吗啡后处理对小儿心内直视手术损伤心肌的影响

The protection of ischemic postconditioning with morphine for injured myocardium in children during open heart surgery

目的探讨不同剂量吗啡后处理对小儿先心纠治术心肌损伤的影响及其机制。方法 45例单纯的房、室间隔缺损患儿随机分为3组(A组为吗啡0.05mg/kg后处理组,B组为吗啡0.1mg/kg后处理组,C组为生理盐水对照组)。在主动脉开放前3min,3组分别将处理因素用生理盐水稀释至10ml经主动脉根部灌注。并于术前(T1)、主动脉开放即刻(T2)、主动脉开放后1h(T3)、主动脉开放后3h(T4)、主动脉开放后24h(T5)、主动脉开放后72h(T6)各时点采集静脉血,测定红细胞压积(Hct)、心肌肌钙蛋白I(cTnI)、磷酸肌酸激酶同工酶(CK-MB)、丙二醛(MDA)、超氧化物歧化酶(SOD)、肿瘤坏死因子-α(TNF-α)。并比较三组术后心脏自动复跳率、心律失常发生率、正性肌力药物使用率、呼吸机应用时间(D1)、CICU病房驻留时间(D2)、术后住院时间(D3)。结果和C组相比,A、B组主动脉开放后各个时间点CK-MB、cTnI均较低(P<0.05);血清中SOD的含量较高,MDA、TNF-α的含量均较低(P<0.05)。A、B组心脏自动复跳率高于C组(P<0.05);多巴胺等正性肌力药物使用率及D1、D2低于C组(P<0.05)。心律失常评分及D3无统计学意义。结论吗啡缺血后处理对小儿先心纠治术的心肌损伤具有一定保护作用,其作用机制可能与抗氧及抗炎有关。

Objective To investigate effects and mechanism of ischemic postconditioning with morphine to myocardium preservation in children during open heart surgery. Methods Forty-five patients who confered congenital heart disease were randomly divided into three groups,group A（ n = 15,morphine 0. 05 mg/kg） ,group B（ n = 15,morphine 0. 1 mg/kg） and group C（ n = 15,saline） . All patients＇aortas were routinely clamped during cardiopulmonary bypass（ CPB） . 3 minuts before open aorta,morphine 0. 05 mg/kg,morphine 0. 1 mg/kg and the same volume of saline were injected to patients in three groups respectively by aorta. The blood samples were taken from central venous catheter for detection of haematocrit（ HCT） ,cardiac troponin I（ cTnI） ,creatine kinase-MB（ CK-MB） ,superoxide dismutase（ SOD） ,macondialdehyde（ MDA） and tumor necrosis factorα（ TNF-α） at various time points,such as, before operation（ T1） ,at aorta opening（ T2） immediately,and at 1 h（ T3） ,3 h（ T4） ,24 h（ T5） ,and 72 h（ T6） after aorta opening,respectively. We observed and recorded the rate of spontaneous resuscitation,the incidence of arrhythmia,the doses of inotropic agents,the duration of ventilation,the days of staying in CICU and the hospitalization days after operation. Results The levels of cTnI,CK-MB,MDA and TNF-α at T2 and T6（ P 0. 05） in group C were higher than those in group A and group B. Compared with group C,the doses of inotropic agents,the duration of ventilation ,the days of staying in CICU in group A and group B were lower and shorter（ P 0. 05,respectively） . But the rate of spontaneous resuscitation was higher（ P 0. 05） . The incidence of arrhythmia and the hospitalization days after operation in three groups were not different. Conclusion This study demonstrates that ischemic postconditioning with morphine can provide protection for injured myocardium in children during open heart surgery,and the mechanism may be associated with antioxidant and anti-inflammatory.