风湿性心脏病患者行瓣膜置换术的体外循环管理体会

目的回顾性总结风湿性心脏病患者行瓣膜置换术的体外循环(cardiopulmonarybypass,CPB)经验。方法选取102例行瓣膜置换术的风湿性心脏病患者,其中男性47例,女性55例,年龄24～71岁。其中59例行二尖瓣置换术,12例行主动脉瓣置换术,31例行主动脉瓣和二尖瓣联合置换术。全部患者采用膜肺,中度低温CPB;预充白蛋白或新鲜冰冻血浆和人工胶体,必要时术中追加;心肌保护应用10℃～15℃4:1(血:晶体)高钾停搏液灌注;CPB中维持灌注流量50～100ml/kg和平均动脉压(MAP)50～90mmHg;开放前应用利多卡因、硫酸镁和碳酸氢钠;后并行期应用超滤、红细胞悬液、速尿等提高HCT;注意纠正低钾、高钾、低钠和酸血症。结果 CPB时间为69～254min(165.7±68.0),升主动脉阻断时间为36～168min(99.5±54.9),自动复跳率为84.4%(86/102),电击复跳率为15.6%(16/102)。全部患者均脱机,无手术死亡。结论在风湿性心脏病患者行瓣膜置换术的体外循环管理中,提高胶体渗透压、注意心肌保护、调节血球压积、纠正酸碱电解质紊乱等是保证体外循环成功的重要因素。

Management of Cardiopulmonary Bypass on Patients with Rheumatic Heart Disease Undergoing Valve Replacement Operations

Objective To summarize the clinical experience of cardiopulmonary bypass（CPB） in valve replacement operations for the patients with rheumatic heart disease.Methods Among 102 patients,male 47 cases,female 55 cases,aged from 24 to 71 years old,received valve replacement surgery under hypothermic CPB.The membrane oxygenator was selected.The human albumin,fresh-frozne plasma and artificial colloids were primed and added during CPB if necessary.Myocardial protection was performed with blood crystalloids（4：1） hyperkalemia cardioplegia and high perfusion flow of 50-100 ml/kg and high mean arteria pressure of 50-90 mmHg during CPB.Ultrafiltration technique,suspend red blood cell,and furosemide were used for the increase of Hct during the latter CPB.Results CPB time was 69-254 min（165.7±68.0）,aortic cross-clamp time was 36-168 min（99.5±54.9）.The incidence of automatic heart resuscitation was 84.4%（86/102）.None of the patients died during surgery.All were emerged successfully from CPB.Conclusion Management of cardiopulmonary bypass on rheumatic patients with valve replacement operations should focus on the increase of blood colloids pressure,the myocardial protection,the control of HCT and the correcting of hyperkalemia,hypokalemia,hyponatremia and acidemia during the CPB.