允许性高碳酸血症对老年患者止血带相关肢体缺血再灌注所致肺损伤的影响

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摘要目的探讨允许性高碳酸血症对老年患者止血带相关肢体缺血再灌注所致肺损伤的影响。方法选取2018年1月～2019年1月中国科学技术大学附属第一医院安徽省立医院骨一科收治的行全膝关节置换患者60例，按随机数字表法分为正常通气组和允许性高碳酸血症组，每组30例。正常通气组术中维持二氧化碳分压（PaCO2）在35～45 mmHg，允许性高碳酸血症组术中维持PaCO2在60～70 mmHg。分别于两组患者麻醉诱导前（T0）、术后30 min（T1）、6 h（T2）、24 h（T3）及48 h（T4）采桡动脉血行血气分析，测动脉血氧分压（PaO2）及PaCO2，计算并记录氧合指数（OI）、肺泡-动脉血氧分压差[P（A-a）DO2]及呼吸指数（RI）。分别于上述时间点采集中心静脉血样，采用酶联免疫吸附试验（ELISA）测定血清肿瘤坏死因子-α（TNF-α）、白细胞介素-10（IL-10）、人补体3a（C3a）及C-反应蛋白（CRP）水平。记录两组患者术后72 h肺部并发症及住院时间。结果与T0比较，两组患者T1～T3时OI明显降低，（A-a）DO2及RI明显升高（P ＜ 0.05），T1～T4时血清TNF-α浓度明显降低，血清IL-10浓度明显升高，T2～T4时血清C3a及CRP浓度明显升高（P ＜ 0.05）。与正常通气组比较，允许性高碳酸血症组T2～T3时OI明显升高，（A-a）DO2及RI明显降低（P ＜ 0.05），T1～T4时血清TNF-α浓度明显降低，血清IL-10浓度明显升高（P ＜ 0.05），T2～T4时血清C3a及CRP浓度明显降低（P ＜ 0.05），住院时间明显缩短（P ＜ 0.05）。两组患者苏醒时间、术后72 h肺部急性呼吸窘迫综合征、肺部感染等并发症发生率比较，差异无统计学意义（P ＞ 0.05）。两组患者术后均无肺不张、肺水肿发生。结论允许性高碳酸血症可减轻老年患者止血带相关肢体缺血再灌注所致肺损伤，改善肺氧合及弥散功能，机制可能与抑制炎性反应有关。

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	周素素许辉疏树华柴小青▲

关键词 ：允许性高碳酸血症, 肢体缺血再灌注, 肺功能, 炎性反应

Abstract：Objective To investigate the effect of permissive hypercapnia on lung injury induced by tourniquet-related limb ischemic repufusion in elderly patients. Methods Sixty patients were scheduled for total knee replacement from January 2018 to January 2019 in Ward One, Department of Orthopedics of the First Affiliated Hospital of University of Science and Technology of China, Anhui Provincial Hospital were selected, and were randomly divided into the normal ventilation group and permissive hypercapnia group by random number table method, 30 cases in each group. In the normal ventilation group, the partial pressure of carbon dioxide (PaCO2) was maintained at 35 to 45 mmHg, while in the permissive hypercapnia group, PaCO2 was maintained at 60 to 70 mmHg. The arterial blood gas analysis were performed and recorded before the induction of anesthesia (T0), 30 minutes (T1), 6 hours (T2) 24 hours (T3) and 48 hours (T4) after surgery of the two groups. The partial pressure of oxygen (PaO2) and PaCO2 were measured, while the oxygenation index (OI), alveolar-arterial oxygen difference [P(A-a)DO2], and respiratory index (RI) were calculated and recorded. Central venous blood samples were collected at the above time points, and the levels of serum tumor necrosis factor-α (TNF-α), interleukin-10 (IL-10), human complement 3a (C3a) and C-reactive protein (CRP) were determined by enzyme-linked immunosorbent assay (ELISA). Pulmonary complications and hospital stay were recorded at 72 h after surgery in both two groups. Results Compared with T0, the OI of two groups were significantly reduced, the [P(A-a)DO2] and RI were significantly increased between T1-T3 (P ＜ 0.05), the serum TNF-α concentration were significantly reduced, and the serum IL-10 concentration were significantly increased between T1-T4. The concentrations of serum C3a and CRP were increased significantly from T2-T4 (P ＜ 0.05). Compared with the normal ventilation group, the OI of permissive hypercapnia group were significantly increased, while (A-a)DO2 and RI were significantly reduced at T2-T3, and the concentration of serum TNF-a were significantly reduced, while the concentration of serum IL-10 were significantly decreased at T1-T4, the concentrations of serum C3a and CRP were significant decreased at T2-T3, and the hospital stay was significantly shorter (P ＜ 0.05). There were no significant differences in the incidence of complications such as wake-up time, pulmonary acute respiratory distress syndrome (ARDS) at 72 hours postoperatively, and pulmonary infection between the two groups (P ＞ 0.05). There were no atelectasis or pulmonary edema occurred in the two groups. Conclusion Permissive hypercapnia can reduce lung injury caused by ischemia-reperfusion of tourniquet-related limbs in elderly patients, and improve lung oxygenation and diffuse function. The mechanism may be related to the suppression of inflammatory responses.

Key words： Permissive hypercapnia Limb ischemic repufusion Lung function Inflammatory response

基金资助:安徽省公益性技术应用研究联动计划项目（160 4f0804019）。

通讯作者: ▲通讯作者

引用本文:

周素素许辉疏树华柴小青▲. 允许性高碳酸血症对老年患者止血带相关肢体缺血再灌注所致肺损伤的影响[J]. 中国医药导报, 2020, 17(4): 89-93.
ZHOU Susu XU Hui SHU Shuhua CHAI Xiaoqing▲. Effect of permissive hypercapnia on lung injury induced by tourniquet-related limb ischemic repufusion in elded patients. 中国医药导报, 2020, 17(4): 89-93.

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