体外循环心脏手术后精神障碍发生率及相关因素

目的研究外科ICU中体外循环心脏手术后精神障碍的发生率,并分析其相关因素.方法 305例体外循环冠脉搭桥和瓣膜手术病人,术前统计年龄、性别、合并症及手术种类,体外循环期间统计最低红细胞压积及总转流时间,术后统计低氧血症、高血糖及电解质紊乱发生情况.术后第1 d起用CAM-ICU量表观察病人精神变化.结果 305例病人中,33例术后发生精神障碍,总发生率为10.82%.其中冠脉搭桥术后发生率为14.43%,心脏瓣膜术后为3.85%;年龄、术前合并糖尿病、冠脉搭桥手术、体外循环期间红细胞压积与术后精神障碍密切相关.结论冠脉搭桥手术病人术后精神障碍发生率较高;高龄、术前合并糖尿病、冠脉搭桥手术及体外循环期间红细胞压积过低与术后精神障碍的发生密切相关.     

老年患者行非心脏手术前红细胞压积水平与手术预后的关系

背景：接受非心脏手术的老年患者出现红细胞压积异常和心血管并发症的危险较高。尽管患者术前几乎都要进行红细胞压积筛查，但是有关术前贫血及红细胞增多症的不良影响的证据较为有限。 目的：于实施非心脏大手术的退伍老兵中评估术前贫血和红细胞增多症的发生率及其对术后30天预后的影响。 设计：利用全国退伍军人事务委员会（VA）于术质量改进计划数据库进行回顾性队列研究。根据术前红细胞压积水平将患者分为三类：贫血（红细胞压积〈39．0％）、正常（红细胞压积39．0％～53．9％）和红细胞增多症（红细胞压积≥54％）。对红细胞压积异常与术后30天心血管事件发生率及死亡率的关系进行评估。 地点及患者：纳入1997至2004年于全美132个退伍军人医疗中心接受非心脏大手术的310311例患者（年龄≥65岁）。 主要观测指标：主要观测指标为术后30天死亡率，次要观测指标包括术后30天死亡率或心脏事件（心脏骤停或Q波心肌梗死）发生率。 结果：与红细胞压积正常者相比，红细胞压积发生正向或负向偏离者术后30天死亡率和心脏事件发生率均有所增加。研究发现，红细胞压积水平较正常范围每增减1个百分点，术后30天死亡率就可增加1．6％（95％可信区间，1．1％-2．2％）。进一步分析显示，当红细胞压积降至39％以下或超过51％时，校正后30天死亡风险和心脏病患病风险就开始增加。 结论：接受非心脏大手术的老年患者（绝大多数为男性退伍军人）术前轻度贫血及红细胞增多症均可增加术后发生死亡和心脏事件的危险。今后的研究应明确上述发现可否见于其他人群，明确术前纠正贫血和红细胞增多症能否降低术后死亡风险。     

冠脉搭桥术后呼吸机辅助时间的影响因素分析

目的分析冠脉搭桥心脏手术后患者呼吸机辅助时间的影响因素，探讨如何减少冠脉搭桥术后机械通气时间。方法回顾分析我院在2002年1月至2005年8月期间122例冠脉搭桥手术后转入ICU患者的临床资料，对这些患者的呼吸机辅助时间、术前左心射血分数（LVEF）、体外循环时间、输血量、术后引流量、术后并发症及入ICU时的氧合指数、红细胞压积和白蛋白水平等指标进行多元线性回归分析，并评价各影响因素的作用大小。结果本组患者术后呼吸机辅助时间为29．23（4—264）小时，病死率为6．56％（8／122）。多因素线性回归分析结果显示．决定术后机械通气时间的主要影响因素依次为患者术后并发症（P〈0．01）、术中及术后总输血量（P〈0．05）及术中体外循环时间（P〈0．05）。结论采取措施防治冠脉搭桥术后并发症、减少围术期输血量及体外循环时间可缩短术后机械通气时间，从而改善患者预后。     

体外循环冠脉搭桥手术后认知功能障碍的预测因素研究

目的 研究分析体外循环冠脉搭桥手术术后认知功能障碍（POCD）的预测因素.方法 对448位体外循环冠脉搭桥手术患者手术前后行的认知功能测验进行比较,得出POCD发生率,并通过逻辑回归分析方法确定POCD的预测因素.结果 59％的患者发生POCD,与POCD发生明显相关的预测因素包括术中体温异常、左心室功能受损、血清肌酐含量上升、肌酐清除率下降、气管插管时间延长.而高龄、伴随劲动脉疾病以及体外循环与术后POCD的发生无明显相关性.结论 患者术前存在血清肌酐含量上升和左心室功能下降是体外循环冠脉搭桥手术POCD发生的高危因素.     

