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目的:探讨婴幼儿体外循环(CPB)术后肺损害机理及平衡超滤联合改良超滤对其肺功能保护效果。方法:60例先天性心脏病患儿随机分为对照组(C)、改良超滤组(M)和平衡超滤联合改良超滤组(U)。M组在转流结束后应用改良超滤,U组在转流开始后进行平衡超滤,转流结束后进行改良超滤。分别在转流前(T1),转流结束后20 min(T2),术后2 h(T3),术后6 h(T4),术后12 h(T5)和术后24h(T6)测定记录气道峰压(Ppeak)、呼吸停顿压(Ppause)、潮气量(TV)、呼吸频率(F)、吸入氧浓度(FiO2)和吸气比例(insp)并测量动脉血中白介素6(IL-6)、肿瘤坏死因子(TNF-α)及黏附因子(sICAM-1)的浓度。结果:各组CPB术后较术前的肺静态顺应性(Cstat)、氧合指数(OI)明显降低,肺泡一动脉氧分压(AaD02)明显增加,在T4、T5时间U组的Cstat、OI明显高于M组和C组,M组高于C组;AaDO2明显低于M组和C组,M组低于C组。IL-6、TNF-α,及sICAM-1术后浓度均明显升高,sICAM-1浓度高峰较迟。在T2、T3、T4及T5时间,U组的IL-6、TNF-α及sICAM-1浓度明显低于M组和C组。结论:术后肺功能损害可能与CPB术后大量炎性细胞因子释放及黏附因子合成与分泌导致肺毛细血管内皮损伤有关。联合应用平衡超滤和改良超滤可降低血浆中的炎性因子的浓度,减轻炎性反应,改善患儿肺的通气功能和换气功能,具有良好肺保护作用。
Objective: To investigate the mechanism of lung injury after cardiopulmonary bypass (CPB) in infants and young children and balance ultrafiltration combined with modified ultrafiltration on lung function. Methods: Sixty children with congenital heart disease were randomly divided into control group (C), modified ultrafiltration group (M) and balanced ultrafiltration plus modified ultrafiltration group (U). In group M, modified ultrafiltration was applied after the end of the commutation, group U was subjected to balanced ultrafiltration after the start of the commutation, and modified ultrafiltration was performed after the end of the commutation. (T6) and postoperative 24h (T6) were measured before treatment (T1), 20 min (T2) after operation, 2 h after operation (T3), 6 h Ppeak, Ppause, tidal volume (TV), respiratory rate (F), inspired oxygen (FiO2) and inspiration ratio were recorded and the levels of IL-6 -6), tumor necrosis factor (TNF-α) and adhesion molecule (sICAM-1). Results: The static compliance (Cstat) and oxygenation index (OI) of pulmonary artery in all groups after CPB were significantly lower than those in preoperative group, and the oxygen partial pressure (AaD02) OI was significantly higher than M and C groups, M group was higher than C group; AaDO2 was significantly lower than M group and C group, M group was lower than C group. IL-6, TNF-α, and sICAM-1 levels were significantly increased, sICAM-1 concentration peak later. At T2, T3, T4 and T5, the concentrations of IL-6, TNF-α and sICAM-1 in U group were significantly lower than those in M and C groups. Conclusion: Postoperative pulmonary dysfunction may be related to the release of a large number of inflammatory cytokines and the synthesis and secretion of adhesion molecules leading to pulmonary capillary endothelial injury after CPB. Combined application of balanced ultrafiltration and modified ultrafiltration can reduce the concentration of inflammatory cytokines in plasma, reduce the inflammatory response, and improve the lung ventilation and ventilation in children with good lung protection.