| With the continuous improvement of technology in video-assisted thoracoscopic surgery (VATS), the indications of VATS are expanding. The patients who received VATS usually combined with a variety of underlying diseases.Diabetes patients are increasing in thoracoscopic operation among them. Diabetes mellitus (DM)is metabolic disorders caused by multiple factors and the character is chronic hyperglycemia. It was a group of clinical syndrome that lead to multisystem damage. More and more domestic and foreign research supported that lung was the target organs damaged by DM. First of all, the characteristic change of pulmonary pathology in diabetic was thickening on the alveolar epithelial basal layer and the capillary endothelial basal layer.Secondly, diabetic patients had abnormal pulmonary function, mainly manifesting as pulmonary ventilation dysfunction, small airway dysfunction and diffusion dysfunction. The abnormal lung pathology and lung function in patients with DM whether causes the corresponding index change of respiratory mechanics during one-lung ventilation (OLV), there are no relevant literature reports now?Diabetic patients had state of chronic low-grade inflammatory,C reactive protein, blood interleukin 6, interleukin 8 and tumor necrosis factor and other inflammatory cytokines of the serum in patients with DM were more than non-diabetic mellitus patients. The ventilated lung and non-ventilated lung were suffered different degrees of damage during one-lung ventilation.The mainly effect of OLV on ventilated lung was mechanical stretch during one-lung ventilation. But the impact of OLV on non-ventilated lung was larger than that of ventilated lung,Lung tissue stretched by surgical operators. The process from collapse to ecruitment on non-ventilated lung was also the process from hypoxia to reoxygenation, ischemia-reperfusion injury to the lung tissue. The study found that OLV and two lung ventilation can lead to interleukin-6 (Interleukin-6, IL-6) and interleukin-8 (Interleukin-8, IL-8) increase, but OLV was more significantly. It is still not clear in the superposition factors how change of the inflammatory cytokines in the serum and bronchoalveolar lavage fluid in the patients with DM during OLV.One of the lung protection strategy for OLV is how to manage the perioperative excessive inflammatory response. The positive effect of anti-inflammatory drug using were supported by more and more research. Ulinastatin is also called urine inhibin which is a glycoprotein separated from the urine.It is a highly efficient broad-spectrum protease inhibitor. It can be widely inhibit trypsin, plasmin and other phospholipase, protease and lipase,and can inhibit the inflammatory cascade reaction in a plurality of ring section,.It is also the lysosomal membrane stability, inhibition of lysosomal release, and can enhance the activity of superoxide dismutase(SOD) and effectively clear oxygen free radical. Ulinastatin can also reduce the inflammatory response of the lungs so to reduce the lung tissue injury. Therefore, ulinastatin is widely used in the treatment of pancreatic and lung injury and other complications. Whether it can effectively exert its anti-inflammatory effect before OLV in patients with DM is worth to study.How to change of the respiratory mechanics index in patients with DM during OLV, and the internal relatation between such changes and lung tissue damage in patients with DM is still unclear.This study attempts to observe the changes of the pulmonary pathology and the characteristics of respiratory mechanics in patients with type 2 diabetes mellitus during OLV, and to observe the changes of inflammatory cytokines in Serum and bronchoalveolar lavage fluid (BLAF) in patients with type 2 diabetes mellitus during OLV and the effects of ulinastatin’intervention.The mainly aim is to provide clinical basis of protective strategy in patients with type 2 diabetes mellitus during OLV.Objective1. To study the changes of the pulmonary pathology, respiratory mechanics and inflammatory cytokines in patients with type 2 diabetes mellitus during one-lung ventilation.2. To observe the changes of inflammatory cytokines in serum and bronchoalveolar lavage fluid (BLAF) in patients with type 2 diabetes mellitus during one-lung ventilation and the effects of ulinastatin’intervention.Methods1. Study on the changes of the