心脏外科术后心房颤动相关因素的分析和预防

心房颤动是心脏外科手术后常见的并发症，增加了术后脑卒中的发病率、病死率和病残率，增加了治疗的费用。既往报道心脏外科手术后心房颤动的发生率在20％～50％之间。近十年来，随着人口老龄化，心脏外科手术的病人的年龄越来越大，术后心房颤动的发生率逐年增加。单纯冠脉搭桥手术（CABG）的病人术后心房颤动的发生率为30％，瓣膜置换或成形术后心房颤动的发生率为40％，同时接受CABG和瓣膜手术的患者术后心房颤动的发生率为50％。术后心房颤动多发生在术后的第2天至第4天，并且在术后第2天发生率最高。有报道70％术后心房颤动发生在术后4d内，94％发生在术后6d内。     

老年冠心病合并糖尿病患者在冠脉搭桥手术中发生压疮的相关因素及护理措施

目的探讨老年冠心病合并糖尿病患者在冠脉搭桥手术中发生压疮的形成因素及护理预防措施。方法2017年1月-2017年12月,我院行老年冠心病合并糖尿病患者冠脉搭桥手术38例,术前进行压疮风险因素评估,术中对患者的危险因素采取针对性的预防护理措施。结果术后发生压疮2例,压疮发生率为5%。结论对易发生压疮的高危人群采取有效的预防措施是减少术中压疮发生的关键。     

心脏手术后精神障碍的原因及护理研究进展

<正>术后精神障碍(POP)是指术前无精神异常的患者出现术后大脑功能活动紊乱,导致认识、情感、行为和意志等不同程度的障碍。临床上表现为3种形式,即术后意识障碍、认知功能障碍和反应性精神病。POP最早发现于老年心脏病人,冠脉搭桥手术者精神障碍发生率最高,其次是瓣膜置换术者,最低的是先天性心     

危重冠心病患者冠状动脉搭桥研究

目的研究探讨对于危重冠心病患者进行不同的冠状动脉搭桥手术的经验及临床疗效。方法该次研究的103例危重冠心病患者中,均为冠状动脉多支病变,针对他们的治疗分为3组。有42例患者进行非体外循环冠脉搭桥,31例进行体外循环心脏不停播冠脉搭桥,其余30例患者进行体外循环心脏停搏冠脉搭桥,经过治疗,分析3组患者进行搭桥手术后心功能改善情况。结果进行非体外循环冠脉搭桥手术的患者无死亡病例,体外循环心脏不停博冠脉搭桥组术后死亡1例,体外循环心脏停搏冠脉搭桥患者术后死亡3例。非体外循环组、体外循环心脏不停搏组和体外循环心脏停搏组搭桥支数分别为（2.81±0.70）、（3.75±0.45）和（3.26±0.40）。3组患者在搭桥手术差异有统计学意义（P〈0.05）。结论在手术前要明确患者的心肌状况,减少手术创伤,根君患者的实际情况选择合适的搭桥方式,这是对危重的冠心病患者冠状动脉搭桥手术成功的重要保证。     

体外循环心脏术后精神障碍的临床分析及护理策略

目的：为探讨体外循环术后精神障碍的病因、防治及护理方法。方法：对663例心脏手术患者进行回顾性分析，研究心脏术后发生精神障碍的危险因素、临床表现、预后及护理对策。结果：本组16例出现精神障碍并发症，发生率为2．41％，经过治疗15例痊愈出院，1例死亡。结论：体外循环心脏术后并发精神障碍的原因有多种，采取个性化的综合护理策略对病情恢复具有重要作用。     

监测血浆蛋白对心脏直视手术的临床意义

我们对20例体外循环心脏直视手术病人进行了血浆蛋白测定,术前、术中及术后处理均常规进行,测得的数据与血红蛋白、红细胞压积等进行对照分析,以探讨其临床意义。     

Investigation and analysis of incidence of awareness in patients undergoing cardiac surgery in Beijing, China

