术前自体血小板分离在心脏手术中的血液保护作用

大部分心脏手术需要在体外循环(cardiopulmonary bypass,CPB)下进行,CPB期间血小板数量的减少和功能的下降是术后凝血功能障碍和异常出血的重要原因之一。CPB前,利用自体血小板分离技术将部分血小板从患者全血中分离出来制成富血小板血浆(platelet-rich plasma,PRP),在CPB结束鱼精蛋白中和后再回输入病人体内,以减少围术期的出血量和血液制品输注量。PRP是一种可行的血液保护方法。     

前列腺素E1脂微球载体制剂对体外循环中患者凝血机能的影响

目的探讨前列腺素E1脂微球载体制剂(Lipo-PGE1)对体外循环(CPB)中患者凝血机能的影响.方法将20例心脏瓣膜置换术患者随机分为观察组及对照组各10例.观察组于麻醉诱导后至CPB结束匀速[3ng/(kg*min)]泵入Lipo-PGE1,预充液中加入5ng/ml;对照组用等容量生理盐水.测定围CPB期肝素化后(T1)、CPB开始30min(T2)及停机即刻(T3)、1h(T4)、24h(T5)五个时点两组血浆TXB2、6-K-PGF1α浓度.结果 TXB2、6-K-PGF1α及其比值在CPB过程中显著升高,停CPB时达峰值(P<0.01),24h后恢复至术前水平.在相应时点,观察组6-K-PGF1α明显高于对照组,TXB2及TXB2/6-K-PGF1α明显低于对照组,P均<0.01.结论 CPB中患者凝血机能紊乱;Lipo-PGE1能部分纠正凝血功能紊乱.     

维吾尔族、汉族先天性心脏病患者体外循环中肝素耐药性差异研究的新进展

体外循环(cardiopulmonary bypass,CPB)技术在心脏手术中的普遍应用使机体围术期可发生复杂的病理生理改变。维吾尔族、汉族先天性心脏病患者由于民族差异,CPB中肝素耐药性存在差异,影响凝血功能,引起术中或术后出血,甚至需要再次手术,严重影响其预后。通过近10年文献的复习,全面分析不同民族先天性心脏病患者CPB肝素耐药性差异的主要因素,探讨不同民族先天性心脏病患者CPB中肝素耐药性差异,提示不同民族先天性心脏病患者体外循环肝素剂量应个体化用药。     

心脏手术围术期血栓弹力图应用进展

<正>体外循环(extracorporeal circulation,CPB)期间凝血系统发生显著改变,术后出血是体外循环下行心脏手术后患者常见的并发症。如果凝血功能改变能早发现、早期进行干预,是预防出血最有效的措施。本文将血栓弹力图检测指标分析的优势,并对其在心脏手术中应用进展进行综述。1.体外循环对凝血系统的影响     

体外循环相关肺损伤研究进展

目前体外循环（CPB）已成为心脏外科手术的基本辅助手段，但其所导致的各脏器、系统不同程度的损伤（如低心排综合征、凝血功能障碍、灌注性肺损伤等）仍然没有完全解决，其中CPB相关肺损伤若发展为急性呼吸窘迫综合症（ARDS，约2％），其病死率高达50%以上。近年来有关CPB相关肺损伤的临床表现、机制、损伤标志物以及肺保护方法等的研究均有新的进展。现综述如下。     

体外循环心脏手术患者血浆神经肽Y水平变化及其干预

接受体外循环（CPB）心脏手术的患者共263例,随机分为超滤组、非超滤组;在围手术期、手术期各时段采集外周静脉血,检测血浆神经肽Y（NPY）。结果显示,术中患者血浆NPY水平较手术当天明显上升（P〈0.05）,CPB时行血液超滤者NPY水平明显下降（P〈0.05）。认为CPB心脏手术可以明显增加患者血浆NPY水平,血液超滤可以明显降低血浆NPY的水平。     

小型猪体外循环动物模型建立及麻醉管理

目的:探讨小型猪体外循环(CPB)实验模型的建立和麻醉管理。方法: 小型猪12头,全麻诱导插管后,应用全血冷灌方法建立中低温阻闭升主动脉的体外循环模型,并于围CPB期进行动、静脉血氧饱和度(SaO2、SvO2)、血细胞比容(Hct)及乳酸水平(Lac)测定,同时监测围CPB期血流动力学变化。结果: 转流过程中SaO2、SvO2均在正常范围,Lac水平随CPB时间延长,显著升高,Hct在CPB后呈中度稀释,平均血压在CPB后自主循环恢复后经过较短时间恢复到正常范围内。结论: 全血冷灌法建立的小型猪CPB模型,可做为CPB条件下开展研究的动物模型。     

