大剂量甲泼尼龙预充对婴幼儿心脏手术中炎性反应的影响

目的 观察大剂量甲泼尼龙预充对婴幼儿心脏手术中炎性反应的影响，以及与术后肺损伤的关系。方法 随机选取20例7kg以下的婴幼儿先天性心脏病患者，根据体外循环(CPB)预充液中是否加入大剂量甲泼尼龙将其分成两组，实验组(n＝10)：用含甲泼尼龙(30mg/kg)的常规预充液预充；对照组(n＝10)：用常规预充液预充。于术前、术后1小时、4小时和24小时检测血清肿瘤坏死因子—α(TNF—α)、白细胞介素—6(IL—6)和白细胞介素—8(IL—8)的含量及变化，同时根据动脉血气结果分析氧合指数、肺泡—动脉血氧分压差(A—aDO2)以评价肺功能，并记录ICU气管内插管时间。结果 两组血清TNF—α和IL—6在术后均升高，实验组TNF—α和IL—6含量在术后4小时和24小时均明显低于对照组(P＜0．01)，IL—8术后24小时明显低于对照组(P＜0．05)；实验组氧合指数在术后24小时明显高于对照组，而A—aDO2则明显低于对照组(P＜0．01)，两组平均气管内插管时间差别无显著性意义(P＞0．05)。结论 对低体重先天性心脏病患者，在CPB预充液中加入大剂量甲泼尼龙，可明显抑制术后全身性炎性反应，减少术后肺损伤。     

含血预充液超滤技术在婴儿心脏手术中的应用

目的探讨体外循环(CPB)手术中含血预充液进行超滤洗涤后是否能使预充液达到生理状态,以及该方法对患者围术期电解质、酸碱平衡和心肺功能的影响。方法选取2009年2月至2009年6月在复旦大学附属儿科医院施行先天性心脏病手术治疗的40例患者,随机分为两组,实验组(n=20):男12例,女8例;年龄131.00±103.00 d,体重4.14±0.96 kg;术前利用CPB管道中血液超滤器对含血预充液进行超滤洗涤20 min。对照组(n=20):男11例,女9例;年龄127.00±88.00 d,体重4.38±1.05 kg;预充液在CPB管道中循环20 min。测定含血预充液洗涤前、后和患者围术期血气分析和电解质等指标;用超声心动图检测心功能指标包括短轴缩短率(FS),射血分数(EF)和心排血量(CO);观察肺功能变化。结果两组患者无死亡,均顺利出院。实验组呼吸机辅助呼吸时间显著短于对照组(2.7±0.3 d vs.4.1±0.4 d,P0.05)。实验组含血预充液经洗涤超滤后的各项指标均达到正常值范围,pH值升高(从6.89±0.22升至7.40±0.57,P=0.001),BE值升高(从-16.12±0.98 mmol/L上升至+0.31±2.40 mmol/L,P=0.000),钾离子浓度降低(从10.33±2.13 mmol/L降至4.27±0.93 mmol/L,P=0.000);白细胞介素-8浓度降低(从78.40±6.10 pg/ml下降至64.30±48.10 pg/ml,P=0.036);缓激肽浓度降低(从5 982±1 353pg/ml下降至531.00±35.00 pg/ml,P=0.031)。实验组FS、EF和CO术后下降幅度均小于对照组,术后4 h实验组CO显著高于对照组(2.77±0.95 L/min vs.1.66±0.75 L/min,P=0.001);术后24 h实验组EF高于对照组(67.44%±6.89%vs.61.17%±9.02%,P=0.003)。术后6 h两组肺泡-动脉血氧分压差(A-aDO2)和呼吸指数(RI)显著上升(P0.05),然后开始逐渐下降恢复至术前水平。实验组趋向于更早开始恢复肺功能。术后48 h,实验组A-aDO2和RI明显低于对照组(P0.05)。结论对含血预充液进行洗涤超滤可使CPB预充液更符合生理状态,减少炎性介质,改善婴幼儿术后心肺功能,这对新生儿和小婴儿进行复杂先天性心脏病手术时显得尤其重要。     