Background Awareness under general anesthesia is a serious complication which leads to psychiatric disorders. The incidence of awareness in patients undergoing cardiac surgery has been reported in as many as 1.5%-23% in foreign countries. But so far, medical literature about awareness during cardiac surgery is still rare in China. Therefore, we investigated the incidence of awareness in patients undergoing different kinds of cardiac surgery, the phases when awareness occured and the effect of cardiopulmonary bypass on the incidence of awareness in coronary artery bypass grafting in Beijing. Methods Patients’ recall of awareness during cardiac surgery was assessed. One hundred patients undergoing coronary artery bypass grafting (CABG) in Chaoyang Hospital, Beijing, one hundred patients undergoing CABG and one hundred patients undergoing valve replacement or septal defect repair in Fuwai Hospital, Beijing, were interviewed 3-6 days after surgery. Every report obout patients on recall of awareness was recorded. An independent research team, blinded to patients’ surgery and anesthesia, assessed every report of awareness.Results The incidence of awareness of patients received CABG under cardiopulmonary bypass (CPB), off -pump CABG, septal repair or valve replacement under CPB was 4.7% (5 of 106 cases), 9.6% (9 of 94 cases) and 4% (4 of 100 cases), respectively. CPB did not greatly affect the incidence of awareness during the period of CABG (P&gt;0.05). The incidence of awareness of patients who received CABG under CPB did not increase significantly, in comparison with that of patients who received septal repair or valve replacement under CPB in Fuwai Hospital (P&gt;0.05). Awareness easily occurred before bypass grafting or CPB.Conclusions Awareness mainly occurs before bypass grafting or CPB in cardiac surgery. Most cases with awareness have auditory perceptions. CPB is not a main factor which affects the incidence of awareness of CABG. Surgical types do not affect the incidence of awareness of patients under CPB.     

Postoperative neuropsychological change and its underlying mechanism in patients undergoing coronary artery bypass grafting

Background  The high incidence of neuropsychologic deficits after cardiac surgery, including cognitive dysfunction and mood status, has significantly influenced the prognosis, outcome of treatment and long-term quality of life of patients. With a circadian secretion pattern, melatonin and cortisol are capable of modulating the human physiological processes and neuropsychological status, whereas disorder of their secretion pattern may lead to many diseases. However, it is unclear whether neuroendocrine variations are related to the neuropsychologic status in patients undergoing coronary artery bypass grafting (CABG).
Methods   Forty male patients scheduled for CABG with hypothermic cardiopulmonary bypass (CPB) (n=20) or off-pump coronary artery bypass (OPCAB) (n=20) were studied. Blood samples were taken intraoperatively at specific time-points and every 3 hours within the first postoperative 24 hours to determine plasma concentrations of melatonin and cortisol. A neuropsychologic test battery including depression and anxiety was administered preoperatively and 7 to 10 days postoperatively. Statistical methods included the nonparametric analysis, multiple linear regression and cosinor analysis.
Results  The patients in the CPB group exhibited more severe neuropsychologic deficits and more anxious than those in the OPCAB group after surgery. In both groups, patients were more depressed postoperatively than preoperatively and recovered 3 months after surgery. Depression and anxiety were correlated with some factors of cognitive dysfunctions.  In the postoperative 24 hours, 2 patients in the CPB group, and 6 patients in the OPCAB group showed a circadian rhythm of melatonin secretion. As for cortisol secretion, there were 3 patients in the CPB group and 7 in the OPCAB group respectively. Parameters of circadian rhythm of melatonin in the CPB group and those of secretion rhythm of cortisol in both groups were correlated with depression and some neuropsychologic tests.
Conclusions  The incidence of neuropsychological deficits was higher in patients receiving CABG with CPB than in those without CPB. The status of mood may contribute to the perioperative cognitive dysfunctions. The disordered circadian rhythm of melatonin secretion in patients undergoing CABG with CPB and the disordered cortisol secretion may correlate directly or indirectly through mood with neuropsychological deficits.

     

无创肢体缺血预处理对心脏换瓣术患者心肌的保护作用

目的:探讨无创肢体缺血预处理（noninvasive limb ischemic preconditioning,NIPC）对体外循环（cardiopulmonary bypass,CPB）下心脏瓣膜置换术患者围术期心肌保护的可能机制.方法:将择期CPB下行瓣膜置换术的风湿性心脏病患者32例随机分为对照组(n=16)和...     