围手术期中低体温对凝血功能影响的研究进展

围手术期中低体温对凝血功能的影响导致术中、术后的失血量增多,围手术期出现低体温的影响因素主要包括手术室室温、麻醉等因素。该文就围手术期发生低体温的原因、机制及其对凝血功能的影响及预防作一综述。     

体外循环心脏术后低蛋白血症的危险因素分析

目的:探讨体外循环(CPB)心脏术后低蛋白血症发生的围术期危险因素。方法:回顾性分析2018年7月至2020年10月在我院择期行心脏手术的成人患者201例,比较术前、术后血清白蛋白(ALB)水平,按术后48 h内的最低血清ALB浓度分为低白蛋白血症组(≤35 g/L)和非低白蛋白血症组(35 g/L),并对两组围术期危险因素进行单因素及多因素Logistic分析。结果:201例心脏病患者术后发生低蛋白血症55例,发生率为27.36%,无院内死亡。CPB术后低蛋白血症单因素分析提示年龄、性别、脂肪肝、术前ALB水平、CPB时间、主动脉阻断时间与术后发生低蛋白血症有关。多因素二元Logistic回归分析提示年龄(OR=1.052,95%CI:1.013～1.093,P=0.008)、CPB时间(OR=1.025,95%CI:1.003～1.048,P=0.029)是CPB心脏术后低蛋白血症的独立危险因素。低蛋白血症组术后气管带管时间(P=0.025)、术后住院时间(P=0.049)明显延长,术后肺部感染发生率明显升高(P0.001)。结论:年龄、CPB时间是CPB心脏术后低蛋白血症的独立危险因素;术后低蛋白血症患者术后气管带管时间、术后住院时间明显延长,肺部感染发生率显著增加。     

1,6-果糖二磷酸对老年体外循环患者肺保护作用

体外循环(CPB)技术是非生理性循环方式,会对患者组织、器官造成不同程度的损伤,而危害最大的就是肺组织。据相关临床统计得出,CPB后患者发生肺功能障碍约为15%～30%,严重时可诱发成人呼吸窘迫综合征(ARDS)并导致患者死亡,特别是对于基础功能和代偿功能较差的老年患者,CPB     

体外循环术中自体血回收对血液成分及凝血功能的影响

目的观察体外循环术中不同自体血回收方式对患者血液成分及凝血功能的影响。方法随机将60例体外循环下心脏手术的成人患者分为A、B两组,均为30例。A组为观察组,全部术野出血用自体血液回收机离心洗涤后于手术结束前回输体内。B组为对照组,不采用自体血液回收机,将肝素化后的术野出血直接吸回体外循环系统停机前回输体内,鱼精蛋白拮抗后机器余血打入输血袋,于手术结束前静脉回输。对两组患者麻醉前、体外循环中及术毕静脉血进行血常规及凝血四项指标的测定,记录停机后两组激活凝血时间（ACT）及术后24h内胸腔引流量和输注异体血用量,并对以上观察结果进行比较分析。结果①观察组患者术后24h内胸腔引流量及异体血用量明显少于对照组,差异有统计学意义（P〈0．05）。②与术前相比,两组患者血红蛋白（Hb）、红细胞比容（Hct）和血小板（PLT）均明显下降,凝血酶原时间（PT）、活化部分凝血活酶时间（APTT）和凝血酶时间（TT）明显延长,但两组间比较差异无统计学意义。③术毕观察组Hb和Hct值较体外循环中明显回升,且与对照组相比差异有统计学意义,但仍略低于术前。④两组术毕PLT、PT、APTT和TT均明显低于术前,但仍在正常范围内,两组间差异无统计学意义。结论体外循环期间自体血回收对患者血液成分及凝血功能的影响不明显,是一种有效的血液保护方法。     

