Butler J, Parker D, Pillai R, Westaby S, Shale D J, Rocker G M
Department of Cardiothoracic Surgery, Oxford Heart Centre, John Radcliffe Hospital, England.
J Thorac Cardiovasc Surg. 1993 Jan;105(1):25-30.
Leukocyte counts, plasma neutrophil elastase, tumor necrosis factor-alpha and C-reactive protein were determined serially in 19 patients undergoing elective coronary artery surgery with cardiopulmonary bypass. Neutrophil counts (mean +/- standard deviation 3.85 +/- 1.20 x 10(9)/L preoperatively) peaked 4 hours postoperatively at 10.35 +/- 4.24 x 10(9)/L (p < 0.001) and remained significantly elevated 48 hours postoperatively at 7.80 +/- 2.70 x 10(9)/L, p < 0.05. Plasma neutrophil elastase level (187 +/- 74 ng/ml preoperatively) peaked at 698 +/- 323 ng/ml at the end of surgery (p < 0.001) and remained significantly elevated at 424 +/- 146 ng/ml 48 hours postoperatively (p < 0.01). Peak elastase levels correlated significantly with duration of bypass (r = 0.47, n = 19, p < 0.05). Monocyte counts (0.29 +/- 0.19 x 10(9)/L preoperatively) peaked 4 hours postoperatively (0.87 +/- 0.41 x 10(9)/L, p < 0.001) and fell to baseline levels by 48 hours postoperatively. Plasma tumor necrosis factor-alpha, detectable in 10 of the 19 patients preoperatively (median 0.39 U/ml, range up to 10.1 U/ml), did not change significantly during or after bypass. Plasma C-reactive protein level (median 1.67 [range 0.69 to 34.33] micrograms/ml preoperatively) rose significantly to 3.99 (range 1.95 to 12.55) micrograms/ml 4 hours postoperatively (p < 0.01) and rose 48 hours postoperatively at 303 (210 to 410) micrograms/ml, p < 0.001. Oxygenation, determined by the respiratory index, was impaired at the end of operation (2.07 +/- 0.82) and remained impaired 24 hours postoperatively (2.48 +/- 0.83). Impairment of oxygenation was temporally related to elevated elastase levels, but neither peak elastase levels nor the change in elastase levels with lung reperfusion correlated significantly with the area under the respiratory index curve up to 6 hours postoperatively. This study demonstrates neutrophil elastase release during cardiopulmonary bypass but fails to show a definite role for neutrophil activation or tumor necrosis factor-alpha in the etiology of pulmonary dysfunction after cardiopulmonary bypass.
对19例行择期冠状动脉搭桥术并使用体外循环的患者，连续测定其白细胞计数、血浆中性粒细胞弹性蛋白酶、肿瘤坏死因子-α和C反应蛋白。中性粒细胞计数（术前平均±标准差为3.85±1.20×10⁹/L）术后4小时达到峰值，为10.35±4.24×10⁹/L（p<0.001），术后48小时仍显著升高，为7.80±2.70×10⁹/L，p<0.05。血浆中性粒细胞弹性蛋白酶水平（术前为187±74 ng/ml）在手术结束时达到峰值，为698±323 ng/ml（p<0.001），术后48小时仍显著升高，为424±146 ng/ml（p<0.01）。弹性蛋白酶峰值水平与体外循环时间显著相关（r=0.47，n=19，p<0.05）。单核细胞计数（术前为0.29±0.19×10⁹/L）术后4小时达到峰值（0.87±0.41×10⁹/L，p<0.001），术后48小时降至基线水平。19例患者中有10例术前可检测到血浆肿瘤坏死因子-α（中位数为0.39 U/ml，范围高达10.1 U/ml），在体外循环期间及之后无显著变化。血浆C反应蛋白水平（术前中位数为1.67[范围0.69至34.33]μg/ml）术后4小时显著升高至3.99（范围1.95至12.55）μg/ml（p<0.01），术后48小时升至303（210至410）μg/ml，p<0.001。通过呼吸指数测定的氧合在手术结束时受损（2.07±0.82），术后24小时仍受损（2.48±0.83）。氧合受损与弹性蛋白酶水平升高在时间上相关，但弹性蛋白酶峰值水平及肺再灌注时弹性蛋白酶水平的变化与术后6小时内呼吸指数曲线下面积均无显著相关性。本研究证明了体外循环期间中性粒细胞弹性蛋白酶的释放，但未能显示中性粒细胞激活或肿瘤坏死因子-α在体外循环后肺功能障碍病因中的明确作用。