零平衡超滤与改良超滤在婴幼儿心脏手术中的联合应用

目的探讨零平衡超滤（ZBUF）和改良超滤（MUF）联合应用于婴幼儿体外循环（CPB）手术中的管理特点及临床效果,以判定二者联合应用的可行性及其临床意义。方法20例复杂先天性心脏病患者,其中男12例,女8例;年龄12．6±7．5个月;体重8．5±3．3kg。选用Gambro FH22型血液超滤器,采用经典MUF途径,CPB期间行ZBUF,CPB结束后行MUF。观察患者血流动力学指标、血气分析、生化离子浓度、炎性介质和血浆胶体渗透压（COP）的变化,同时收集滤液测定白细胞介素8（IL-8）和肿瘤坏死因子α（TNF-α）的浓度。结果所有患者MUF结束时平均动脉压（MAP）明显升高（P=0．001）;血液乳酸、TNF-α和IL-8在ZBUF前、后差异无统计学意义;COP在MUF结束明显升高,与ZBUF结束比较差异有统计学意义（P=0．002）。MUF滤液中TNF-α浓度高于ZBUF滤液（P=0．036）。结论ZBUF与MUF联合应用于婴幼儿CPB手术中有排除炎性因子、改善机体免疫应答的能力;MUF可快速减少体内水分、提高COP和红细胞压积,从而改善心肺功能。     

常规超滤与改良超滤在婴幼儿体外循环心脏手术中的应用分析

目的总结分析婴幼儿先天性心脏病体外循环心脏手术中超滤的临床经验。方法总结分析2004-02～2008-10进行的13kg以下先天性心脏病手术患儿80例的临床资料并随机分组:常规超滤组(CUF组)30例,改良超滤组(MUF)30例,对照组(无超滤组)20例。分析各组各时期K+、HCT、Hb数据及呼吸机辅助时间,术后应用血管活性药物时间、术后引流量、术后胶体应用量等临床资料。结果改良超滤组超滤停止时,其HCT、Hb均高于停机时,高于常规超滤停止时,差异具有统计学意义(P0.01)。常规超滤组停机时,其HCT、Hb均高于改良超滤组停机时,差异具有统计学意义(P0.01)。在呼吸机辅助时间、血管活性药物应用时间及术后胶体用量等方面,改良超滤组优于常规超滤组及对照组,常规超滤组优于对照组,差异具有统计学意义(P0.01)。3组术后引流量未见明显差异。结论常规超滤及改良超滤能较好的改善婴幼儿体外循环手术后的心肺功能,利于术后恢复。     

改良超滤对婴幼儿心脏手术输血的影响

目的　观察改良超滤技术在婴幼儿体外循环心血管手术中对输血及术后出血的影响。方法　 6 0例接受体外循环下心血管手术的先天性心脏病患儿 ,均分为对照组 (不接受任何超滤 )、常规超滤组 (CUF组 )和改良超滤组 (MUF组 )。观察术中库血用量、血浆用量、血球压积的变化及术后2 4h出血量 ,并用SSPS/PC进行统计学处理。结果　MUF组库血用量、血浆用量、术后 2 4h出血量显著低于对照组和CUF组 (P <0 0 1) ,且滤出水量明显多于CUF组 (P <0 0 1)。结论　在婴幼儿心血管手术中 ,改良超滤可有效排出体内水分 ,提高血球压积 ,明显减少输血及术后出血 ,是节约用血的重要手段之一。     

