添加精胺酸、麩醯胺酸及胺基酸混和液的復甦治療對創傷出血性休克大鼠發炎反應及標的器官損傷的探討

The investigation of trauma-hemorrhage shock induced inflammatory responses and organ damages in rats when arginine-, glutamine-, or amino acid mixture as resuscitation fluids

黃富煥(Fu-Huan Huang)

指導教授 ： 周明智

中山醫學大學/醫學院/醫學研究所/碩士(2018年)

摘要

研究目的： 臨床上創傷失血性休克的患者，常因嚴重的失血以及能量喪失和缺氧後，導致多器官衰竭甚至死亡。提供大容量的復甦液來恢復血壓是傳統的臨床策略;然而，大量的自由基生成可能會惡化臨床結果。我們先前的研究發現，精胺酸、瓜胺酸或麩醯胺酸可能不會改變失血性休克大鼠的炎症反應。在此，我們透過動物實驗比較探討精胺酸，麩醯胺酸和胺基酸混合物補充的復甦液對創傷失血性休克和給予限制容量的復甦液大鼠的炎症反應和器官損傷的影響。
研究方法及資料：雄性SD大鼠施予頸動脈和頸靜脈插管，中線剖腹手術5 cm，使其失血性休克(平均動脈壓控制在35mmHg)或無失血休克的假手術組（SHA組）。60分鐘後，使用抽出的血液和等體積的林格氏液不含其他添加(THR組）或添加L-丙胺酸（ALA組）、L-精胺酸加L-丙胺酸（ARG組），L-丙胺-麩醯胺酸（GLN組）或L-胺基酸混合物加L-丙胺酸（AMX組），然後連續輸注42小時（〜1.3ml/h）。 大鼠犧牲後，血液檢體與器官組織收集後進行分析來了解其中的發炎反應與器官損傷。
研究結果： 與SHA組相比，THR組的血漿IFN-γ和脾臟重量顯著降低，循環血小板和腎臟硝酸鹽/亞硝酸鹽（NOx）顯著升高，空腸萎縮明顯。 ALA組些微增加循環血小板，腎臟NOx和空腸萎縮些微增加；循環血紅素，血比容，血漿促炎介質和腎細胞凋亡減少以及肺中細胞增殖增加。ARG組增加肺臟濕乾重比，IL-4和空腸細胞凋亡。GLN組增加了脾臟重量，循環血紅素和血比容以及腎臟髓過氧化物酶(MPO)活性和細胞凋亡並減輕了空腸萎縮。AMX組可增加循環血紅素和血比容，降低空腸萎縮和腎臟NOx，並增加肺臟、肝臟和腎臟細胞增殖，腎臟細胞凋亡和肺臟髓過氧化物酶(MPO)活性。這些結果表明胺基酸補充復甦液對循環血液學具有正向作用，並且對器官炎症反應和損傷具有不同作用。
結論： 補充胺基酸的復甦液對於創傷失血性休克患者可能具有潛在臨床營養療法的效果，並且胺基酸補充的使用應該是根據器官需要而有所不同。

關鍵字

出血性休克 ； 復甦 ； 胺基酸

並列摘要

Objective：Patients with trauma-hemorrhagic shock suffer from extensive blood loss and energy and oxygen deficiency that causes multiple organ failure and even death. To provide large volume of resuscitation fluid to recover blood pressure is the traditional clinical strategy; however, extensive production of free radicals may worsen the clinical outcome. We previously showed that arginine, citrulline, or glutamine may not alter inflammatory response in rats with hemorrhagic shock. Herein, we compared the impacts of arginine-, glutamine-, and amino acid mixture-supplemented resuscitation fluids on inflammatory responses and target organ damages in rats with trauma-hemorrhagic shock and limited-volume of resuscitation fluids.
Methods and Materials：Male SD rats were suffered from carotid arterial and jugular vein cannulations with 5 cm midline laparotomy and blood loss to mean arterial pressure at 35 mmHg or sham operation (SHA group). After 60 minutes, rats were resuscitated with shed blood and equal volume of lactate Ringer’s solution without (THR group) or with L-alanine (ALA group), L-arginine plus L-alanine (ARG group), L-alanyl-L-glutamine (GLN group), or L-amino acid mixture plus L-alanine (AMX group) within 10 minutes and followed by continuous infusion for 42 h (~1.3 ml/h). After sacrifice, blood and organs were collected for further analysis about inflammatory response and organ damage.
Results：The THR group had significantly decreased plasma IFN-γ and spleen weight, increased circulating platelet and renal nitrate/nitrite (NOx), and significant jejunal atrophy compared to the SHA group. The ALA group had alleviated increases in circulating platelet, renal NOx and jejunal atrophy, decreased circulating hemoglobin, hematocrit, plasma pro-inflammatory mediators, and renal apoptosis, and increased cell proliferation in the lung; the ARG group had increased lung wet-to-dry weight and IL-4 and jejunal apoptosis; the GLN group had increased spleen weight, circulating hemoglobin and hematocrit and renal myeloperoxidase activity and apoptosis and had alleviated jejunal atrophy; and the AMX group had reversed circulating hemoglobin and hematocrit, decreased jejunal atrophy and renal NOx, and increased lung, liver, and renal cell proliferation, renal apoptosis, and lung myeloperoxidase activity. These results suggest that amino acid supplemented-resuscitation fluids have beneficial effects on hematology and have differential effects on organ inflammatory response and damages.
Conclusion：Amino acid-supplemented resuscitation fluids may have potentials to be a clinical useful nutrition therapy for patients with trauma-hemorrhagic shock and the use of amino acid supplementation should be organ-dependent.

並列關鍵字

hemorrhagic shock ； resuscitation ； amino acids

參考文獻

1. Fraga, A. O., Malbouisson, L. M., Prist, R., Rocha, E. S. M. & Auler Junior, J. O. (2006). Anesthetic induction after treated hemorrhagic shock: experimental study comparing ketamine and etomidate. Rev Bras Anestesiol 56, 377-390.

2. Jarrar D, W. P., Cioffi WG, Bland KI, Chaudry IH. (2000). Critical role of oxygen radicals in the initiation of hepatic depression after trauma-hemorrhage. J Trauma. 49(5), 879-885.

3. Santry, H. P. & Alam, H. B. (2010). Fluid resuscitation: past, present, and the future. Shock 33, 229-241.

4. Handrigan, M. T., Bentley, T. B., Oliver, J. D., Tabaku, L. S., Burge, J. R. & Atkins, J. L. (2005). Choice of fluid influences outcome in prolonged hypotensive resuscitation after hemorrhage in awake rats. Shock 23, 337-343.

5. Subeq, Y. M., Hsu, B. G., Lin, N. T., Yang, F. L., Chao, Y. F., Peng, T. C., Kuo, C. H. & Lee, R. P. (2012). Hypothermia caused by slow and limited-volume fluid resuscitation decreases organ damage by hemorrhagic shock. Cytokine 60, 68-75.