目的心脏手术患者液体治疗策略历来存有争论。文中旨在观察目标导向血流动力学管理策略对非体外循环冠状动脉搭桥手术患者预后的影响。方法选取安徽医科大学第一附属医院2016年1-12月择期行非体外循环冠状动脉搭桥术的98例患者纳入研究。以2016年6月20日进行质量改进为截点。质量改进前56例患者纳入对照组、质量改进后42例患者纳入试验组。质量改进措施为采用以每博量变异和心脏指数为目标导向液体治疗输注液体,标准化使用血管活性药物,优化血流动力学。通过电子病历系统采集术中和术后数据,比较两组患者的液体出入量、术后住院天数和并发症、术后苏醒时间、24小时胸腔引流量、6小时内拔管率、ICU驻留时间、术后第1天肌钙蛋白I水平、30天病死率以及半年病死率。结果采用目标导向血流动力学管理后,试验组较对照组液体总入量差异无统计学意义,其中万汶输注量显著增加[(676.79±380.90)mL vs(890.48±222.58)mL]、晶体输注量显著减少[(663.84±224.97)mL vs(430.24±201.76)mL]、尿量显著增加[(516.07±224.87)mL vs(695.24±311.53)mL],液体正平衡显著减少[(683.82±556.08)mL vs(456.43±505.36)mL],差异均有统计学意义(P<0.05);自体血回输、红细胞输注比例、出血量两组间差异无统计学意义(P>0.05)。两组术后苏醒时间、24小时胸腔引流量、6小时内拔管率、术后第1天肌钙蛋白I水平、ICU驻留时间无统计学差异(P>0.05)。两组术后住院天数试验组较对照组显著减少(11.81 d vs 13.82 d,P<0.05)。对其对数转换后进行多元线性回归分析,得出质量改进措施的标准化系数B为-0.296(SE=0.061,P<0.05),说明其他条件相同时,采用目标导向血流动力学管理能减少术后住院天数19.4%(95%CI 7.3%～31.5%)。术后并发症从41.07%下降至16.67%,差异有统计学意义(P<0.05)。结论非体外循环冠状动脉搭桥术中采用目标导向血流
Objective To assess the role of p38 MAPK in protective effect of remifentanil preconditioning(RPC) on myocardial ischemia reperfusion injury in rat hearts.Methods Male Spargue-Dawley rats weighing 300 g to 350 g were used.They were randomly assigned to 1 of 8 groups: Control(CON,saline vehicle),SB 203580(SB,a p38 MAPK inhibitor),RPC,ischemia preconditioning(IPC),SB+RPC,SB+IPC, RPC+SB and IPC+SB.Infarct size(IS),a percentage of the area at risk(AAR),was determined by triphenyltetrazolium(TTC) staining.Tissue simple were processed from the entire AAR of left ventricle for the determination of p38 MAPK protein expression(5 hearts/group).The bands representing the proteins were visualised using an enhanced chemiluminescence detection system.Results IS/AAR was reduced by IPC or RPC,compare to CON.SB administered prior to PC abolished effect of IS/AAR reduction of IPC but RPC Treatment of SB prior to sustained ischemia diminished both protective effect of RPC and IPC on IS/AAR.In IPC group,phospho-p38 MAPK protein increased significantly within 5 min ischemia and remained elevating at 30 min reperfusion,while phospho-p38 MAPK protein in RPC increased significantly at 30 min reperfusion only.Conclusion The activation of p38 MAPK acts as a mediator of RPC,while it may have trigger and mediator effects in IPC.
