磷酸肌酸钠复合氨甲环酸对非体外循环冠状动脉旁路移植术患者心肌和血液保护作用的研究

Objective To investigate whether the supplement of creatine phosphate sodium and tranexamic acid to cardioplegic solutions can improve myocardial protection and blood conservation in off-pump coronary artery bypass graft(OPCABG).Methods 280 patients undergoing OPCABG were randomly assigned to experimental group (CP with TA group, n=70 ) , creatine phosphate sodium group (CP group, n=70), tranexamic acid group (TA group, n=70) and control group (n=70). Before BACG,creatine phosphate sodium ( 100 mg/kg) combined with tranexamic acid (30 mg/kg), creatine phosphate sodium ( 100 mg/kg),tranexamic acid (30 mg/kg), and equal volume of normal saline were given intravenously in each group respectively. Venous blood samples were taken preoperatively, and at 0, 6, 12, 24, 48, 72 h, 7 d postoperatively to analyze creatine kinase isoenzyme (CK-MB), troponin (cTnI) ; Meanwhile, the amount of cumulative chest fluid drainage and inotropic agent and blood transfused were also recorded. Results The plasma concentrations of CK-MB in experimental group at 6, 12, 24, 48, 72 h postoperatively (15±6), (14±5), (16±10), (15±6) and (13±6) U/ml and the plasma concentrations of cTnI(235±1.53), (2.72±1.46), (2.64±1.32),(1.16±0.76) and (0.48±0.24) mg/L were significantly lower than those in group CP, group TA and control group (P＜0.05). The amount of postoperative cumulative chest fluid at 6, 12, 24, 48, 72 h were (246±56), (420±82), (680±114), (725±126) and (730±130) ml drainage and blood transfuison in experimental group (5/70) were also significantly lower than those in other groups (P＜0.05). Conclusion For patients undergoing OPCABG, creatine phosphate sodium combined with tranexamic acid plays an important role in myocardial protection and blood conservation without increasing the surgical mortality and the incidence of postoperative complications.     

Swan-Ganz导管拔除困难2例

病例1 男性,51岁,体重64 kg,拟在全身麻醉下行体外循环冠状动脉旁路移植术.术前经右颈内静脉置入六腔7FSwan-Ganz导管(Edwards Lifesciences公司,美国)58 cm.术后第4天拔除Swan-Ganz导管3 cm时遇到阻力.胸部X线检查示导管在右心室内盘绕在一起,但未打结;超声心动图检查示心肌、瓣膜和乳头肌内未见异常回声,证实导管盘绕部位不在心肌、瓣膜和乳头肌内.做好外科手术准备的同时,在X线指导下,缓慢地反复推送和回退导管,最终将导管与鞘管一起顺利拔除,拔除Swan-Ganz导管后,未见三尖瓣损伤、肺梗塞和心律失常等并发症发生.     

北京市三甲医院为实施诊断相关分组（DRGs）制度应做的准备工作

通过回顾北京市实施DRGs的历程和国内其他地区的经验,归纳DRGs的临床适用范围,讨论三甲医院在DRGs实施过程中会遇到的困难.进一步结合工作实际,提出三甲医院应在医院信息化,积累DRGs相关的病历收费数据,标准化诊断和操作编码,推广临床路径等领域做好准备.     

肝素诱导血小板减少症一例

1临床资料 男性患者,45岁.12年前活动后出现心慌、气短.当地医院行主动脉瓣替换术.术后复查心脏超声心动图示升主动脉扩张,未行特殊治疗.     

大剂量磷酸肌酸钠预先给药对心脏瓣膜置换术患者心肌缺血再灌注损伤的影响

目的 探讨大剂量磷酸肌酸钠预先给药对心脏瓣膜置换术患者心肌缺血再灌注损伤的影响.方法 择期拟行二尖瓣-主动脉瓣置换术患者246例,年龄42～71岁,体重45～80 kg,随机分为2组:对照组(NS组,n=122)和磷酸肌酸钠预先给药组(CP组,n=124).CP组切皮时开始中心静脉输注磷酸肌酸钠10g(溶于100ml生理盐水),输注时间60 min,NS组静脉输注等容量生理盐水,分别于麻醉前、术后第1天和第5天采集颈内静脉血样,检测血清磷酸肌酸激酶、乳酸脱氢酶、肌酸激酶同工酶的活性,测定心肌肌钙蛋白I浓度,观察心律失常、心肌梗塞的发生情况及自动复跳情况,记录使用正性肌力药多巴胺(≥5 μg·kg-1·min-1)和肾上腺素的患者例数及左室射血分数.结果 与NS组比较,CP组术后第1天和第5天血清磷酸肌酸激酶、乳酸脱氢酶、肌酸激酶同工酶的活性及心肌肌钙蛋白I浓度降低,使用多巴胺和肾上腺素的患者例数减少,术后心律失常和心肌梗塞的发生率降低,自动复跳率及左室射血分数升高(P<0.05).结论 大剂量磷酸肌酸钠(10 g)预先给药可减轻二尖瓣-主动脉瓣置换术患者的心肌缺血再灌注损伤,改善心脏功能.     