温度对体外循环预充液的吸入麻醉药液/气分配系数的影响

目的 探讨温度对吸入麻醉药体外循环预充液／气分配系数的影响。方法 采用注射器两次平衡法,利用气 谱仪分别测定乳酸林格氏液、琥珀酰明胶、人体血浆和库血在３７℃、℃３３℃、２９℃、２５℃、２１℃和１７℃的六个不同温度点的液／气分配系数。结果 地氟醚、异氟醚和氟烷分别在乳酸林格氏液、琥珀酰明胶、人体血浆和库血中的液／气分配系数均与温度之间呈负直线相关（Ｐ〈０．０５）,同一种液体在同一温度中,地氟醚的液／     

零平衡超滤对冠状动脉旁路移植术后患者肺功能的影响

目的探讨零平衡超滤对改善体外循环（CPB）冠状动脉旁路移植术（CABG）患者术后肺功能的临床效果。方法选择2006年6月至2008年12月在中国医科大学附属第一医院接受CABG患者40例,按照采用的不同超滤方法分为两组,试验组（n=20）：男14例,女6例;年龄65.43±8.31岁;于CPB开始后行零平衡超滤及常规超滤;对照组（n=20）：男15例,女5例;年龄66.51±7.62岁;仅于复温后施行常规超滤。术前常规检测两组患者肺功能和动脉血气分析;分别于CPB前、CPB结束时、术后6 h和12h测定两组患者气道阻力（Raw）、氧合指数（OI）和肺泡-动脉血氧分压差[P（A-a）O2],记录术后呼吸机辅助通气时间。结果两组患者术前肺功能和动脉血气指标比较差异均无统计学意义（P〉0.05）。两组患者CPB前Raw、OI和P（A-a）O2比较差异无统计学意义（P〉0.05）,而术后6 h和12 h试验组的Raw显著低于对照组[2.22±0.31 cm H2O/（L.s）vs.2.94±0.42 cm H2O/（L.s）,F=0.061,P〈0.05;1.89±0.51 cm H2O/（L.s）vs.2.52±0.29 cm H2O/（L.s）,F=0.096,P〈0.05];术后6 h和12 h试验组P（A-a）O2显著低于对照组（86.74±7.63 mm Hg vs.111.66±7.49 mm Hg,F=0.036,P〈0.05;74.82±5.67 mm Hg vs.95.23±6.78 mm Hg,F=0.059,P〈0.05）;术后6 h和12 h试验组OI显著高于对照组（384.33±30.67 vs.324.63±31.22,F=0.033,P〈0.05;342.24±23.43 vs.293.67±25.44,F=0.047,P〈0.05）;术后呼吸机辅助通气时间试验组短于对照组（15.44±3.93 h vs.20.68±5.77 h,P〈0.05）。结论零平衡超滤可以改善CABG患者术后肺功能、缩短术后机械通气时间。     

低预充体外循环对全身炎性反应的影响

体外循环激活炎症反应是心脏外科领域研究的热点[11].体外循环非生理性因素的介入是引起心脏手术后复杂的全身炎症反应的重要原因之一.我们将观察低预充体外循环系统对全身炎性反应相关指标的影响报道如下.     

体外循环用不同胶体预充对血液流变学的影响

本文以人血白蛋白和血浆为对照 ,研究聚明胶肽用于体外循环 (ＣＰＢ)预充对血液流变学的影响。资料与方法研究对象和方法　先天性房、室间隔缺损修补术病人 32例 ,男 18例 ,女 14例 ,年龄 5～ 13岁 ,体重 15～ 37ｋｇ ,ＡＳＡⅠ～Ⅱ级。用安定、芬太尼、氯胺酮、维库溴铵、安氟醚静吸复合麻醉 ,ＣＰＢ采用德国人工心肺机 ,国产鼓泡式氧合器 ,非搏动性灌注 ,ＣＰＢ结束后用鱼精蛋白中和肝素。按胶体预充液不同随机分为聚明胶肽组 (Ｈ组 ,ｎ =12 )、白蛋白组 (ＨＡ组 ,ｎ =10 )、血浆组 (Ｐ组 ,ｎ =10 ) ,胶体液用量 18～ 32ｍｌ·ｋｇ-1,晶体…     