pulmonary pathology, respiratory mechanics and inflammatory cytokines in patients with type 2 diabetes mellitus during one-lung ventilation1.1 patientsWith Ethics Committee approval and written informed consent,40 patients (age range,45-73 year,ASA physical status I or II)undergoing lobectomy operation were enrolled in the study. According to the 2003 American diabetes association (ADA)diagnostic criteria for diabetes, whether the patients with type 2 diabetes mellitus or not were divided into diabetic group (DM group) and non diabetes mellitus group (C group),20 cases in each group.Exclusion criteria included:asthma;active upper respiratory tract infection;pulmonary infection;atelectasis;cardiac insufficiency;hypertension;hepatic inadequacy;nephrosis;anemia;or for any contraindication to the anaesthetic drugs described below.The recovery rate of BALF was more than 40%;re-expand lung less than 5 times during operation.Patients whose blood loss more than 15%of weight or transfusion were exclude from study.The case was excluded when the patients need to inhale FiO2>80% more than 1 hours.1.2 General anaesthesia and ventilation methodMidazolam 0.05mg/kg and atropine O.Olmg/kg were intramuscular injected 30 minutes before anesthesia. Patients had the vital signs and bispectral index (BIS) monitor after getting into the operation room.All patients were placed radial arterial catheter and established invasive blood pressure detection. Blood gas analysis and blood glucose testing were be done as the basis of value. After inhalation of oxygen for 3 min,Anaesthesia was induced with target controlled infusing propofol(target blood concentration 3 ug/ml),sufentanyl 0.4 ug/kg and cisatracurium 0.2 mg/kg.A flexible styletted DLT was accomplished via direct laryngoscopy according to a standardized protocol,and a fiberoptic bronchoseope (FOB)was then employed to confirm correct positioning of the tube.All the selected patients had the same volume controlled ventilation mode.The patients were ventilated with a FiO2 of 0.6 through out, ventilator settings were adjusted to a VT of 6-8 ml/kg,rate of 12-15 every minute and I:E ratio 1:1.5 to maintain end-tidal partial pressure of carbon dioxide (PetCO2)between 35～40 mmHg. Ventilator settings were kept constant during the study. After intubation, All patients were placed central venous catheter. In order to maintain anaesthesia and maintain bispectral index (BIS) at 40～55 in operation, target controlled infusion (TCI) of propofol 2.5～4ug/ml,0.05～0.3ug/kg.min of continuous infusion of remifentanil and intermittent intravenous injection of cisatracurium were be used. Respiratory secretions was sucked before the ending of operation.Two lung ventilation were be recovered.Patients were sent to the postanaesthesia care unit (PACU).Postoperative analgesia and analgesic drugs were the same in all patients.The patients were extubated in the PACU when they were fully awake to meet tracheal extubation criteria.Thereafter they were transferred to the intensive care unit for continue treatment.The patients were receiving oxygen via nasal catheter(2 L/min).1.3 Observations time pointsTl:before anaesthesia;T2:before one lung ventilation;T3:before the end of surgery;T4:24 hours after surgery.1.4 Sample processing and variables recording1.4.1 HR,MAP,SpO2 of two groups were recorded at T1 to T4.1.4.2 Ppeak,Cdyn,PetCO2,MV of two groups were recorded at T2 and T3 by Datex-Capnomac Ultima-SV monitor.1.4.3 Intermittent sugar and arterial blood gas analysis was performed at T1 to T4 respectedly.PH,PaO2,PaCO2,HCO3-,xygenation index(PaO2/FiO2),and bicarbonate were measured by i-STAT.The serum of patients in two groups were taken to measure the concentrations of IL-2,IL-4,IL-6,IL-8,IL-10,TNF-a by Bio-Plex Suspension Assay System.1.4.4 BALF was performed at T2 and T3.Put the top of bronchoscopy to the opening of segment or sub-segmental bronchi,and used silicone tube rapidly injecting sterile normal saline 30ml through the biopsyhole(10ml/time,total 30rnl).Lavage fluid was stored at a clean sputum collection through a vacuum suction and recorded the recovery volume.The specimens of patients in two groups were taken to measure the concentrations of IL-2,IL-4,IL-6,IL-8,IL-10,TNF-a by Bio-Plex Suspension Assay System and pulmonary surfactant protein A(SPA) by enzyme-linked immunosorbent assay (ELISA).1.4.5 Lung