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目的探讨婴幼儿体外循环术后肺损伤机制及平衡超滤联合改良超滤对肺功能的保护效果。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(TI),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24 h(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C3a、C5a及白介素-6(IL-6)、肿瘤坏死因子-α(TNF-α)的浓度。结果各组体外循环术后较术前的肺静态顺应性(Cstat)、氧合指数(OI)明显降低,肺泡-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。C3a、C5a术后浓度明显降低,各组差别不明显。IL-6、TNF-α术后浓度均明显升高。在T2、T3、T4、T5时间U组的IL-6、TNF-α浓度明显低于M组和C组。结论术后肺功能损害可能与CPB术后补体激活致细胞因子大量释放致肺毛细血管内皮损伤有关。血浆补体浓度减低可作为观察炎性反应及组织损害早期指标。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 in infants and young children and the effect of balanced ultrafiltration combined with modified ultrafiltration on pulmonary 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. Blood samples were collected before TI, 20 min (T2), 2 h (T3), 6 h (T4), 12 h (T5) and 24 h (T6) Ppeak, Ppause, tidal volume (TV), respiratory rate (F), FiO2 and inspiration were measured and arterial C3a, C5a And interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α). Results After operation, the static compliance (Cstat) and oxygenation index (OI) were significantly decreased and the alveolar-arterial oxygen pressure (AaD02) significantly increased after cardiopulmonary bypass. The Cstat, 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. C3a, C5a postoperative concentration was significantly reduced, the difference was not obvious in each group. The levels of IL-6 and TNF-α were significantly increased after operation. The concentrations of IL-6 and TNF-α in group U at T2, T3, T4 and T5 time points were significantly lower than those in M and C groups. Conclusions Postoperative pulmonary dysfunction may be related to the release of cytokines caused by complement activation in CPB patients after pulmonary embolism. Plasma complement reduction can be used as an early indicator of inflammatory response and tissue damage. 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.