体外循环辅助下原发性气管肿瘤切除3例临床分析

目的总结体外循环（CPB）下气管肿瘤外科手术治疗的临床经验。方法回顾性分析我院2002～2006年3例经体外循环辅助下切除气管肿瘤的临床资料，其中良性肿瘤1例，恶性肿瘤2例；2例患者经右股动、静脉插管建立体外循环，1例患者开胸经右心房和升主动脉插管；2例患者行气管环形切除、气管断端行端端吻合，1例患者行气管环形切除加肿瘤剔除。结果体外循环时间38-135min，平均76min，术后呼吸困难均有明显好转，平均切除气管长度为3．6cm，围手术期无死亡。结论对于气管严重梗阻的原发性气管肿瘤患者，应用体外循环（CPB）技术可降低麻醉手术风险，提供清晰术野和手术空间等有利条件，是解决气管切除及气道重建的有效方式。     

小体质量婴幼儿体外循环管理策略及合理使用超滤的重要性

目的:总结392例8kg以下患儿体外循环(CPB)管理经验,探讨小体质量婴幼儿CPB中超滤和围体外循环期液体管理的重要性。方法:2006年7月至2008年8月392例8kg以下患儿在CPB下行心脏手术。患儿分成2组:A组(2006年7月至2007年7月)共208例,B组(2007年8月至2008年8月)共184例,比较2组术前、围体外循环期的临床情况及术后的结果,总结小体质量婴幼儿CPB管理经验。结果:2组患儿一般临床资料,CPB时间和阻断时间以及术后结果没有统计学意义;CPB过程中2组悬浮红细胞和血浆的用量没有明显差别;B组白蛋白(7.1±3.4)g的应用明显低于A组(8.1±2.9)g;B组晶体用量明显多于A组;B组总超滤量明显高于A组。结论:改良超滤技术+白蛋白的应用可以改善小体质量患儿围体外循环期管理质量,但需要科学管理和有效的监测。     

Blood lactate levels during cardiopulmonary bypass for valvular heart surgery

Cardiopulmonary bypass (CPB) is widely used to maintain systemic perfusion and oxygenation during open-heart surgery. Tissue hypoperfusion with resultant lactic acidosis during CPB, may occur during hypothermia, extreme haemodilution, low flow CPB, and excessive neurohormonal activation. There has been no documentation of the correlation between blood lactate level elevations in the perioperative period, and its relation to preoperative New York Heart Association (NYHA) classification and the use of ionotropic support during weaning from CPB, duration of postoperative ventilatory support and perioperative mortality. We studied the perioperative blood lactate levels in 82 patients undergoing valvular heart surgery. Arterial blood samples were collected at different stages of CPB. The observed mean baseline lactate levels were 1.9+/-0.8 mmol/L (normal range of 0.9 to 1.7 mmol/L). The mean circulating lactate levels at 15 min and 45 min after institution of CPB increased to 7.01+/-2.6 mmol/L and 9.92+/-3.5 mmol/L. A progressive decline in the mean lactate level, was seen during rewarming (at 35 degrees C), immediately off-bypass, 24 hours and 48 hours postoperatively with mean lactate levels being 7.01+/-3.2 mmol/L, 4.75+/-1.01 mmol/L, 3.06+/-1.1 mmol/L, and 2.10+/-1.05 mmol/L respectively. Comparison of mean lactate levels in NYHA class I, II, III, and IV patients showed that in the intraoperative period and immediately after CPB, the elevation in lactate levels were statistically significant (p< 0.001) in patients in NYHA Class IV. However the values, in all classes, were similar at 24 and 48 hours after CPB. Also, patients with lactate levels >4 mmol/ L required prolonged inotropic and ventilatory support.     

黄芪注射液在心内直视手术体外循环中的心肌保护作用

目的探讨心内直视手术中黄芪注射液对心肌的保护作用。方法选取心内直视手术的患者90例,分为3组：围手术期组在围手术期给予黄芪注射液,手术体外循环时给予黄芪注射液预充,体外循环过程中再次给药;体外循环组只是在体外循环预充及过程中给予黄芪注射液;对照组不给药。三组患者分别在麻醉前、主动脉开放和术后检测不同时期血清肌酸激酶同工酶（CK—MB）及血清肌钙蛋白T（eTnT）;在手术前、后比较心电图ST段抬高或压低。结果围手术期组和体外循环组CK—MB、cTnT水平及心电图ST段变化程度较对照组低（P〈0．05）。围手术期组CK—MB、cTnT水平及心电图ST段变化程度较体外循环组低（P〈0．05）。结论在心内直视手术中,黄芪注射液可明显改善心脏能量供应,有效减少心肌细胞损伤,对心肌起到明显保护作用,围手术期使用效果更佳。     