心肌缺血再灌注损伤的研究进展

对于急性心肌梗死患者,利用溶栓或早期用经皮冠状动脉介入治疗(PCI)进行有效的心肌再灌注是缩小心肌梗死面积,改善临床转归的有效方法.缺血预适应和缺血后适应不仅对动物的心脏有保护作用,同样对人类心脏也具有保护作用.通过再灌注损伤补救激酶(RISK)途径,阻止线粒体转运通道(PTP)开放等干预再灌注损伤递质的措施,能够明显减轻急性心肌梗死患者心肌缺血再灌注损伤.     

镁预处理对不稳定性高血压患者心脏术中血压的影响

目的:观察硫酸镁预处理对血压不稳定患者心脏手术中血压的影响.方法:未系统治疗高血压患者40例,随机分为两组:补镁组(20例)和对照组(20例).切皮前取深静脉血测血镁水平.补镁组患者胸骨劈开前用硫酸镁40 mg/kg经深静脉注入再配合硝酸甘油和硝普钠进行降压治疗,对照组患者用硝酸甘油和硝普钠进行降压.记录和观察两组患者麻醉前、诱导、气管插管、切皮、劈胸骨、拧钢丝和缝皮时各时点的平均动脉压水平、血压波动值和硝酸甘油或硝普钠的平均用量.结果:补镁组与对照组比较在麻醉前、诱导、气管插管、切皮时平均动脉压、血压波动值和硝酸甘油、硝普钠用量差异均无统计学意义.补镁组与对照组比较在劈胸骨、拧钢丝、缝皮时的平均动脉压、血压波动值和硝酸甘油、硝普钠用量均降低,差异均有统计学意义(P＜0.05).结论:不稳定性高血压患者心脏手术中,劈胸骨前补充硫酸镁,可使患者血压更加平稳,并可减少降压药的用量.     

非体外循环冠状动脉旁路移植术患者术中血糖波动水平与短期预后的关系

Objective To investigate the effect of intraoperative fluctuation in blood glucose concentration (BGCF) on short-term clinical outcomes in patients after off-pump coronary artery bypass graft (CABG) .Methods Two hundred and fourteen ASA Ⅰ -Ⅲ patients ( NYHA grade Ⅰ -Ⅲ ) of both sexes aged 18-64 yr with body mass index 23-29 kg/m2 underwent elective off-pump CABG. Their left ventricular ejection fraction was ≥30% .Blood samples were obtained once an hour for determination of blood glucose concentration (BGC) between 10 min after induction of anesthesia and 10 min after closure of sternum. The maximum and minimum BGCs were record-ed . Intraoperative BGCF was defined as the difference between the maximum and minimum BGCs. Other factors which may influence clinical outcome were also recorded, including prolonged ICU stay ( ≥24 h), prolonged me-chanical ventilation ( ≥12 h) , postoperative complications (cardiac insufficiency secondary to operation, arrhyth-mia, myocardial infarction, respiratory insufficiency, stroke, infection, pleural effusion and surgical bleeding) and prolonged postoperative hospital stay ( ≥ 7 d) . The patients were divided into 2 groups using intraoperative BGCF 400 mg/L as cutoff point: group L < 400 mg/L and group H ≥400 mg/L. Receiver operating characteristic (ROC)curve was used to evaluate if intraoperative BGCF was a good index of postoperative outcomes. Results The area under the ROC curve of intraoperative BGC against prolonged ICU stay was 0. 804 (0.739-0. 869), against prolonged mechanical ventilation 0. 604 ( 0.415-0.793 ), against postoperative complications 0.801 ( 0.720-0. 882 )and against postoperative hospital stay 0.615 (0.523-0.707). The duration of ICU stay was significantly longer and the incidences of complications and prolonged postoperative hospital stay were higher in group H than in group L (P < 0.01). Conclusion Intraoperative BGCF is closely related to postoperative outcomes in patients after offpump CABG. The patients with the BGC≥400 mg/L has a poor prognosis.