tissues were taken from the same parts of pre lobectomy. Lung tissues were soaked in 10% buffered formalin and fixed,then embedded in paraffin,slice,row, hematoxylin-eosin stainng.Lung pathologic morphology was viewed under an ordinary optical. Advanced glyeosylated end products (AGEs) and pulmonary surfactant protein A(SPA) were be analysised for positioning and quantitative with immunohistochemistry.1.5 Other observation items(1)duration of surgery;(2)duration of anesthesia;(3)the amount of blood loss and urine;(4)intraoperative intravenous input;(5) amount of narcotic drugs;(6)the stay days in the hospital;(7)the stay days after surgery;(8)the stay time in the ICU;(9)costs of antibiotics;(10) record the abnormal chest X-ray results in 3 days after surgery.1.6 Statistical analysesDescriptive statistics(x±s)were used to summarize the continuous data, medians were used in categorical data.SPSS 13.0 statistical software package was used for all analyses.The independent samples T test was used to compare demographic data and all testing indexs (hemodynamics, respiratory mechanics,blood gas values and the concentrations of IL-2,IL-4,IL-6,IL-8,IL-10,TNF-a) between the two groups, while analysis of variance of repeated measures data was used to compare intragroup variables(hemodynamics,respiratory mechanics,blood gas values and the concentrations of IL-2,IL-4,IL-6,IL-8,IL-10,TNF-a)of different periods. Chi·square was used to compare count data.P values<0.05 were considered to be statistically significant.2. The changes of inflammatory cytokines in Serum and bronchoalveolar lavage fluid in patients with type 2 diabetes mellitus during OLV and the effects of ulinastatin’intervention2.1 patientsWith Ethics Committee approval and written informed consent,30 patients (age range,49-79 year,ASA physical status I or II)with type 2 diabetes mellitus undergoing lobectomy operation were enrolled in the study according to the 2003 ADA diagnostic criteria for diabetes.30 Patients were assigned randomly to two groups(n=15):diabetic group (DM group) and diabetes mellitus group intervention with ulinastatin(DMU group). Exclusion criteria:same as the first stage.2.2 General anaesthesia and ventilation methodMidazolam 0.05mg/kg and atropine O.Olmg/kg were intramuscular injected 30 minutes before anesthesia. Patients had the vital signs and bispectral index (BIS) monitor after getting into the operation room.All patients were placed radial arterial catheter and established invasive blood pressure detection. Blood gas analysis and blood glucose testing were be done as the basis of value.After inhalation of oxygen for 3 min,Anaesthesia was induced with target controlled infusing propofol(target blood concentration 3 ug/ml).sufentanyl 0.4 ug/kg and cisatracurium 0.2 mg/kg.A flexible styletted DLT was accomplished via direct laryngoscopy according to a standardized protocol.and a fiberoptic bronchoseope (FOB)was then employed to confirm correct positioning of the tube. All the selected patients had the same volume controlled ventilation mode.The patients were ventilated with a FiO2 of 0.6 through out, ventilator settings were adjusted to a VT of 6-8 ml/kg,rate of 12-15 every minute and I:E ratio 1:1.5 to maintain PetCO2 between 35～40 mmHg. Ventilator settings were kept constant during the study. After intubation, All patients were placed central venous catheter.After induction of anesthesia,5000U/kg of ulinastatin was diluted to 50ml by continuous intravenous infusion in group DMU in 20min and the same volume of saline in group DM as the control.In order to maintain anaesthesia and maintain BIS at 40-55 in operation, target controlled infusion (TCI) of propofol 2～4ug/ml,0.05～ 0.3ug/kg.min of continuous infusion of remifentanil and intermittent intravenous injection of cisatracurium were be used. Respiratory secretions was sucked before the ending of operation,Two lung ventilation were be recovered.Patients were sent to the PACU. Postoperative analgesia and analgesic drugs were the same in all patients.The patients were extubated in the postanaesthesia care unit when they were fully awake to meet tracheal extubation criteria.Thereafter they were transferred to the intensive care unit for continue treatment.The patients were receiving oxygen via nasal catheter(2 L/min).2.3 Observations time pointsT1:before anesthesia;T2:before one lung