心内直视手术中鱼精蛋白毒性反应的发生及处理

目的分析心内直视手术中鱼精蛋白毒性反应发生情况、临床特点，探讨处理措施。方法2001年1月～2006年1月，连续行1163例心内直视手术中发生鱼精蛋白毒性反应31例，其中轻度反应（血压下降〈30mmHg）26例，中度、重度反应（中度反应血压下降30～49mmHg，重度反应血压下降≥50mmHg）5例；低血压型28例，过敏反应／类过敏反应型2例，肺血管收缩型1例。所有患者均给予立即停止使用鱼精蛋白或减慢鱼精蛋白泵入速度、补充血容量、抗过敏、血管活性药物或再次体外循环治疗。结果26例出现轻度鱼精蛋白毒性反应者经停止使用或减慢鱼精蛋白泵入速度及相应治疗后，均很快好转；5例出现中度、重度鱼精蛋白毒性反应者，经停止使用鱼精蛋白、抗过敏、补充血容量、血管活性药物和再次体外循环支持，4例好转，1例死亡。27例门诊随访3个月，恢复正常学习和工作。结论心内直视手术中鱼精蛋白毒性反应发生率高，中度、重度反应者死亡率高。鱼精蛋白毒性反应的发生与其用量和使用方法密切有关，充分认识鱼精蛋白毒性反应的临床特点，精确鱼精蛋白用量和改进使用方法能在一定程度上防治毒性反应的发生。     

心内直视术中鱼精蛋白毒副反应的危险因素分析

目的　探讨心内直视手术中鱼精蛋白毒副反应发生的危险因素 ,找出预防措施。　方法　回顾性分析连续行心内直视手术的 2 10 5例患者输入鱼精蛋白的情况 ,按术中是否发生鱼精蛋白毒副反应将其分为有毒副反应组(n=83)和无毒副反应组 (n=2 0 2 2 )。比较两组间和有毒副反应组轻度与中重度反应患者间的临床特点。用 L ogistic回归方法分析术中发生鱼精蛋白毒副反应的高危因素。　结果　有毒副反应组平均鱼精蛋白用量显著高于无毒副反应组 (P<0 .0 5 )。有毒副反应组中重度反应患者毒副反应持续时间、体外循环 (CPB)时间和主动脉阻断时间均较轻度反应患者长 (P<0 .0 5 ) ;鱼精蛋白采用传统剂量患者毒副反应发生率 (4 .8% )较低剂量患者高 (3.0 % ,P<0 .0 5 )。多因素分析结果 ,鱼精蛋白剂量偏大是唯一的独立危险因素 (P=0 .0 0 3)。　结论　心内直视手术中鱼精蛋白毒副反应的发生难以预测 ,将鱼精蛋白剂量控制在最佳范围是预防毒副反应发生的重要措施之一。     

小儿心内直视术后应激性溃疡10例

小儿心内直视术后应激性溃疡１０例贺端清，曹振飞上消化道应激性溃疡出血是体外循环心内直视术后少见的并发症，发病率０．ｌｌ％～０．８５％。且多伴有重要脏器功能紊乱，死亡率高达３０％～５０％。我们治疗１０例，就其发生原因，诊疗情况介绍如下：临床资料男、女各...     

体外循环心内直视术后再次开胸止血

目的 通过分析体外循环心内直视术后再桨开胸止血的临床结果，指导今后的临床工作。方法 回顾分析４９０８例心内直视术后再镒开胸止血的临床病例。结果本组再次开胸止血的发生率为１．６％，再次开胸止血时凶活动性出血者为２２．８％，不同疾病再次开胸止血的发生率不同，再次开胸止血可增加手术死亡率及手术切口并发症的发生率等。结论 正确掌握再次开胸止血的手术适应证及正确的手术技术可减少再次开胸止血的发生率。     

体外循环心内直视术后再次开胸止血的临床分析与护理

目的:通过分析体外循环心内直视术后再次开胸止血的临床结果,指导今后的临床工作。方法:回顾分析535例心内直视术后的临床病例,探讨15例再次开胸止血的原因和防治措施。结果:本组再次开胸止血的发生率为2.8％,再次开胸时未见活动性出血者53.3％;再次开胸止血距离一次手术时间为3~15h,在术后6h内的占66.7％;死亡2例,死亡率13.3％。结论:术中重视预见性措施,术后加强监护、正确而及时的处理,可减少再次开胸止血的发生率和手术死亡率。     