精氨酸对体外循环术后细胞免疫功能变化的影响

６０例体外循环手术患者分为实验与对照两组。实验组于术前３天至术后７天静脉滴注精氨酸，对照组输等量葡萄糖液。于术前，麻醉后，体外循环术后１、３、５、７、１４天等时点，抽外周血测定Ｔ细胞亚群和自然杀伤细胞活性。结果证实，精氨酸能明显减少体外循环术后细胞免疫功能下降幅度，缩短恢复至正常所需的时间。     

Effect of cardiopulmonary bypass on cytokine network and myocardial cytokine production

BACKGROUND: In addition to the well-investigated proinflammatory cytokine expression, there is an ever increasing interest in the field of anti-inflammatory response to cardiopulmonary bypass (CPB). Evidence suggests that myocardium serves as an important source of cytokines during reperfusion and application of CPB. The effect of coronary artery bypass graft (CABG) without CPB on myocardial cytokine production has not as yet been investigated. HYPOTHESIS: Cardiopulmonary bypass can cause long-term disturbance in pro- and anti-inflammatory cytokine balance, which may impede a patient's recovery following surgery. Therefore, the effect of CPB on the balance of the pro-/anti-inflammatory cytokines network and myocardial cytokine outflow was assessed throughout a longer period after surgery. METHODS: Twenty patients were scheduled for CABG with CPB and 10 had off-pump surgery. Blood samples were taken before, during, and over the first week following surgery. Coronary sinus blood samples were collected during surgery. The ratio of pro- and anti-inflammatory cytokines was calculated and the cytokine concentration of peripheral and coronary sinus blood were compared in both groups. RESULTS: Pro-/anti-inflammatory cytokine ratio decreased early after CPB followed by a delayed and marked increase. A more balanced ratio was present following off-pump surgery. Coronary sinus levels of certain cytokines exceeded the concentration of systemic blood in the course of CPB but not during off-pump operation. CONCLUSION: Patients show pro-inflammatory predominant cytokine balance at a later stage after CPB in contrast to those without CPB. The heart produces a remarkable amount of cytokines only in the course of surgery with CPB.     

Bleeding complications associated with cardiopulmonary bypass

Bleeding after CPB has been difficult to characterize and its treatment equally difficult to standardize. The complexity of this problem is related to the hemostatic process, the technical variations in the operative procedures, and the many uncontrolled variables associated with CPB, including the effects of anesthetic or pharmacologic agents, the nature of the priming solution, hemodilution, hypothermia, the type of oxygenator, and the use of transfused blood products. Although there are multiple and generally predictable complex changes in the hemostatic mechanism during CPB, the temporary loss of platelet function is the most common and clinically relevant. This transient platelet dysfunction occurs in all patients undergoing CPB; however, it only causes excessive bleeding in a small percentage of patients. Unfortunately, it has not yet been possible to predict which patients will develop hemorrhagic complications, although prolonged pump times are a contributing risk factor. Over the past decade there has been extensive investigation into the management of bleeding associated with CPB, provoked primarily by the increased awareness of transfusion-transmitted viral diseases and the inappropriately excessive use of homologous blood products. Several approaches to autotransfusion of shed blood and autologus blood donation have been developed to minimize perioperative homologous blood transfusion. Pharmacologic agents such as desmopressin, aprotinin, and topical fibrin glues have also been introduced to improve hemostasis during CPB. The protease inhibitor aprotinin is particularly promising in the reduction of bleeding associated with CPB when given prophylactically. Aprotinin may provide new insights into the mechanism of CPB-induced platelet dysfunction. Desmopressin is indicated only for the treatment of bleeding after CPB. The management of bleeding associated with CPB will undoubtedly     

血栓弹力图在主要外科手术围手术期中的应用

影响围手术期凝血功能的因素具有多样性,目前检测凝血功能的方法包括凝血酶原时间(PT)、活化部分凝血酶原时间(APTT)、血小板(PLT)计数、纤维蛋白原(FIB)浓度等传统凝血检测项目和血栓弹力图(TEG),而传统的凝血检测只能监测凝血过程中的一部分,不能反映凝血的动态变化,无法准确判断凝血异常的原因。TEG可以快速、准确、全面、动态地监测血液凝固的全过程,合理地评估围手术期的凝血功能,为临床治疗提供理论依据。