ventilation;T3:before the end of surgery;T4:24 hours after surgery.2.4 Sample processing and variables recording2.4.1 HR,MAP,SpO2 of two groups were recorded at Tl to T4.2.4.2 Ppeak, Cdyn, PetCO2,MV of two groups were recorded at T2 and T3 by Datex-Capnomac Ultima-SV monitor.2.4.3 Intermittent sugar and arterial blood gas analysis was performed at T1 to T4 respectively.PH,PaO2,PaCO2,HCO3-,xygenation index(Pa02/Fi02),and bicarbonate were measured by i-STAT.The serum of patients in two groups were taken to measure the concentrations of IL-2,IL-4,IL-6,IL-8,IL-10,TNF-a by Bio-Plex Suspension Assay System.2.4.4 BALF was performed at T2 and T3.Put the top of bronchoscopy to the opening of segment or sub-segmental bronchi,and used silicone mbe rapidly injecting sterile normal saline 10ml through the biopsyhole(10ml/time, total 30ml).Lavage fluid was stored at a clean sputum collection through a vacuum suction and recorded the recovery volume.The specimens of patients in two groups were taken to measure the concentrations of IL-2,IL-4,IL-6,IL-8,IL-10,TNF-a by Bio-Plex Suspension Assay System.2.5 Other observation items(1)duration of surgery;(2)duration of anesthesia;(3)the amount of blood loss and urine;(4)intraoperative intravenous input;(5) amount of narcotic drugs;(6)the stay days in the hospital;(7)the stay days after surgery; (8)the stay time in the ICU; (9)costs of antibiotics;(10) record the abnormal chest X-ray results in 3 days after surgery.2.6 Statistical analysesDescriptive statistics(x±s)were used to summarize the continuous data, medians were used in categorical data.SPSS 13.0 statistical software package was used for all analyses.The independent samples T test was used to compare demographic data and all testing indexs (hemodynamics, respiratory mechanics, blood gas values and the concentrations of IL-2,IL-4,IL-6,IL-8,IL-10,TNF-a)between the two groups, while analysis of variance of repeated measures data was used to compare intragroup variables of different periods. Chi·square was used to compare count data.P values<0.05 were considered to be statistically significant.Results1. Study on the changes of the pulmonary pathology and respiratory mechanics in patients with type 2 diabetic mellitus during one-lung ventilation1.1 Demographic dataThe independent samples T test showed that the two groups were comparable in terms of age,weight,height,FEVl/FVC (%)of pulmonary function,duration of anaesthesia, duration of surgery, dose of anesthesia agents, volume of fluid,blood loss, and urinary output(P>0.099). FVC%,FEV1% and MVV% of pulmonary function in the DM group were lower than in the C group (P<0.012).Blood loss of two groups patients were not more than 500ml, and no patient required blood transfusion.1.2 Hemodynamic and SpO2The repeated measures ANOVA analysis showed that HR,MAP and SpO2 had no significant difference between two groups (P>0.074). HR,MAP and SpO2 had significant difference between different time point(P<0.003). There had no interaction between groups and time points(P>0.283).These suggested that the trend of HR,MAP,SpO2 of different groups are same with time.1.3 Data of respiratory mechanicsThe repeated measures ANOVA analysis showed that Ppeak and Cdyn had significant difference between two groups(P<0.038). PetCO2 and MV had no significant difference between two groups (P>0.05). Ppeak, Cdyn, PetCO2 and MV had significant difference between different time point(P=0.000). Cdyn, PetCO2 and MV of each group had no interaction with time points(P>0.053), but Ppeak of each group had interaction with time points(P=0.004). These suggested that the trend of Cdyn, PetCO2 and MV in each group was same with time,but the trend of Ppeak was different with time.Further analysis, the results showed that the comparison of Ppeak had significant difference between groups at different time points(P=0.000).There had significant difference between time points at different groups (P<0.03).1.4 Comparison of blood sugar and blood gas valuesThe repeated measures ANOVA analysis showed that Blood sugar,PaO2 and oxygenation index had significant difference between two groups (P<0.007). Blood sugar, PH,PaO2,PaCO2,HCO3-,BE and oxygenation index had significant difference between different time point(P<0.001). Blood sugar,PaO2,HCO3-,BE and oxygenation index of each group had no interaction with time points(P>0.101), but PH and PaCO2 