两种抗纤溶治疗方案对体外循环心脏手术患者围术期血浆纤维连接蛋白水平的影响

目的:评估两种抗纤溶治疗方案对体外循环心脏手术患者围术期血浆纤维连接蛋白水平和术后出血的影响。方法:将入组的139例行体外循环冠状动脉旁路移植术或瓣膜置换术患者采用计算机生成随机数字表法分为三组:低剂量组(n=46)、高剂量组(n=46)和对照组(n=47);低剂量组即氨甲环酸负荷量10 mg/kg,维持量10 mg/(kg·h);高剂量组即氨甲环酸负荷量20 mg/kg,维持量15 mg/(kg·h);对照组即给予等容量生理盐水。三组各顺序选择20例患者,分别于手术开始前(T1)、手术结束时(T2)、术后6 h(T3)和术后24 h(T4)时间点取静脉血,用酶联免疫吸附测定(ELISA)法测定血浆纤维连接蛋白的水平。记录并比较三组术后胸管引流量和异体红细胞(异体RBC)、血小板(PLT)及新鲜冰冻血浆(FFP)的使用情况。结果:低剂量组和高剂量组患者术后血浆纤维连接蛋白水平均显著高于对照组(P均<0.05)。低剂量组与高剂量组比,患者血浆纤维连接蛋白水平差异无统计学意义(P>0.05)。对照组患者血浆纤维连接蛋白水平于T3逐渐升高,低剂量组和高剂量组患者分别于T2逐渐升高,三组患者血浆纤维连接蛋白水平均于T4达到24 h内峰值,均显著高于术前水平(P均<0.05)。低剂量组和高剂量组患者术后总引流量较对照组明显减少,异体RBC、FFP、PLT使用量和使用率均显著下降(P均<0.05)。结论:氨甲环酸可以提高患者术后血浆纤维连接蛋白表达,同时减少体外循环术后出血和异体输血。     

Incidence,Risk Factors,and Outcomes of Hyperferritinemia after Pediatric Cardiac Surgery with Cardiopulmonary Bypass: A Retrospective Study

Objective: Serum ferritin has been identified as a prognostic marker in patients with a variety of diseases. In the present study we aim to determine the prevalence of risk factors and outcomes for hyperferritinemia in children undergoing cardiac surgery with cardiopulmonary bypass for congenital heart defects. Methods: The serum ferritin levels of 457 children between the ages of twentyeight days and three years undergoing cardiopulmonary bypass surgery between June 1, 2017 and June 1, 2018 were analyzed. The prevalence of early postoperative hyperferritinemia was investigated; hyperferritinemia was defined as a ferritin level ≥250 ng/ml. Multivariable regression models including candidate risk factors were constructed to determine the independent predictors of serum ferritin levels post-bypass, analyzed as continuous variables (linear regression) and categorized variables (logistic regression). Multivariable logistic regression was applied to assess the relationship between postoperative hyperferritinemia and a composite of in-hospital mortality, acute kidney injury, extracorporeal life support, prolonged postoperative hospital length of stay and prolonged postoperative mechanical ventilation. Results: Of the 457 included patients, frequency of post-cardiopulmonary bypass hyperferritinemia was 59/457 (10.9%). In multivariate logistic analyses, age [odds ratio (OR) 0.776/90 days], maximum cardiopulmonary bypass flow [OR 1.031/(1 ml/kg)], cardiopulmonary bypass duration (OR 1.095/10 mins) and preoperative hemoglobin [OR 1.207/(10 g/L)] were significantly associated with early postoperative day 1 hyperferritinemia. After risk adjustment, hyperferritinemia was independently associated with the composite outcome (OR 6.373; 95%CI 2.863~14.184, p < 0.001), and improved model discrimination, (AUC 0.868; 95%CI 0.821∼0.916) compared with basic clinical prediction alone (AUC 0.840; 95%CI, 0.790∼0.890; △AUC = 0.0279, p = 0.0218). Conclusion: In this study, we found early postoperative hyperferritinemia was relatively common in pediatric patients after cardiopulmonary bypass. The occurrence of hyperferritinemia may help identify a population at risk of unfavorable in-hospital outcome.     

The Hemostatic Defect of Cardiopulmonary Bypass

Cardiac surgery involving cardiopulmonary bypass is a common yet complex procedure that results in considerable disruption of hemostasis during and following surgery. Despite the relatively common and widespread use of this procedure, there remains a significant peri-operative risk of both thrombosis and hemorrhage in some patients. This is known as the hemostatic defect of cardiopulmonary bypass.Strategies including the use of pharmacological agents, hemodilution, autologous blood transfusion, rapid in-theatre monitoring of hemostatic potential with fine-tuning of the degree of heparinization, minimally invasive surgery and the use of biologically coated cardiopulmonary bypass equipment have been employed to ameliorate the effects of cardiopulmonary bypass on hemostasis. However there exists a fine line between preventing hemorrhage and promoting thrombosis. Likewise attempts to prevent thrombosis may result in increased hemorrhage. Research into many strategies for minimizing the hemostatic defect of cardiopulmonary bypass is incomplete, with safety and efficacy the subjects of intensive investigation.     

