急性炎性疾病患者乳酸林格氏液液体动力学

Volume kinetics of Ringer's lactate in acute inflammatory disease

目的:探索炎性疾病患者的乳酸林格氏液(Ringer's lactate,RL)液体动力学特征以及炎性生物标记物是否可以作为协变量影响RL分布和排泄。方法:本研究为前瞻性队列研究。选择40例美国麻醉医师分级(ASA)I-II级,腹腔镜下择期胆囊切除术(胆囊炎组,n=20)或者腹腔镜下急诊阑尾切除术(阑尾炎组,n=20)。所有患者麻醉诱导前开始输注RL,按15 mL/kg,35 min内输毕。采用酶联免疫(enzyme-linked immunosorbent assay,ELISA)方法测定血浆炎症(TNF-α,IL-10和CRP)或者内皮损伤生物标记物(syndecan-1,SDC-1);利用血红蛋白(Hb)稀释-时间曲线和尿量,使用Phoenix软件,采用非线性混合效应模型分析计算RL液体动力学参数和协变量的影响。结果:与胆囊炎组相比,阑尾炎组RL从组织间隙到血浆的转运速率常数(k_(21))显著降低(14×10^(-3)min^(-1)versus 35×10^(-3)min^(-1);P=0.012)。阑尾炎组C反应蛋白(CRP)升高[中位数38.1(1.8-143.6)μg/mL versus 1.3(0.1-159.0)μg/mL;P<0.001];与清醒状态相比,麻醉期间(输液开始后30～45 min),液体从中央室中到外周室的转运速率常数(k_(12))显著增加(57×10^(-3)min^(-1)versus 32×10^(-3)min^(-1);P<0.01)。清除速率常数(k_(10))降低90%(0.6×10^(-3)min^(-1)versus 5.3×10^(-3)min^(-1);P<0.001)。无论在清醒状态还是麻醉状态下低血压均能降低液体清除;炎症或者内膜损伤的生物标记物不能作为显著影响RL液体动力学参数的协变量。结论:阑尾炎或者胆囊炎患者术前输入液体后"炎症反应的生物标记物"不是RL的液体动力学的协变量,但是两组患者中,全身麻醉期间输入液体的清除率下降。

AIM : To explore the volume kinetics of Ringer's lactate (RL) in acute inflammatory disease and whether the inflammatory biomarker would be associated with altered distribution and elimination of RL. METHODS : In this prospective cohort study, we enrolled 40 ASA physical status Ⅰ-Ⅱ patients undergoing elective laparoscopic cholecystectomy (cholecystitis group, n =20) or emergency laparoscopic appendectomy (appendicitis group, n =20). All of the patients were infused RL (15 mL/kg) intravenously over 35 min, starting before the induction of general anesthesia. Plasma concentrations of inflammatory (tumor necrosis factor-α, interleukin-10, and C-reactive protein) and endothelial damage (syndecan-1, SDC-1) biomarkers were quantified by enzyme-linked immunosorbent assay (ELISA). The kinetics of RL and the effects of covariates were calculated by plasma dilution based on the dilution of hemoglobin-time curve, urinary excretion by using Phoenix software for mixed effects modeling. RESULTS :Compared with the cholecystitis group, the rate constant for fluid transfer from the peripheral fluid space to the central fluid space ( k 21 ) decreased significantly in the appendicitis group (14×10^-3 min -1 versus 35×10^-3 min^-1;P = 0.012 ), in whom higher plasma concentrations of C-reactive protein (CRP) were measured [median: 38.1(1.8-143.6)μg/mL versus 1.3 ( 0.1 - 159.0 )μg/mL, P < 0.001 ]. Compared with conscious period, ongoing anesthesia (duration: 30 min-45 min after beginning of infusion) increased the rate constant for fluid transfer from the plasma to the extravascular space ( k 12 ) significantly (57×10^-3 min -1 versus 32×10^-3 min^-1 ), and decreased the elimination rate constant ( k 10 : from 0.6 ×10^-3 min^-1 to 5.3 ×10^-3 min^-1;P < 0.001 ). A lower mean arterial pressure was associated with reduced elimination, independent of conscious/anaesthetized state. However, no biomarkers for inflammation or endothelial damage were significantly associated covariates in the kinetic model. CONCLUSION : No association was found between the volume kinetics of Ringer's lactate and the degree of inflammation (as indicated by established biomarkers) in patients with cholecystitis or appendicitis. However, the rate of elimination was greatly retarded by general anesthesia in both groups.