The pathophysiology of skeletal muscle ischemia and the reperfusion syndrome: a review
The pathophysiology of skeletal muscle ischemia and the reperfusion syndrome: a review
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DOI：
10.1016/s0967-2109(02)00070-4
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发表时间：
2002-12-01
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影响因子：
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通讯作者：
Blaisdell, FW
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文献类型：
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作者：
Blaisdell, FW
肢体缺血后的再灌注综合征有两个组成部分。再灌注后的局部反应包括肢体肿胀，可能加重组织损伤和全身反应，导致多器官衰竭和死亡。很明显，骨骼肌是肢体的主要组织，但也是最容易缺血的组织。生理学和解剖学研究表明，不可逆的肌肉细胞损伤在缺血3小时后开始，并在6小时时几乎完成。这些肌肉变化与进行性微血管损伤并行。微血管变化似乎是在骨骼肌损伤之后而不是之前发生的，因为毛细血管对缺血的耐受性随组织再灌注而变化。细胞损伤越严重，微血管变化越大，随着组织死亡，微血管流动在数小时内停止，无回流现象。此时组织肿胀停止。再灌注后的炎症反应差异很大。当肌肉组织均匀死亡时，如止血带缺血或肢体再植后，炎症反应很少。在大多数情况下，血栓或栓塞后的再灌注，在可能有侧支血流的区域会有不同程度的缺血性损伤。该区域的范围将决定炎症反应的大小，无论是局部的还是全身的。无论是切开筋膜防止微循环受压闭塞，还是抗凝以防止进一步的微血管血栓形成，只有在这个区域治疗才会有任何益处。由于许多炎症介质是由凝血行为产生的，抗凝将通过减少炎症反应而具有额外的益处。如果这个过程涉及到下肢的大部分，截肢而不是尝试血运重建可能是最谨慎的方法，以防止缺血肢体中的有毒产物进入体循环。(C) 2002年国际心血管外科学会。Elsevier Science Ltd.出版。版权所有。
There are two components to the reperfusion syndrome, which follows extremity ischemia. The local response, which follows reperfusion, consists of limb swelling with its potential for aggravating tissue injury and the systemic response, which results in multiple organ failure and death. It is apparent that skeletal muscle is the predominant tissue in the limb but also the tissue that is most vulnerable to ischemia. Physiological and anatomical studies show that irreversible muscle cell damage starts after 3 h of ischemia and is nearly complete at 6 h.These muscle changes are paralleled by progressive microvascular damage. Microvascular changes appear to follow rather than precede skeletal muscle damage as the tolerance of capillaries to ischemia vary with the tissue being reperfused. The more severe the cellular damage the greater the microvascular changes and with death of tissue microvascular flow ceases within a few hours-the no reflow phenomenon. At this point tissue swelling ceases.The inflammatory responses following reperfusion varies greatly. When muscle tissue death is uniform, as would follow tourniquet ischemia or limb replantation, little inflammatory response results. In most instances of reperfusion, which follows thrombotic or embolic occlusion, there will be a variable degree of ischemic damage in the zone where collateral blood flow is possible. The extent of this region will determine the magnitude of the inflammatory response, whether local or systemic. Only in this region will therapy be of any benefit, whether fasciotomy to prevent pressure occlusion of the microcirculation, or anticoagulation to prevent further microvascular thrombosis. Since many of the inflammatory mediators are generated by the act of clotting, anticoagulation will have additional benefit by decreasing the inflammatory response. In instances in which the process involves the bulk of the lower extremity, amputation rather than attempts at revascularization may be the most prudent course to prevent the toxic product in the ischemic limb from entering the systemic circulation. (C) 2002 The International Society for Cardiovascular Surgery. Published by Elsevier Science Ltd. All rights reserved.