冠脉旁路移植术后患者延迟撤机的危险因素分析

目的 分析影响冠脉旁路移植术后患者延迟撤机的术前、术中及术后早期的危险因素.方法 对2008年1月～2010年12月该院行冠脉旁路移植术后入住重症外科(SICU)患者共152例进行回顾性研究,根据患者机械通气时间分为延迟撤机组(机械通气≥24h)和早期撤机组(机械通气时间＜24 h),对患者术前、术中及术后早期共31项指标作为相关影响因素的分析对象,进行单因素分析,将单因素分析有统计学意义的指标再进行Logistic回归分析.结果 单因素分析提示,心功能(NYHA)分级、体外及非体外循环(ON/OFFPUMP)、主动脉阻断时间、体外循环时间、瓣膜置换、搭桥数目、术中出血量、术中输血总量、术中输液总量、术中出入量平衡、术后血白蛋白及肌酐、术后8h胸液量、术后8h输血量等14项指标在两组间有统计学意义(P＜0.05),进一步行Logistic回归分析表明,NYHA分级(P=0.035,OR=1.5)、体外循环时间(P =0.000,OR=4.53)、搭桥数目(P=0.041,OR=0.683)、术中出血量(P =0.001,OR=2.25)及术后8h胸液量(P =0.005,OR=1.75)5项指标是冠脉旁路移植术后机械通气时间延长的独立影响因素.结论 术前心功能水平、术中体外循环时间、搭桥数目、术中及术后早期的出血量是影响冠脉旁路移植术后呼吸机早期撤离的危险因素.     

心脏外科围术期38例主动脉内球囊反搏应用的适应证与效果分析

目的:回顾分析主动脉内球囊反搏在心脏外科围术期使用的适应证选择与效果.方法:2004年6月至2007年8月,对38例心脏外科手术患者实施了主动脉内球囊反搏术,其中冠心病28例,瓣膜病10例;术中预防性植入球囊反搏5例,因为无法停机植入球囊22例,其余均为术后在监护室紧急植入.均采用低分子肝素抗凝,控制激活全血凝固时间(activated clotting time,ACT)150～170 s.结果:38例患者中死亡13例,总成功率66%,冠心病成功率82%,瓣膜病为20%.术中预防性植入球囊反搏患者均顺利恢复,无1例死亡;术中因为无法停机植入的患者中16例顺利停机,6例血压无法维持而死亡;术后11例中,6例抢救成功,5例因低心排综合征无法纠正而死亡.无1例出现与球囊反搏相关的严重并发症.结论:主动脉内球囊反搏对于冠心病患者效果明显优于瓣膜病.术中预防性植入球囊反搏的效果明显优于无法停机时紧急植入以及术后使用.低分子肝素抗凝可以替代常规肝素抗凝,ACT控制在较低的150～170 s比较合适.     

经食管超声心动图在心血管外科手术中的应用

目的探讨经食管超声心动图(TEE)在心血管外科手术中的应用价值。方法在TEE监测体外循环下行心外科手术患者90例,于体外循环前和心脏复跳后对患者心脏及大血管的结构和功能进行监测和评价。结果对27例瓣膜手术患者进行术后即刻评价,均未发生瓣周漏,其中2例左房室瓣修复术后因左房室瓣中度反流遂改为瓣膜置换术;23例在体外循环下行机器人心脏外科手术患者术中在TEE引导下完成动静脉插管及心脏停跳液灌注;20例行左室室壁瘤切除及左室成形术者术后即刻观察左室形状及计算左室容积指数;1例Morrow手术患者术中行TEE检查即刻观察到SAM现象消失,最大压力阶差由144mmHg减至50mmHg,没有发生室间隔穿孔等并发症。90例患者均未发生TEE相关的并发症。结论术中TEE检查是心血管外科手术中一项重要的即刻监测和评价手段。     

体外循环下手术治疗35例重症心瓣膜病患者资料的回顾性分析

目的探讨并总结体外循环下行重症心瓣膜病外科手术中体外循环的管理方法。方法回顾性分析35例心瓣膜置换术患者的临床资料,体外循环下行二尖瓣置换术10例,主动脉瓣置换术7例,二尖瓣并主动脉瓣置换术7例,二尖瓣置换术合并冠状动脉旁路移植术5例,主动脉瓣置换术合并冠状动脉旁路移植术4例,二尖瓣、主动脉瓣置换术合并冠状动脉旁路移植术2例;流转期间灌注压维持60⁷0 mm Hg,中心静脉压070 mm Hg,中心静脉压0⁵ cm H2O,对合并冠状动脉旁路移植术患者采用顺灌+逆灌相结合的灌注方法,所有患者均采用超滤技术,记录患者体外循环时间、主动脉阻断时间及心脏复跳比例及手术结局。结果体外循环时间为(189.5±44.8)min;升主动脉阻断时间为(115.4±28.5)min;心脏自动复跳率为88.6%,除颤复跳率为11.4%;体外循环中患者均成功脱机;术后2例(5.7%)死于合并肾衰竭、多器官功能障碍综合征。结论选择合适的灌注方法、进行心肌和肾脏保护、适时采用超滤技术、准确掌握脱机指征是确保手术成功的重要环节。     