of each group had interaction with time points(P<0.044).These suggested that the trend of Blood sugar, PaO2,HCO3-,BE and oxygenation index in each group was same with time,but the trend of PH and PaCO2 was different with time.Further analysis, the results showed that the comparison of PH and PaCO2 had significant difference between groups at different time points(P<0.001).There had no significant difference between time points at different groups (P>0.101).1.5 Comparison of lung tissue of optical microscope, AGEs and SPA immunohistochemical score1.5.1 Comparison of lung tissue of optical microscopePulmonary pathological changes in the performance of the patients in the DM group:alveolar wall and arterial wall were thickened generally,Obvious proliferation of fibrous tissue and pulmonary interstitial inflammatory cell infiltration could be saw.While alveolar wall and arterial wall were thickened slightly and pulmonary interstitial infiltration of inflammatory cells were less in C group,1.5.2 Comparison of AGEs and SP-A immunohistochemical scoreAGEs immunohistochemical scores were:(3.57+1.09) and (2.82+0.99); SPA immunohistochemistry score were (3.62+1.06) and (3.32+1.13) points in DM group and C group, respectively.The independent samples T test showed that there was significant difference compared with AGEs immunohistochemical score between the two groups (P=0.000),but there was no difference compared with SPA immunohistochemical score between the two groups (P=0.131)1.6 Comparison of SPA in BLAFThe repeated measures ANOVA analysis showed that the concentrations of SPA in the ventilated lung had significant difference between two groups(P=0.048),but the concentration of SPA in the non-ventilated lung had no difference between two groups(P=0.773).The concentration of SPA had significant difference between different time point (P<0.005). There had no interaction between groups and time points(P>0.186).These suggested that the trend of SPA of different groups are same with time.1.7 The concentrations of IL-6 and IL-8 in serumThe repeated measures ANOVA analysis showed that the concentrations of IL-8 in serum had significant difference between two groups(P=0.003),but the concentration of IL-6 in serum had no difference between two groups(P=0.773).The concentration of IL-6 and IL-8 in serum had significant difference between different time point(P<0.002).There had no interaction between groups and time points(P>0.083).These suggested that the trend of IL-6 and IL-8 in serum of different groups are same with time.1.8 The concentrations of IL-2,IL-4,IL-6,IL-8,IL-10 and TNF-a in BLAFThe repeated measures ANOVA analysis showed that the concentrations of IL-6 in ventilated lung, IL-8 and TNF-a in bilateral lungs in BLAF had significant difference between two groups(P<0.004). The concentrations of IL-2,IL-4,IL-6,IL-8,IL-10 and TNF-a in BLAF in bilateral lungs had significant difference between different time point(P<0.007). IL-4,IL-6 and IL-10 in the non-ventilated lung had no interaction between groups and time points(P>0.057). IL-2,IL-8,and TNF-a in bilateral lungs and IL-4,IL-6 and IL-10 in ventilated lung had interaction with time points(P<0.047). These suggested that the trend of IL-4,IL-6 and IL-10 in the non-ventilated lung of different groups are same with time,but the trend of IL-2,IL-8,and TNF-a in bilateral lungs and IL-4,IL-6 and IL-10 in ventilated lung are different with time.Further analysis,the results showed that IL-2 in bilateral lungs, IL-4 and IL-10 in ventilated lung had significant difference between time points at different groups (P<0.007),but There had no significant difference between time points at different groups (P>0.135).IL-2,IL-8,and TNF-a in bilateral lungs and IL-4,IL-6 and IL-10 in ventilated lung had significant difference between groups and different time points (P<0.004).1.9 Postoperative data and complicationThe independent samples T test or Chi-square test showed that the total duration of hospitalization, the postoperative duration of hospitalization and the duration of ICU in DM group were longer than in C group (P<0.047). There were no differences between groups with the incidence of pulmonary inflammation and costs of antibiotics(P>0.121).2. The changes of inflammatory cytokines in Serum and bronchoalveolar lavage fluid in patients with type 2 DM during OLV and the effects of