体外循环肺保护的研究进展

肺损伤是体外循环心内直视手术的主要并发症之一,随着心肌保护技术的日益成熟,肺保护成为近年的研究热点。肺保护的方法多种多样,如药物干预、肺动脉灌注低温保护液、白细胞滤过等,其目的在于降低全身性炎症反应,减轻或避免缺血再灌注损伤。作者回顾近年来体外循环肺保护方法的研究状况。     

Emboli and Neuropsychological Outcome Following Cardiopulmonary Bypass

The dramatic decline in mortality related to cardiac surgery has resulted in over 330,000 surgeries involving cardiopulmonary bypass (CPB) being performed yearly in the United States. Although few patients die as a result of cardiac surgery, over two thirds of the patients demonstrate evidence of acute neuropsychological dysfunction postoperatively. The potential mechanisms contributing to post-CPB neuropsychological deficits are many, but two major inter-related etiologic factors, hypoperfusion and emboli, are suggested as the probable culprits. If embolism is the cause of the deficits, increasing cerebral perfusion would deliver more emboli and increase the amount and severity of injury. Conversely, if hypoperfusion is the cause of the injury, then decreasing brain blood flow to minimize embolic delivery would increase the likelihood of perfusion injury. By monitoring the carotid arteries of patients undergoing coronary artery bypass graft surgery, we have determined the frequency and quantity of embolic signals that occur during CPB. Although we have not been able to determine the nature of the embolus, gaseous or solid, we have demonstrated a relationship between the overall embolic load and the probability of having NP dysfunction.     

Acute Normovolemic Hemodilution does not Reduce Antithrombin Concentration for Cardiac Surgery

BACKGROUND: Acute normovolemic hemodilution (ANH) is used to reduce allogeneic blood transfusion with cardiac surgery. This procedure involves pre-operatively removing and storing a volume of whole blood and replacing the volume with crystalloid. The stored blood is then available for transfusion, if required. Hemodilution associated with ANH may reduce the effectiveness of heparin anticoagulation due to dilution of antithrombin. The aim of this study was to determine if antithrombin concentrations are reduced in patients who undergo one unit of ANH during cardiac surgery. METHODS: Patients scheduled for cardiac surgery (n = 71) were grouped according to whether they did or did not undergo ANH pre-operatively. Antithrombin concentrations were measured before and after ANH. This study had 80% power to detect a difference in reduction of antithrombin concentration of 6% between groups following ANH with an alpha error of <0.05. The effect of one unit ANH was expected to cause a difference of 12% or greater. RESULTS: No significant difference in the concentration of antithrombin between ANH patients and those that did not have ANH, nor was there a difference in the decrease in antithrombin between groups. CONCLUSIONS: The results indicate that one unit of ANH does not significantly reduce the concentration of antithrombin prior to cardiac surgery. Thus patients who undergo one unit of ANH are not at increased risk due to dilution of antithrombin.     

超滤法对体外循环心脏手术价值的临床研究

体外循环下心内直视手术病人80例分为两组,超滤组采用三种血液滤器,超滤时间为63.5±26.0分钟,每次滤液1441.9±597.8毫升。超滤组液体平衡+448.4±277.0毫升,对照组为+1568.8±327.0毫升,呈高度显著性差异;Hct和Hb从超滤前的24.15vol％和69.2g/L显著地分别上升到32.15vol％和97.2g/L,且显著地大于对照组停机时相应的23.92vol％和75.0g/L。超滤后全血体积平均减少28.2％,血浆体积减少35.1％,细胞外液减少39.9％,组织间隙液减少4.8％;超滤能提高血浆蛋白浓度和胶体渗透压。上述变化率均明显超过对照组。滤液能排出K~+、Na~+、Cl~-、HCO_3~-、BUN、Cr和肝素,但超滤未严重干扰体内电解质平衡,酸硷平衡和凝血因素,未引起严重溶血。作者认为:超滤法是一种简单,安全和有效的体外循环新技术,可以作为心内直视手术中一种常规方法。     

