早期使用纳洛酮防治非心源性危重患者心肌损伤的疗效研究

Clinical study on the curative effect of using naloxone to prevent and cure myocardial injury in non-cardiac critically ill patients

目的探讨非心源性危重患者心肌损伤与血浆β-内啡肽(-βEP)的关系,以及早期使用纳洛酮防治非心源性危重患者心肌损伤的疗效。方法选取2009年8月至2010年11月在我院重症监护病房住院的180例非心源性危重患者,入院后抽血测定血浆-βEP、肌酸激酶(CK)和肌酸激酶同工酶(CK-MB)和肌钙蛋白(CT-nI),作床边心电图,根据心肌损伤判定标准分为A组(心肌损伤组)42例和B组(非心肌损伤组)138例,分析心肌损伤与血浆-βEP之间的关系。A组再随机分为A1、A2和A3组各14例,B组再随机分为B1、B2和B3组各46例。A1和B1组给予危重病常规治疗;A2和B2组在常规治疗基础上加用纳洛酮0.2 mg.kg-1.d-1,分3次静脉滴注,每8 h 1次;A3和B3组在常规治疗基础上加用纳洛酮0.2 mg.kg-1.d-1,于24 h匀速静脉泵入。入院24、487、2 h再分别抽血测定CK、CK-MB和CTnI值,以及作床边心电图,72 h后评价A组CK、CK-MB和CTnI值的变化和临床疗效,评价B组预防心肌损伤的疗效。结果非心源性危重患者的心肌损伤发生率约23.3%,A组的血浆-βEP水平显著高于B组(P<0.01)。与A1组相比,A2和A3组治疗24、487、2 h的CK、CK-MB和CTnI降低值均显著增高(P<0.05),治疗72 h后的总有效率亦显著增高(P<0.05);A2和A3组的CK、CK-MB、CTnI降低值和总有效率差异均无统计学意义(P>0.05);与B1组相比,B2和B3组预防心肌损伤的疗效均显著增高(P<0.05),B2和B3组之间差异无统计学意义(P>0.05)。结论非心源性危重患者血浆-βEP的升高可能是引起心肌损伤的原因之一。早期使用纳洛酮可在一定程度上预防心肌损伤的出现,同时对已损伤心肌有一定的治疗作用,不同的给药方式预防和治疗效果差异无统计学意义。

Objective To explore the relationship between impairment of myocardium and plasma levels of β-endorphin in non-cardiac critically ill patients,and the curative effect of using naloxone to prevent and cure myocardial injury in non-cardiac critically ill patients.Methods One hundred and eighty cases of non-cardiac critically ill patients in our hospital were selected from August 2009 to January 2010,β-endorphin,CK,CK-MB or CTnI levels were measured and electrocardiogram record beside bed was immediately performed after admission.The patients were divided into group myocardial injury（group A=42） and non-myocardial injury（group B=138） according to criterion.The relationship between impairment of myocardium and plasma levels of β-endorphin in non-cardiac critically ill patients were analyzed.Group A were randomly divided into 3 subgroups,each of them has 14 cases（group A1,group A2 and group A3）.Group B were randomly divided into 3 subgroups,each of them has 46 cases（group B1,group B2 and group B3）.The patients of group A1 and group B1 received conventional treatment.Group A2 and Group B2 received conventional therapy plus naloxone 0.2 mg·kg（-1）·d（-1）,every 8 hours received intravenous injection.Group A3 and Group B3 received conventional therapy plus naloxone 0.2 mg·kg（-1）·d（-1）,by continuously-pumped which has constant speed.CK,CK-MB or CTnI levels were measured in each patients and electrocardiogram record beside bed was performed immediately 24,48 and 72 hours after admission.To evaluate the change in value of CK,CK-MB or CTnI and clinical effects of group A.Meanwhile the prevention effect in curing myocardial injury of group B was evaluated.Results The incidence rate of myocardial injury is 23.3%.The levels of β-endorphin in blood of myocardial injury group were significant than those in non-myocardial injury group（P0.01）.Compared with group A1,the reduction value of CK,CK-MB and CTnI increased significantly after 24,48 and 72 hours,treatment in group A2 and group A3（P0.05）,the total effective rate also increased significantly after 72 hours,treatment（P0.05）.There is no significant difference in the reduction value of CK,CK-MB,CTnI and the total effective rate after 72 hours,treatment between group A2 and group A3（P0.05）;compared with group B1,the prevention effect of myocardial injury in group B2 and group B3 increased significantly（P0.05）.There is no significant difference between group B2 and group B3 in prevention of myocardial injury（P0.05）.Conclusion It is possible that the increase of β-endorphin in non-cardiac critically ill patients results in myocardial injury.Early use of naloxone to prevent and cure myocardial injury in non-cardiac critically ill patients has the curative effect.Meanwhile it has the therapeutic action to the patients whose myocardial was injured.There is no significant difference about dosage regimen in prevention and treatment effect.