| Objective: This study was to observe level changes of thromboxane A2 (TXA2) and prostacyclin (prostaglandin I2. PGI2) and the changes of hemodynamic effects in patients undergoing combined spinal-epidural anesthesia (CSEA) during renal transplantation. To discuss that if CSEA and the management will not only be able to meet the needs and ensure the safety of patients but also improve the microcirculation of the body, thus playing a role in the protection of organs and mechanisms. To provide more comprehensive theory for the choice of anesthesia for the renal transplantation.Methods: We chose 40 cases of renal transplantation to perform CSEA, intraoperative fentanyl and propofol sedation analgesia. Intraoperative monitoring radial artery blood pressure: systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial blood pressure (MBP), central venous pressure (CVP), electrocardiogram (ECG), pulse oximetry (SpO2), heart rate(HR) and temperature. Measuring thromboxane B2 (TXB2) and 6-keto - prostaglandin (6-K-PGF1a,6-K) concentration at 5 time points:supine after spinal anesthesia (T0), 5 minites after skin incising (T2), adding three wings clamp (T2), bladder flushing (T3) and skin closing(T4) and recording corresponding time points of systolicblood pressure, diastolic blood pressure, central venous pressure, heart rate and oxygen saturation changes.Results: 1. hemodynamic changes: MAP and DBP during T1~T4 decreased more than those of T0, and decreased gradually; Compare with that at T0, The levels of MAP at T2, T3, T4 decreased significantly different (p<0.05) and at the other time points, there was no significant difference between each other (p>0.05). Compare with that at T0, The levels of SBP at T1, T2, T3, T4 decreased, but no significant changes (P>0.05). Changes in HR and SpO2 was no statistically significant difference (p>0.05).2. Compare with that at T0, the levels of TXB2 were higher at T1, T2, T4 and lower at T3. There was no significant changes (P>0.05). Compare with that at T0, T1, T2, the levels of 6-K were higher at T3, T4, and there was significant changes (P<0.05). The ratio of 6-K and TXB2 (K/T) increased from the beginning, reaching the peal at T4. Compare with that at T0, T1, T2, K/T value has gradually increased at T3 with statistically significant difference (p<0.05). Compare with that at T0, it has gradually increased at T4 with statistically significant difference (p<0.05).Discussion: The study found that while most patients died of renal transplantation, the kidneys were still functional. cardiovascular and cerebrovascular diseases were the most important cause of death in renal transplant recipients. Guaranteethe survival rate of transplanted kidney and the prognosis of transplant patients is the fundamental surgical treatment, such treatment has always run through the work and is particularly important during perioperative. During anesthetic management process, we should ensure that the maximum renal perfusion and all the vital organs and functions of the microcirculation to achieve short-term and long-term survival good dual purposes.Ischemia reperfusion injury (IRI) in ischemic acute renal failure is a major injury link and the main factors of ransplanted kidney function recovery. There are varying degrees of renal ischemia- reperfusion injury in patients of renal transplantation. PGI2 is vascular endothelial growth factor in endothelial cells, it can inhibit platelet aggregation and smooth muscle proliferation. Renal prostaglandin synthesis primarily by the kidney itself, and its basic role is to regulate renal blood flow. In hypoxic-ischemic conditions, resulting in TXA2 synthesis, vasoconstriction cramps, platelet aggregation thrombosis, disseminated intravascular coagulation and renal arteries. TXA2 is a strong vasoconstrictor agents and platelet aggregation, and vascular PGI2 is a platelet aggregation inhibitor and vasoconstrictor relaxants. TXA2 is a strong vasoconstrictor agents and platelet aggregation, and vascular PGI2 is a platelet aggregation inhibitor and vasoconstrictor relaxants. Physiological conditions, the two are mutually antagonistic in regulating vasculartone and platelet function, and stable Endovascular environment.Reported abroad, the ratio of K/T decreased when renal ischemia-reperfusion injury, and it led to serious kidney damage. Plasma levels of TXB2 of patients in this study has no significant difference. While K/T ratio from the onset of anesthesia to the end of surgery show upward trend. This suggested that anesthesia and management could increase the ratio of K/T of surgery patients and reverse the imbalance of K/T, thereby improved micro-circulation in the body. The mechanism may be related to the following:â‘ PGI2 can reduce platelet activity and inhibit platelet aggregation, thereby lowering blood viscosity, improve microcirculation.â‘¡Angioplasty, reducing vascular permeability.â‘¢PGI2 improve nitric oxide (NO) synthase andrelease. They both reduced TXA2, endothelin and angiotensin in vasoconstrictor effect; PGI2 can also play the same as NO to inhibit negative feedback of synthesis of endothelin and TXA2 by cAMP.â‘£Inhibiting leukocyte - endothelial cell adhesion, blocking inflammation cascade.It may be related to the following that CSEA and the intraoperative management of anesthesia maintain hemodynamic stability and increase the ratio of K/T:1. Analgesic effect of CSEA fully, so traumatic stress was suppressed during operation; Anesthesia regional vasodilator will moderate decline in blood pressure and systemic vascular resistancedecreased after cardiac reduce the load and prevent the occurrence of congestive heart failure and pulmonary edema. It was beneficial for patients with hypertension.2. Reasonable fluid therapy: Reduce the volume of crystalloid and increase the volume of blood transfusion and artificial colloid to expand blood volume and improve microcirculation. 6% hetastarch (200/05) (HAES200/0.5) can reduce the release of vasoactive substances. 3. Propofol has the protective effect against oxidative stress as a sedative narcotic analgesic:propofol can not only provide comfort, relieve tension, fear, emotional and mental stress but also have remove oxygen free radicals, anti-oxidative stress and anti-apoptotic role, which the study of protection to the animals in vivo had a similar conclusion.Conclusion: 1.CSEA can provid definite analgesic effect, full of muscle relaxant and relatively small impact on the circulation and respiration. Anesthesia and the management of can ensure renal transplant patients hemodynamic stability. 2.Speculate on the microcirculation with CSEA, CSEA improve microcirculation may be achieved by increasing the ratio of K/T. CSEA and operation management can guarantee that important organ perfusion while promoting microcirculation function, to be safe, effective anesthesia.
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