氨甲环酸用于非体外循环冠状动脉搭桥术血液保护作用的Meta分析

目的采用系统回顾和Meta分析评价氨甲环酸用于非体外循环冠状动脉搭桥术（OPCAB）的血液保护效果及安全性。方法全面检索Pubmed、Cochrane CENTRAL、EMBASE数据库,将行OPCAB术患者,分为氯甲环酸组和对照组进行比较,报道了至少一项明确临床结果的所有随机临床试验均纳入本Meta分析,日期截止至2012年1月。使用Review Manager 5．1统计学软件行Meta分析,计数资料计算优势比（OR）和95％可信区间（CI）,连续变量计算加权均数差（WMD）和95％CI。结果共10项随机临床试验中的849例病人纳入该Meta分析。在OPCAB术中,同对照组相比,氨甲环酸可明显减少病人24h的胸腔引流量（WMD-209ml,95％CI：-310ml--107ml,p〈0．001）,并显著降低异体红细胞（OR 0．46,95％CI：0．33～0．63,p〈0．001）和新鲜冰冻血浆（OR 0．30,95％CI：018～0．51,p〈0．001）的使用率。两组病人术后严重栓塞并发症（包括急性心肌梗死、中风和肺栓塞）和肾功能衰竭的发生率,以及ICU停留时间、住院时间均无显著差别。结论现有证据表明OPCAB术应用氨甲坏酸可减少术后出血量,减低异体血使用率,有明确的血液保护作用。     

Localised Cerebral Phosphorus-31 MR Spectroscopy in Man Before and Immediately after Coronary Bypass Surgery with Hypothermic Cardiopulmonary Bypass

Coronary artery bypass surgery classically is undertaken with hypothermic cardiopulmonary bypass (CPB). There is a high incidence of neuropsychological defects after cardiac surgery, which may be related to cerebral ischaemia during the rewarming period. In this study, phosphorus-31 magnetic resonance spectroscopy (³¹P MRS) was used to identify changes in cerebral ³¹P MR spectra in patients before and immediately after hypothermic CPB. Four neurologically normal patients undergoing coronary artery bypass surgery were studied. Localised cerebral ³¹P MRS (TR 5000 ms) was performed at 1.5 Tesla on each patient the day before and within an hour of completion of surgery. Peak areas for phosphomonoesters (PME), inorganic phosphate (Pi), phosphodiesters (PDE), phosphocreatine (PCr) and beta ATP (ATP) were measured. Metabolite peak area ratios and relative percentages of each ³¹P MR resonance with respect to the total ³¹P MR signal were calculated. In the post-operative MR spectra, each patient displayed a marked reduction in Pi/ATP and increase in PCr/Pi ratios. Spectral changes in percentage metabolite signals following surgery varied both in magnitude and pattern between patients. In two patients there was an increased postoperative percentage PME and percentage PCr with a decrease in percentage ATP. The converse was found in the other two patients, but all four subjects displayed a markedly decreased percentage Pi after CPB. These metabolite changes probably reflect rebound phosphorylation in the immediate postoperative period and suggest increased metabolic activity in the hyperaemic brain on rewarming from hypothermic CPB.     

Using Pharmacokinetic Modeling and Electronic Health Record Data to Predict Clinical and Safety Outcomes after Methylprednisolone Exposure during Cardiopulmonary Bypass in Neonates

Background: Infants undergoing cardiac surgery with cardiopulmonary bypass (CPB) frequently receive intra-operative methylprednisolone (MP) to suppress CPB-related inflammation; however, the optimal dosing strategy and efficacy of MP remain unclear. Methods: We retrospectively analyzed all infants under 90 days-old who received intra-operative MP for cardiac surgery with CPB from 2014–2017 at our institution. We combined real-world dosing data from the electronic health record (EHR) and two previously developed population pharmacokinetic/pharmacodynamic models to simulate peak concentration (Cmax) and area under the concentration-time curve for 24 h (AUC24) for MP and the inflammatory cytokines interleukin-6 (IL-6) and interleukin-10 (IL-10). We evaluated the relationships between post-operative, safety, and other clinical outcomes obtained from the EHR with each predicted exposure using non-parametric tests. Results: A total of 142 infants with median post-natal age 8 (interquartile range [IQR]: 5, 37) days received a total dose of 30 (19, 49) mg/kg of MP. Twelve (8%) died, 37 (26%) met the composite post-operative outcome, 114 (80%) met the composite safety outcome, and 23 (16%) had a major complication. Predicted median Cmax and AUC24 IL-6 exposure was significantly higher for infants meeting the composite post-operative outcome and those with major complications. Predicted median Cmax and AUC24 MP exposure was significantly higher for infants requiring insulin. No exposure was associated with death or other safety outcomes. Conclusions: Pro-inflammatory IL-6, but not MP exposure, was associated with post-operative organ dysfunction, suggesting current MP dosing may not adequately suppress IL-6 or increase IL-10 to impact clinical outcomes. Prospective study will be required to define the optimal exposure-efficacy and exposure-safety profiles in these infants.     

