远隔缺血预处理减轻肺叶切除术后氧化性肺损伤：单中心随机双盲对照试验
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Remote Ischemic Preconditioning Decreases Oxidative Lung Damage After PulmonaryLobectomy: A Single-Center Randomized, Double-Blind, Controlled Trial.
背景与目的
肺癌患者行肺叶切除术期间，手术侧肺往往存在萎陷和低灌注，肺复张时可发生缺血/再灌注损伤。我们假设远隔缺血预处理（RIPC）会降低肺的氧化损伤及改善术后气体交换。
方 法
我们对罹患非小细胞肺癌行择期肺叶切除的患者进行了一项单中心、随机、双盲试验。全麻诱导后即刻53例患者随机分为接受肢体RIPC组（3个周期：通过大腿缺血袖套模拟5分钟缺血/ 5分钟的缺血再灌注）和/或无RIPC对照组。麻醉诱导后和RIPC、手术前和术中立即测定呼出气冷凝液和动脉血中的氧化应激标志物(EBC)（T0，基础值） ；在萎陷肺，复肺通气恢复前即刻（TLV）（T1）；恢复TLV即刻（T2）；恢复TLV120分钟后(T3)。主要结果为EBC在T1、T2和T3时点 8-异前列腺素的水平。次要成果包括以下内容：NO2，NO3，H2O2含量和EBC和血中pH（8-异前列腺素，NO2+NO3）及肺气体交换变量（PaO2/FiO2、A-aDO2，a/A比和呼吸指数）。
结 果
与对照组相比，T1、T2和T3时点，接受RIPC的患者EBC中 8-异前列腺素水平较低（均值和95%置信区间的差异）：分别为-15.3（5.8-24.8），P = .002；-20（5.5-34.5），P = .008；和-10.4（2.5-18.3），P =.011。RIPC组在T1、T2、T3EBC 中NO2，NO3和H2O2的水平也低于对照组（P < .05）。RIPC组在T2时点，血8-异前列腺素和NO2 、NO3较低(P < .05)。肺叶切除术后，RIPC组与对照组相比，在2小时、8小时和24小时有更好的PaO2/FiO2。
结 论
肺切除术中，肢体RIPC降低 EBC中 8-异前列腺素水平和其他氧化性肺损伤标志物。RIPC提高了由PaO2/FiO2比值反映的术后的气体交换。
原始文献摘要
García-de-la-Asunción J1, Bruno L, Perez-Griera J, Galan G, Morcillo A
Remote Ischemic Preconditioning Decreases Oxidative Lung Damage After PulmonaryLobectomy: A Single-Center Randomized, Double-Blind, Controlled Trial. Anesth Analg. Aug 2017 ;125(2):499-506. doi: 10.1213/ANE.0000000000002065.
BACKGROUND:
During lobectomy in patients with lung cancer, the operated lung is often collapsed and hypoperfused. Ischemia/reperfusion injury may then occur when the lung is re-expanded. We hypothesized that remote ischemic preconditioning (RIPC) would decrease oxidative lung damage and improve gas exchange in the postoperative period.
METHODS:
We conducted a single-center, randomized, double-blind trial in patients with nonsmall cell lung cancer undergoing elective lung lobectomy. Fifty-three patients were randomized to receive limb RIPC immediately after anesthesia induction (3 cycles: 5 minutes ischemia/5 minutes reperfusion induced by an ischemia cuff applied on the thigh) and/or control therapy without RIPC. Oxidative stress markers were measured in exhaled breath condensate (EBC) and arterial blood immediately after anesthesia induction and before RIPC and surgery (T0, baseline); during operated lung collapse, immediately before resuming two-lung ventilation (TLV) (T1); immediately after resuming TLV (T2); and 120 minutes after resuming TLV (T3). The primary outcome was 8-isoprostane levels in EBC at T1, T2, and T3. Secondary outcomes included the following: NO2+NO3, H2O2 levels, and pH in EBC and in blood (8-isoprostane, NO2+NO3) and pulmonary gas exchange variables (PaO2/FiO2, A-aDO2, a/A ratio, and respiratory index).
RESULTS:
Patients subjected to RIPC had lower EBC 8-isoprostane levels when compared with controls at T1, T2, and T3 (differences between means and 95% confidence intervals): -15.3 (5.8-24.8), P = .002; -20.0 (5.5-34.5), P = .008; and -10.4 (2.5-18.3), P = .011, respectively. In the RIPC group, EBC NO2+NO3 and H2O2 levels were also lower than in controls at T2 and T1-T3, respectively (all P < .05). Blood levels of 8-isoprostane and NO2+NO3 were lower in the RIPC group at T2 (P < .05). The RIPC group had better PaO2/FiO2 compared with controls at 2 hours, 8 hours, and 24 hours after lobectomy in 95% confidence intervals for differences between means: 78 (10-146), 66 (14-118), and 58 (12-104), respectively.
CONCLUSIONS:
Limb RIPC decreased EBC 8-isoprostane levels and other oxidative lung injury markers during lung lobectomy. RIPC also improved postoperative gas exchange as measured by PaO2/FiO2 ratio.
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