新型超滤技术在婴幼儿体外循环手术中的临床应用

目的探讨新型超滤技术的临床应用和防止和减轻体外循环（CPB）后重要器官损伤的作用，以提高手术治疗效果，减少术后并发症。方法将30例先天性心脏病患者分成两组，改良超滤组（n=15）：常规CPB后应用改良超滤；新型超滤组（n=15）：CPB手术中应用新型超滤方法；观察两组患者血浆中炎症介质浓度、红细胞压积（HCT）、白蛋白浓度、肺功能指标、手术时间和器官功能指标的改变。结果新型超滤组CPB后超滤时间较改良超滤组明显缩短（6．35±1.28minvs．12．45±4．52min，P=0．000）；CPB结束后血浆白细胞介素6（IL-6）、肿瘤坏死因子α（TNF—α）浓度明显低于改良超滤组（292．84±58．23μg／Lvs．383．79±66．24μg／L，P=0．000；13．32±2．31μg／Lvs．16．41±2．65μg／L，P=0．000）；CPB结束后HCT和白蛋白浓度明显高于改良超滤组（0．39＋0．04vs．0．35±0．03，P=0．003；38．32±4．26g／Lvs．34．04±2．83g／L，P=0．003）；术后呼吸机辅助时间和住ICU时间均短于改良超滤组（P〈0．05），重要器官功能损害较改良超滤组轻。结论CPB中采用新型超滤技术，可有效地减少部分炎症介质，浓缩血液，缩短手术时间，减轻重要器官组织的水肿和损伤。     

Pyruvate Effects on Red Blood Cells During In Vitro Cardiopulmonary Bypass With Dogs’ Blood

To investigate the effects of pyruvate (Pyr) on adenosine triphosphate (ATP), endothelial nitric oxide synthase (eNOS), and nitric oxide (NO) in red blood cells (RBCs) during the cardiopulmonary bypass procedure (CPB), blood, 500 mL, was collected from each of 10 healthy dogs (weight 12–18 kg). The blood was divided into two parts (250 mL each) and randomly assigned into the control group (Group C, n = 10) or the Pyr group (Group P, n = 10). The blood was commingled with an equal volume of 0.9% NaCl and pyruvated isotonic solution (Pyr 50 mM) in the extracorporeal circuit in the two groups, respectively. The CPB procedure was fixed at 120 min, and the transferring flow was 4 L/min. Contents of ATP in RBCs, eNOS activities, and NO productions in plasma were measured before CPB and during CPB at 30, 60, 90, and 120 min in both groups. The ATP level, eNOS activity, and NO production were not different prior to CPB between the two groups. A decline of ATP levels was shown in both groups but remained significantly higher in Group P than in Group C at the same time points during in vitro CPB (P < 0.01). Values of eNOS and NO were significantly increased in Group C but markedly reduced in Group P during CPB, compared with pre‐CPB (P < 0.01). The CPB procedure significantly damaged dogs’ RBCs in the ATP level, eNOS activity, and NO production, in vitro, but Pyr effectively protected RBCs in these functions during CPB. Pyr would be clinically protective for RBCs during CPB.     

Zero‐Balance Ultrafiltration of Priming Blood Attenuates Procalcitonin and Improves the Respiratory Function in Infants After Cardiopulmonary Bypass: A Randomized Controlled Trial