ulinastatin’ intervention2.1 Demographic dataThe independent samples T test showed that the two groups were comparable in terms of age,weight,height,FVC%,FEV1%,FEV1/FVC (%)and MVV% of pulmonary function,duration of anaesthesia, duration of surgery, dose of anesthesia agents, volume of fluid,blood loss,and urinary output(P>0.203). Blood loss of two groups patients were not more than 500ml, and no patient required blood transfusion.2.2 Hemodynamic and SpO2The repeated measures ANOVA analysis showed that HR,MAP and SpO2 had no significant difference between two groups (P>0.854). HR,MAP and SpO2 had significant difference between different time point(P<0.008). There had no interaction between groups and time points(P>0.306).These suggested that the trend of HR,MAP,SpO2 of different groups are same with time.2.3 Data of respiratory mechanicsThe repeated measures ANOVA analysis showed that Ppeak, Cdyn, PetCO2 and MV had no significant difference between two groups (P>0.687). Ppeak, Cdyn, PetCO2 and MV had significant difference between different time point(P<=0.012). Ppeak, PetCO2 and MV of each group had no interaction with time points(P>0.395), but Cdyn of each group had interaction with time points(P=0.041).These suggested that the trend of Ppeak, PetCO2 and MV in each group was same with time,but the trend of Cdyn was different with time.Further analysis, the results showed that the comparison of Cdyn had significant difference between groups at different time points(P=0.000).There had no significant difference between time points at different groups (P=0.816).2.4 Comparison of blood sugar and blood gas valuesThe repeated measures ANOVA analysis showed that PH and PaCO2 had significant difference between two groups(P<0.03). Blood sugar, PH,PaO2,PaCO2,HCO3-,BE and oxygenation index had significant difference between different time point(P<0.005). PH,PaO2,PaCO2,HCO3-,BE and oxygenation index of each group had no interaction with time points(P>0.608).These suggested that the trend of PH,PaO2,PaCO2,HCO3-,BE and oxygenation index in each group was same with time.2.5 The concentrations of IL-6 and IL-8 in serumThe repeated measures ANOVA analysis showed that the concentrations of IL-8 in serum had significant difference between two groups(P=0.026),but the concentration of IL-6 had no difference between two groups(P=0.550).The concentration of IL-6 and IL-8 in serum had significant difference between different time point(P<0.002).There had no interaction between groups and time points(P>0.136).These suggested that the trend of IL-6 and IL-8 in each groups are same with time.2.6 The concentrations of IL-2,IL-4,IL-6,IL-8,IL-10 and TNF-a in BLAFThe repeated measures ANOVA analysis showed that the concentrations of IL-2,IL-4,IL-6,IL-8,IL-10 and TNF-a in bilateral lungs in BLAF had no significant difference between two groups(P>0.239). the concentrations of IL-2,IL-4,IL-6,IL-8 and TNF-a in bilateral lungs and IL-10 in the non-ventilated lung had significant difference between different time point(P<0.003). IL-2,IL-4,IL-6,IL-8,IL-10 and TNF-a in bilateral lungs in BLAF had no interaction between groups and time points(P>0.182). These suggested that the trend of IL-2,IL-4,IL-6,IL-8,IL-10 and TNF-a in bilateral lungs of each groups are same with time.2.7 Postoperative data and complicationThe independent samples T test or Chi-square test showed that there were no differences between groups with the total duration of hospitalization, the postoperative duration of hospitalization,the duration of ICU,the incidence of pulmonary inflammation and costs of antibiotics(P>0.092).Conclusion1. The reducing of Cdyn, oxygenation index and the rising of Ppeak may be related to the damage of pulmonary function and lung tissue and deposition of advanced glycation end products (AGEs) in the lung tissue in type 2 diabetes mellitus patients during one-lung ventilation.2. IL-8 in serum and IL-6, IL-8, TNF-a in bronchoalveolar lavage fluid were all increased in type 2 diabetes mellitus patients during one-lung ventilation.3.5000U/kg of ulinastatin pretreatment could reduce the levels of the IL-8 in Serum but it did not reduce the levels of IL-6 in serum and IL-2,IL-4,IL-6,IL-8,IL-10,TNF-a in bronchoalveolar lavage fluid in patients with type 2 diabetes mellitus patients during one-lung ventilation. |
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