尹江濤　萬兵　孫志偉

[摘要] 目的 探討右美托咪定（DEX）對(duì)需機(jī)械通氣膿毒癥患者腹內(nèi)壓（IAP）及腸黏膜通透性的影響。 方法 選取江蘇大學(xué)附屬醫(yī)院綜合ICU 2013年1月～2015年12月住院的需機(jī)械通氣治療的腹腔感染患者40例，按隨機(jī)數(shù)字表法將其分為DEX組和咪達(dá)唑侖組，每組20例。DEX組予負(fù)荷劑量1.0 μg/kg，以0.2～0.8 μg/（kg·h）的劑量維持；咪達(dá)唑侖組予負(fù)荷劑量0.05 mg/kg，以0.06～0.2 mg/（kg·h）劑量維持，兩組均使Ramsay鎮(zhèn)靜評(píng)分維持在3～4分，分別記錄患者鎮(zhèn)靜治療前、鎮(zhèn)靜后24及48 h的IAP水平，并檢測(cè)血漿D-乳酸含量和二胺氧化酶（DAO）的活性。 結(jié)果 鎮(zhèn)靜前兩組IAP水平比較差異無統(tǒng)計(jì)學(xué)意義（P > 0.05）；DEX組于鎮(zhèn)靜后24及48 h 的IAP水平顯著低于同時(shí)間點(diǎn)咪達(dá)唑侖組（P < 0.05）。DEX組24及48 h的D-乳酸含量和DAO活性亦明顯低于同時(shí)間點(diǎn)咪達(dá)唑侖組（P < 0.05）。 結(jié)論 與咪達(dá)唑侖相比，DEX可以更有效地降低機(jī)械通氣膿毒癥患者的IAP，且能有效降低患者腸道黏膜通透性，減少腸道細(xì)菌易位，改善腸功能障礙。

[關(guān)鍵詞] 右美托咪定；膿毒癥；腹內(nèi)壓；腸黏膜通透性

[中圖分類號(hào)] R631 [文獻(xiàn)標(biāo)識(shí)碼] A [文章編號(hào)] 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

嚴(yán)重膿毒癥或膿毒癥休克[1]多伴有多器官功能障礙綜合征（multiple organ dysfunction syndrome，MODS），既往對(duì)于膿毒癥合并嚴(yán)重心、肝、肺、腎等臟器損傷研究較多[2-3]。但是，研究發(fā)現(xiàn)，胃腸道是最易受損的靶器官，其損傷時(shí)往往會(huì)出現(xiàn)胃腸動(dòng)力障礙，表現(xiàn)為腸黏膜機(jī)械屏障損傷及胃腸道生態(tài)紊亂等[4]。同時(shí)，胃腸道也是膿毒癥的啟動(dòng)器官，胃腸道損傷后可導(dǎo)致腸道細(xì)菌和內(nèi)毒素易位，從而引起腸源性感染，進(jìn)而使病情加重，形成惡性循環(huán)，提高死亡率[5]。胃腸道功能損傷臨床早期通常不明顯，無特異性指標(biāo)提示，一旦發(fā)生嚴(yán)重功能障礙，患者大多預(yù)后不良[6]。右美托咪定（dexm-edetomidine，DEX）是一種新型的鎮(zhèn)靜藥物[7]，其原理是通過興奮藍(lán)斑核內(nèi)的α2腎上腺素能受體，從而產(chǎn)生劑量依賴性的鎮(zhèn)靜、催眠、抗焦慮及交感神經(jīng)抑制等作用，近年來，越來越多的研究發(fā)現(xiàn)，DEX不僅具有鎮(zhèn)靜、鎮(zhèn)痛的效果，在膿毒癥中還具有抑制炎癥反應(yīng)及減少炎癥介質(zhì)的作用，并對(duì)腦、心、腎及肺等器官起到一定的保護(hù)作用[8]。本研究旨在比較DEX與咪達(dá)唑侖對(duì)機(jī)械通氣膿毒癥患者IAP及腸黏膜通透性的影響。