不同体外循环方式在主动脉瘤外科手术中的应用

目的：探讨对不同部位、不同病变程度的主动脉瘤的体外循环方式的选择。方法：本组在体外循环下行主动脉瘤外科手术５６例，其中升主动脉瘤３８例，降主动脉瘤１８例。采用低温全身体外循环３１例；左心转流１５例；深低温停循环１０例，其中深低温停循环上腔静脉逆行灌注脑保护方法９例。结果：术中死亡１例，为巨大升主动脉瘤，因吻合口不能控制出血而死亡。术后死亡３例，１例为突发心室颤动，１例为术中大量气体进入主动脉，术后昏迷、肾功能衰竭死亡，第３例为降主动脉瘤术后突发心肌梗死。除１例因动脉插管进入夹层，在开始体外循环时即血压下降、心跳停止，以及术后长时间有神经精神症状外，其余病例均无神经系统并发症。结论：主动脉瘤手术的体外循环方式要根据病变情况决定。     

吲哚美辛对体外循环心脏手术患者免疫调节作用的实验观察

目的：探讨体外循环对机体免疫功能的影响以及吲哚美辛的免疫调节作用。方法：用￣３Ｈ－胸腺嘧啶脱氧核苷参入法检测了１５例体外循环心脏手术患者术前及术后２天外周血单个核细胞产生白介素－２（Ｉｎｔｅｒｌｅｕｋｉｎ－２，ＩＬ－２）的能力以及吲哚美辛对ＩＬ－２产生的影响。结果：术后ＩＬ－２的产生明显低于术前。术前１１．２０±１．６１Ｕ／ｍｌ（±ｓ），术后３．９５±０．３１（Ｐ＜０．０１）。吲哚美辛组（７．１５±０．４１）明显高于对照组（３．７１±０．３８），但仍低于术前（Ｐ＜０．０１）。结论：体外循环手术对机体产生ＩＬ－２有抑制作用，吲哚美辛能部分地提高ＩＬ－２的分泌，增强免疫力。     

116例微创心脏外科手术的体外循环管理

［］：目的 探讨微创心脏外科手术体外循环管理方法和经验。方法：自2013年7月至2014年12月间,我院心胸外科共开展116例右胸前外侧小切口微创心脏手术,其中男性71例,女性45例,年龄13-72岁,平均(40.6±14.2)岁,体重35-85Kg,平均(50.5±10.8)Kg。手术方式包括房间隔缺损修补术,室间隔缺损修补术,二尖瓣成形/置换术,主动脉瓣置换术,三尖瓣成形术,左房/右房粘液瘤摘除术。所有患者均为右胸前外侧小切口进行手术,采用股动脉插管灌注,食道超声引导下的二极股静脉进行插管引流,如有必要可加用上腔静脉插管。其他病例则采用同侧股动脉,股静脉,上腔静脉或右侧颈内静脉插管建立体外循环。除心脏不停跳的术式外,升主动脉顺行灌注4:1冷含血停搏液进行心肌保护。浅低温,中高流量灌注。全组病例都应用负压辅助静脉引流装置(vacuum-assist venous drainage, VAVD)和常规超滤。体外循环结束后,股动脉插管处重建,颈内经脉压迫止血。结果：全组病例均顺利完成手术,体外循环转流时间31-158(82.3±31.7)min,主动脉阻断时间16-96(48.1±19.8)min,超滤量1100-3500ml。除47例不停跳手术外,其余病人中56例心脏自动复跳,自动复跳率81.2%。术后呼吸机辅助时间3-16(4.5±1.4)h,胸腔引流量90-550(160±65)ml,术后住院时间6-21(9.1±2.7)d。88例病人(75.9%)住院期间未输血。115例痊愈出院,1例死于术后感染引起的多脏器功能衰竭,死亡率0.86%。结论：各种外周插管建立的体外循环;VAVD技术的应用;适宜的灌注流量和灌注压力;良好的心肌保护;综合全面的体外循环管理为微创心脏手术提供了坚实的保障,实用性强,值得临床上推广和应用。     

婴幼儿围体外循环期毛细血管渗漏综合征

毛细血管渗漏综合征常发生于低龄、低体重体外循环心血管手术或复杂畸形体外循环时间较长的患儿,直接影响术后的恢复。现对其发病机制、危险因素及防治作简要的综述。     

法鲁四联症体外循环手术对血浆内皮素的影响

对２１例法鲁四联症患儿体外循环手术前后血浆内皮素的变化进行动态检测，并以单纯室间隔缺损２３例作为对照。结果显示，除术后１年外．法鲁四联症组各期内皮素值均较室缺组为高。术后１小时两组内皮素值均达最高峰，室缺组术后３天恢复，四联症组术后７天仍高于术前。内皮素值与体外循环时间及主动脉阻断时间在四联症组呈高度相关。文章讨论了体外循环期间内皮素变化的原因及临床意义。