Blood priming is needed for cardiopulmonary bypass (CPB) in neonates and infants to avoid exceeding hemodilution; however, transfusion‐related inflammation affects post‐CPB outcomes in infant open‐heart surgery. Procalcitonin, a newly detected inflammatory moderator and a sensitive parameter for predicting pulmonary dysfunction secondary to CPB, rises after CPB. We hypothesized that the hemofiltration of priming blood before CPB might decrease inflammatory mediators in the blood and post‐CPB inflammatory replications, thereby improving the respiratory function after CPB in infants. Sixty infants with a weight below 10 kg were divided randomly into two equal groups of CPB with the zero‐balance ultrafiltration (Z‐BUF) of priming blood and CPB without it. The procalcitonin level was measured before anesthesia, after admission to the intensive care unit (ICU), and 24 h afterward. The respiratory index and pulmonary compliance were measured after anesthesia, at the end of CPB, and 2 h after admission to the ICU. Additionally, time to extubation was recorded. The Z‐BUF of priming blood maintained electrolytes within a physiologic level, and procalcitonin had a slighter rise in the Z‐BUF Group at 24 h after admission to the ICU (P = 0.05). The respiratory index was decreased in the Z‐BUF Group, but the difference with the control group did not reach statistical significance (P > 0.05). The change in pulmonary compliance was significantly increased in the cyanotic patients in the intervention group, but there was no significant difference between the two groups. The time to extubation and the ICU stay were shorter in the Z‐BUF Group (P < 0.05). A positive correlation was found between the peak procalcitonin concentration and the time to extubation directly and pulmonary compliance reversely. These results suggest that the Z‐BUF of priming blood may have some beneficial clinical effects such as improved respiratory function and attenuated procalcitonin.     

Effect of Ultrafiltration During Cardiopulmonary Bypass for Pediatric Cardiac Surgery

The effect of ultrafiltration during cardiopulmonary bypass (CPB) was evaluated for correcting ventricular septal defects with associated pulmonary hypertension in patients less than 18 months old. Interleukin (IL)-6 and IL-8 concentrations in the blood, ultrafiltrate, and urine were measured. The blood IL-6 concentration increased to 128.4 ± 20.2 pg/ml by the end of surgery, which is lower than the concentration seen in adult patients (273.1 ± 48.2 pg/ml, p < 0.02). The blood IL-8 concentration was not significantly different than that of adults. The total amounts of excreted IL-6 in the ultrafiltrate and urine during CPB were 11.5 ± 0.32 pg/kg and 0.32 ± 0.07 pg/kg, respectively (p < 0.05). The total amounts of excreted IL-8 in the ultrafiltrate and urine were 4.64 ± 0.69 pg/kg and 1.92 ± 0.56 pg/kg, respectively (p < 0.05). No differences were seen in these values for excretion between children and adults. We conclude that ultrafiltration during CPB in pediatric patients is more effective in removing proinflammatory cytokines than in adults and more effective than renal filtration alone.     

改良超滤对婴幼儿心内直视术后血液流变学的影响

目的评估改良超滤(MU F)对婴幼儿心内直视术后血液流变学的影响。方法选取需行手术治疗、体重<10kg的室间隔缺损(V SD)合并肺动脉高压(PH)患者22例,按住院号的奇、偶数分为对照组(10例,尾数为奇数者)和实验组(12例,尾数为偶数者)。对照组体外循环(CPB)结束后不行MU F,实验组于CPB停机后行MU F,超滤时间10~15m in,超滤流量10~15m l/m in.kg。分别于术前、CPB停机时、CPB后15m in/MU F结束时、术后2h和24h 5个时间点采集桡动脉血2.5m l,采用M DK-3200双通道全自动血液流变测试分析仪检测血液流变学相关指标的变化。结果实验组MU F结束时血红蛋白、红细胞压积、红细胞计数、屈服应力、血浆粘度、全血高切粘度、全血中切粘度、全血低切粘度、全血高切还原粘度、全血中切还原粘度、全血低切还原粘度和卡松粘度均较对照组CPB后15m in明显升高(P<0.05);红细胞变形指数、红细胞聚集指数各时间点两组间比较差异均无统计学意义(P>0.05)。结论使用MU F可明显提高CPB后患者的血红蛋白、红细胞压积、红细胞计数,婴幼儿CPB后采用MU F,其血液粘度高于未行MU F患者。