体外循环与非体外循环冠状动脉旁路移植术后早期房颤发生率的对比观察

目的对比观察该院非体外循环搭桥术(off-pump coronary artery bypass grafting,or off-pump,CABG)后早期房颤的发生率并分析其危险因素.方法回顾性分析106名首次行OpCABG的病例与86名首次行常规体外下搭桥(on-Pump coronary artery bypass grafting,or on-pump,CABG)的病例,两组病例作比较性研究分析.记录两组病人术后发生房颤的情况.结果 OPCABG组有31名病人于术后发生了房颤,发生率为29 2%;CPB组有24名病人于术后发生了房颤,发生率为27.9%,两组病人的房颤发生率差异没有显著性(P>0.05).高龄是术后发生房颤的一个危险因素.结论 OPCABG没有降低术后AF的发生率.     

盐酸戊乙奎醚在体外循环中的应用

[目的]探讨盐酸戊乙奎醚(长托宁)在体外循环(CPB)期间对病人微循环功能的影响。[方法]选择40例风湿性心脏病或冠心病患者,在浅低温心脏停跳体外循环下行瓣膜置换术或搭桥术,随机分为两组,每组20例。A组为盐酸戊乙奎醚(长托宁)组,B组为对照组。A组在转机初始加入长托宁0.05 mg/kg,转机30 min后降温平稳后两组病人分别抽血化验并记录和计算动脉血氧分压(PaO2)与静脉血氧分压(PvO2)之差;同时抽动脉血检测乳酸(BL)含量,并且记录平均动脉压(MAP);转中尿量、鼻温和中心温度(直肠)的复温时间。[结果]两组对比,A组较B组的BL明显降低,动静脉血氧分压之差扩大明显,尿量明显增多,差异有显著性意义(P<0.05),A组鼻温、肛温复温时间均较B组明显减少,差异也有显著性意义(P<0.05)。[结论]体外循环期间应用盐酸戊乙奎醚可以有效改善微循环。     

Analysis of risk factors for valve replacements in 5128 cases from a single heart center in China

Background Numerous studies have developed a ＂severity score＂ or ＂risk index＂ for short-term mortality associated with coronary artery bypass grafting （CABG）. Due to the different distribution of disease types, the number of valve surgeries in the US and Europe is relatively small. Thus, a risk-scoring system for valve surgeries was developed later and used less than that for the CABG surgery. We retrospectively reviewed 5128 cases of heart valve replacement, to quantitatively assess the risk factors for hospital mortality, and establish risk models for the hospital mortality of cardiac valve replacement patients.Methods A total of 1549 cases of aortic valve replacement, 2460 cases of mitral valve replacement, and 1119 cases of combined aortic valve and mitral valve replacement that were recorded from January 2005 to December 2009 in the cardiac surgery database at Beijing Anzhen Hospital were selected for this study. The cases were randomly assigned to a indicators were selected as possible influencing factors for hospital mortality. Single-factor analysis was performed to screen these factors, and then multi-factor analysis was used to determine the risk factors for hospital mortality in the three surgeries and to establish risk models.Results In the multi-factor analysis, age, body surface area, etiology, cardiopulmonary bypass time, preoperative cardiothoracic ratio, cardiac functional classification, and preoperative creatinine were risk factors for aortic valve replacement. Etiology, preoperative history of heart failure, cardiopulmonary bypass time, preoperative cardiothoracic ratio, and preoperative left ventricular end systolic diameter were risk factors for mitral valve replacement. Age, body mass index, cardiopulmonary bypass time, and cardiac function classification were risk factors for combined aortic valve and mitral valve replacement. The risk models showed good predictive ability （Hosmer-Lemeshow test： P=0.981 in the model for aortic valve replacement, P=0.503 in the model for mitral valve replacement, and P=0.154 in the model for combined aortic valve and mitral valve replacement）. The area under the ROC curve of the validation group was 0.958 （95% CI： 0.936-0.975） for the aortic valve replacement model, 0.876 （95% CI： 0.805-0.948） for the mitral valve replacement model, and 0.845 （95% CI： 0.753-0.939） for the combined aortic valve and mitral valve replacement,indicating that the risk models were good in predicting hospital mortality for surgeries.Conclusion The three risk models can quantitatively assess the hospital mortality risk in the patients treated with cardiac valve replacement.