluation of cytokines were performed. Blood samples were sequentially taken after the institution of CPB, at the beginning of CPB, at the end of CPB, at 6 hours postoperatively, on postoperative days 1. Results A group allowed a reduced hemodilution with a higher hematocrit level during CPB and postoperative time compared with B group （P〈0.05）. With autologous blood priming, perioperative transfusion was significantly reduced （10% vs 32%, P〈0.01 ）. The arterial IL-6 concentration was significantly lower in patients in A group than in B group [at the end of CPB, （347±37）pg/ml vs （461±47）pg/ml, at 6 hours postoperatively, （476±35）pg/ml vs （627±57）pg/ml,P〈0.05 ]. The arterial IL-8, TNF-α concentration was significantly higher in patients in group B than in A group during the circulation time at the beginning and the end of CPB. Coneluslon Using the autologous CPB priming technique is the successful method for the reduction of hemodilution, homologous blood transfusion requirement and the attenuation of the systemic inflammatory response.