右美托咪定对机械通气脓毒症患者腹内压及肠黏膜通透性的影响

尹江涛　万兵　孙志伟

[摘要] 目的 探讨右美托咪定（DEX）对需机械通气脓毒症患者腹内压（IAP）及肠黏膜通透性的影响。 方法 选取江苏大学附属医院综合ICU 2013年1月～2015年12月住院的需机械通气治疗的腹腔感染患者40例，按随机数字表法将其分为DEX组和咪达唑仑组，每组20例。DEX组予负荷剂量1.0 μg/kg，以0.2～0.8 μg/（kg·h）的剂量维持；咪达唑仑组予负荷剂量0.05 mg/kg，以0.06～0.2 mg/（kg·h）剂量维持，两组均使Ramsay镇静评分维持在3～4分，分别记录患者镇静治疗前、镇静后24及48 h的IAP水平，并检测血浆D-乳酸含量和二胺氧化酶（DAO）的活性。 结果 镇静前两组IAP水平比较差异无统计学意义（P > 0.05）；DEX组于镇静后24及48 h 的IAP水平显著低于同时间点咪达唑仑组（P < 0.05）。DEX组24及48 h的D-乳酸含量和DAO活性亦明显低于同时间点咪达唑仑组（P < 0.05）。 结论 与咪达唑仑相比，DEX可以更有效地降低机械通气脓毒症患者的IAP，且能有效降低患者肠道黏膜通透性，减少肠道细菌易位，改善肠功能障碍。

[关键词] 右美托咪定；脓毒症；腹内压；肠黏膜通透性

[中图分类号] R631 [文献标识码] A [文章编号] 1673-7210（2016）12（c）-0161-04

[Abstract] Objective To discuss the effects of Dexmedetomidine on the intra-abdominal pressure （IAP） and intestinal permeability in septic patients with mechanical ventilation. Methods A total of 40 septic patients with mechanical ventilation were admitted into the Department of Genernal ICU， the Affiliated Hospital of Jiangsu University between January 2013 to December 2015 were enrolled. They were divided into a Dexmedetomidine group （n=20） and a Midazolam group （n=20） by random number table method. The patients in the Dexmedetomidine group were given a loading dose （1 μg/kg） and then maintained with 0.2-0.8 μg/（kg·h）， the patients in the Midazolam group were given a loading dose （0.05 mg/kg） and then maintained with 0.06-0.2 mg/（kg·h）， sedation level was assessed by Ramsay score and maintained a score of 3-4. IAP was recorded before sedation at 24 h as well as 48 h after， content of D-lactic acid and activity of diamine oxidase in serum was detected also. Results IAP in Dexmedetomidine group was significantly lower than that in Midazolam group at 24 h and 48 h （P < 0.05）， however， there was no significant differences before sedation （P > 0.05）. And the content of D-lactic acid and activity of diamine oxidase in serum in Dexmedetomidine group was obviously lower than that in Midazolam group at 24 h and 48 h （P < 0.05）. Conclusion Dexmedetomidine can significantly decrease IAP compared with Midazolam for the septic patients with mechanical ventilation， as well as depress intestinal permeability and relieve sepsis symptom resulted from bacterial translocation.

[Key words] Dexmedetomidine； Sepsis； Intra-abdominal pressure； Intestinal permeability

严重脓毒症或脓毒症休克[1]多伴有多器官功能障碍综合征（multiple organ dysfunction syndrome，MODS），既往对于脓毒症合并严重心、肝、肺、肾等脏器损伤研究较多[2-3]。但是，研究发现，胃肠道是最易受损的靶器官，其损伤时往往会出现胃肠动力障碍，表现为肠黏膜机械屏障损伤及胃肠道生态紊乱等[4]。同时，胃肠道也是脓毒症的启动器官，胃肠道损伤后可导致肠道细菌和内毒素易位，从而引起腸源性感染，进而使病情加重，形成恶性循环，提高死亡率[5]。胃肠道功能损伤临床早期通常不明显，无特异性指标提示，一旦发生严重功能障碍，患者大多预后不良[6]。右美托咪定（dexm-edetomidine，DEX）是一种新型的镇静药物[7]，其原理是通过兴奋蓝斑核内的α2肾上腺素能受体，从而产生剂量依赖性的镇静、催眠、抗焦虑及交感神经抑制等作用，近年来，越来越多的研究发现，DEX不仅具有镇静、镇痛的效果，在脓毒症中还具有抑制炎症反应及减少炎症介质的作用，并对脑、心、肾及肺等器官起到一定的保护作用[8]。本研究旨在比较DEX与咪达唑仑对机械通气脓毒症患者IAP及肠黏膜通透性的影响。