心内直视术后出血再次开胸手术常见原因及临床防治

【目的】探讨体外循环心内直视术后出血和心脏压塞的临床特点。[方法】回顾性分析湘雅二医院因心脏直视术后出血和心脏压塞再次开胸手术87例病例,采集相关数据,进行统计学分析。【结果】术后活动性出血21例,急性心脏压塞63例,延迟性心脏压塞3例,死亡11例（活动性出血组3例,急性心脏压塞8例）。活动性出血组术后动脉收缩压、舒张压、中心静脉压、尿量进行性下降,心率增快,引流量显著增多（P〈0．05）。急性心脏压塞组术后pH值、动脉收缩压和舒张压突然快速降低及尿量显著减少,中心静脉压及心率很快增高,引流量突然减少（P〈0．05）。术后活动性出血以心脏切口、胸腺、骨膜及骨髓腔、剑突血管、心包切缘、钢丝穿孔点等多见。【结论】术前心功能不全及继发多脏器功能失调,体外循环凝血机制紊乱,术中止血不彻底,术后处理不及时是心内直视术后出血或心脏压塞的主要原因。调整术前脏器功能,加强血液保护,止血彻底,术后严密监护,必要时及时开胸止血是防治术后出血的关键。

Common Causes,Clinical Prevention and Treatment of Bleeding after Cardiac surgery

[Objective]To summarize the clinical features of bleeding and cardiac tamponade after cardiac surgery and to explore its causes, prevention and treatment. [Methods] Totally 87 re-thoracotomy cases for postoperative bleeding and cardiac tamponade in cardiothoracic surgery department in Second Xiangya Hospital from June 2007 to April 2008 were analyzed retrospectively. The related data were collected and the statistic analysis was performed. [Results]After operation, there were 21 cases of active bleeding, 63 acute cardiac tamponade, 3 delayed cardiac tamponade and 11 death including 3 active bleeding and 8 acute cardiac tamponade. In the postoperative active bleeding group, artery systolic blood pressure（SABP）, artery diastolic blood pressure（ADBP）, central venous pressure（CVP） and urine volume（UV） all decreased significantly, and both heart rate（HR） and drainage volume increased significantly（ P 〈0.05）. In the postoperative acute cardiac tampon- ade group, pH, SABP and DABP decreased suddenly and quickly, and UV reduced obviously, and CVP and HR increased rapidly, and drainage volume suddenly reduced（ P 〈0.05）. The postoperative active bleeding chiefly presented in the incision of the heart, thymus, periosteum, bone marrow cavity, xiphoid vessels, peri cardial margin and perforation of steel wires. [Conclusion]The main causes of bleeding and cardiac tamponade after cardiac surgery include preoperative heart failure, secondary multiple organ dysfunction, clotting mechanism disturbance after cardiopulmonary bypass, incomplete stanching during the operation and untimely postoperative care. The key points of prevention and treatment for postoperative bleeding include preoperative ad justment of organ function, reinforcement of blood protection, complete stanch and postoperative care, and timely thoracotomy for hemostasis if necessary.