经皮穴位电刺激对亲体肝移植术患儿术后急性肺损伤的影响

Effect of transcutaneous electrical acupoint stimulation on postoperative acute lung injury in pediatric patients undergoing living-related liver transplantation

目的评价经皮穴位电刺激(TEAS)对亲体肝移植术患儿术后急性肺损伤(ALI)的影响。方法择期行左外叶背驮式亲属活体肝移植术患儿60例,年龄4~24月,ASA分级Ⅱ或Ⅲ级,NYHA分级Ⅰ或Ⅱ级,Child-Pugh分级B或C级,性别不限。采用电脑随机数法将其分为2组(n=30):对照组(C组)和TEAS组(T组)。于麻醉诱导前30 min行TEAS,选择刺激穴位为双侧足三里、内关以及肺俞穴。刺激参数:选择疏密波,设置初始电刺激电流强度0.5 mA、频率2/15 Hz,逐渐增加电流强度至局部轻微肌颤,刺激持续刺激30 min,间歇30 min为1个循环,至术毕。术后每日相同时间行TEAS 30 min,至1周。C组选择刺激穴位旁开0.5 cm处贴表面附有惰性介质的电极片,连接针疗仪,但无有效电流输出。分别于切皮前(T0)、门静脉阻断后30 min(T_(1))、新肝开放后1 h(T_(2))和术毕(T_(3))时记录气道平台压、气道峰压和肺顺应性(Cdyn),并计算气道峰压与平台压差(ΔP)。采集颈内静脉血2 ml,采用ELISA法检测血浆克拉拉细胞分泌蛋白16(CC16)、表面活性蛋白-D(SP-D)、高级糖基化终末产物可溶性受体(sRAGE)、TNF-α及IL-10浓度。各时点分别抽取桡动脉血样行血气分析,记录PaO_(2)和肺泡气-动脉血氧分压差(A-aDO_(2))并计算氧合指数(OI)和呼吸指数(RI)。记录术后气管导管留置时间和ICU停留时间。术后48 h时行肺损伤超声评分,记录术后1周内ALI的发生情况。结果与T0时比较,2组T_(2),3时OI降低,RI升高,血浆IL-10浓度升高,T_(1)~3时血浆TNF-α、CC16、sRAGE和SP-D浓度升高(P<0.05);与C组比较,T组T_(2),3时OI升高,RI降低,血浆sRAGE浓度降低,IL-10浓度升高,T_(1)~3时血浆TNF-α、CC16和SP-D浓度降低,气管导管留置时间和ICU停留时间缩短,肺损伤超声评分降低(P<0.05),ALI发生率差异无统计学意义(P>0.05)。结论TEAS可减轻亲体肝移植术患儿术后ALI。

Objective To evaluate the effect of transcutaneous electrical acupoint stimulation(TEAS)on postoperative acute lung injury(ALI)in the pediatric patients undergoing living-related liver transplantation.Methods Sixty pediatric patients of either sex,aged 4-24 months,of American Society of Anesthesiologists Physical Status classificationⅡorⅢ,with New York Heart Association(NYHA)classⅠorⅡ,with Child-Pugh B or C,scheduled to undergo elective left external lobe piggyback living-related liver transplantation,were divided into 2 groups(n=30 each)using a computer-generated table of random numbers:control group(group C)and TEAS group(group T).In group T,bilateral Zusanli(ST_(3)6),Neiguan(PC6),and Feishu(BL13)acupoints were stimulated with disperse-dense waves at the initial intensity of 0.5 mA and frequency of 2/15 Hz,the current intensity was gradually increased until local slight muscle shaking appeared,and continuous stimulation lasted for 30 min at a 30-min interval(a cycle)until the end of operation.TEAS was performed for 30 min at the same time every day up to 1 week after surgery.Stimulus locations in group C were selected at 0.5 cm lateral to the acupoints,and the electrodes with inert medium were attached to the location,with no effective current output from acupuncture treatment instrument.The peak inspiratory pressure,plateau pressure,and pulmonary compliance were recorded before skin incision(T0),at 30 min after portal vein occlusion(T_(1)),at 1 h after portal vein opening(T_(2)),at the end of operation(T_(3)),and the difference between peak inspiratory pressure and plateau pressure was calculated.Blood samples from the jugular vein were collected at T0-3 to determine the levels of plasma club cell protein 16(CC16),surfactant protein D(SP-D),soluble receptor for advanced glycation end products(sRAGE),tumor necrosis factor-alpha(TNF-α),and interleukin-10(IL-10)by enzyme-linked immunosorbent assay.Blood samples from the radial artery were collected at T0-3 for blood gas analysis,PaO_(2)and A-aDO_(2)were recorded,and oxygenation index(OI)and respiratory index(RI)were calculated.The indwelling time of postoperative tracheal tube and length of ICU stay were also recorded.The lung injury was assessed and scored using ultrasound at 48 h after surgery.The occurrence of ALI within 1 week after operation was also recorded.Results Compared with baseline at T0,OI was significantly decreased,RI was increased,and plasma IL-10 concentrations were increased at T_(2),3,and the plasma concentrations of TNF-α,CC16,sRAGE and SP-D were increased at T_(1)-3 in both groups(P<0.05).Compared with group C,OI was significantly increased,RI was decreased,the plasma concentrations of sRAGE were decreased,and the plasma concentrations of IL-10 were increased at T_(2),3,and the concentrations of plasma TNF-α,CC16 and SP-D were decreased at T_(1)-3,the indwelling time of postoperative tracheal tube and length of ICU stay were shortened,the ultrasound score of lung injury was decreased(P<0.05),and no significant change was found in the incidence of ALI in group T(P>0.05).Conclusions TEAS can alleviate ALI in the pediatric patients after living-related liver transplantation.