阻塞性黄疸患者外周血内毒素和T淋巴细胞亚群变化的研究

对３２例阻塞性黄疸（下称阻黄）患者的外周血内毒素含量和Ｔ淋巴细胞亚群进行测定。结果发现阻黄患者内毒素阳性率为５９．３８％，平均０．０２８±０．０６ＥＵ／ｍｌ。中重度组的阳性率远高于轻度组（Ｐ＜０．０５）。术后一周９２．８６％患者转为阴性，术后二周全部阴性。胆道阻塞患者ＣＤ３降低（Ｐ＜０．０５），ＣＯ４在中重度组也明显降低（Ｐ＜０．０５），中重度组和恶性组的Ｃ０／ＣＤ８比值降低（Ｐ＜０．０５），术后二周患者的免疫功能尚未恢复正常。术后并发症发生率和手术死亡率以中重度组和恶性组为高。上述结果表明阻黄患者存在内毒素血症和细胞免疫功能降低，与阻黄患者术后并发症多和死亡率高有关。     

心脏术后患者并发精神异常的护理

随着人工心肺机装置。灌注技术及心内直视操作的不断改进，尤其在术中使用微泡氧合器和在体外循环管道中装配微孔过滤器排除心腔残留气体后，心脏术后脑损害的发病率显著下降。但由于ICU的特殊环境，疼痛、失眠等影响可并发精神障碍。1990年我院行心内直视手术322例，发生精神障碍4例，占1．24％。通过分析其发生的原因，加强预防护理，1996年1～6月行心内直视手术220例，仅发生1例精神异常，发生率降至0．45％。现将护理措施介绍如下。1临床资料322例心内直视手术患者并发精神障碍4例，均为男性，平均年龄42．5岁。换双瓣3例，左室室壁瘤…     

体外循环心内直视手术中鱼精蛋白致严重循环抑制的治疗

目的总结体外循环心内直视手术中鱼精蛋白所致严重循环抑制的救治经验。方法回顾性分析2016年6月至2017年7月我中心体外循环心内直视手术中给予鱼精蛋白中和肝素后出现严重循环抑制9例患者的临床资料,其中男7例,女2例,年龄62.3(36~78)岁。7例为左心室肥厚者。分析其临床特点及处理方法。结果 1例因反复给予鱼精蛋白而循环衰竭死亡,1例因非鱼精蛋白原因死亡,余7例经肝素化转机和/或垂体后叶素等血管活性药抢救后好转。结论鱼精蛋白毒性反应所导致的严重循环抑制为突发事件且往往危及生命,果断肝素化转机和垂体后叶素的及时应用是成功挽救患者生命的重要环节。     

体外循环心内直视手术后20例上消化道大出血的处理

体外循环心内直视手术后上消化道大出血是一种严重的并发症,死亡率甚高。现将我们处理20例的经验介绍如下: 临床资料 1964年8月～1993年8月我们共行体外循环心内直视手术7760例,发生上消化道大出血20例,发生率0.26％。本组20例中男14例,女6例;年龄2～54岁。手术包括二尖瓣替换和法乐四联症修复术各5例,法乐三联症修复术3例,右心室双出口和大室缺     

心内直视术后高淀粉酶症

心内直视术后高淀粉酶症张晓膺，范晋明，高克柔，王中林，姜建平前瞻性研究了心内直视术后血、尿淀粉酶增高，发现其与术后急性胰腺炎无关。报告如下：临床资料自１９９１年１２月至１９９２年７月，连续行心内直视手术２７例，其中男１５例，女１２例。平均年龄１９．４...     

A case of severe coronary artery spasm associated with anaphylactic reaction caused by protamine administration

A 65-year-old man with mitral regurgitation and atrial fibrillation underwent mitral valve plasty and Maze's operation. Cardiopulmonary bypass (CPB) was finished uneventfully. But after protamine administration, severe systemic hypotension occurred suddenly with electrocardiographic ST-segment elevation and wide QRS intervals. We thought that this reaction had been caused by coronary spasm and not by anaphylactic reaction because he was without typical anaphylactic manifestations such as general rash and bronchospasm. We administered epinephrine, methylprednisolone, heparin for restarting CPB, and used IABP support to assist systemic circulation. We again tried to administer protamine to neutralize the anticoagulative effect of heparin when his vital sign had recovered, but the same reaction occurred immediately with small amounts of protamine. The second CPB was necessary for some time. This case suggests that coronary artery spasm associated with anaphylactic reaction was induced by administration of protamine. It is known that intravenous protamine administration sometimes causes adverse events. As in this case, we should consider the possibility of severe coronary spasm associated with anaphylactoid reaction even if other symptoms of anaphylactic reactions such as cutaneous manifestation and bronchospasm are not present.     

Clinical role of blood heparin level monitoring during open heart surgery.

Protamine has been used for neutralizing heparin and its dosage is decided by the initial fixed dose of heparin. Adequate protamine neutralization is very important to reduce complications. To attenuate excess reactions, in particular, whole blood heparin concentration during and after cardiopulmonary bypass was measured using Hepcon, and the efficacy of optimal protamine dose in open heart surgery was evaluated. Twenty patients were randomly divided into two comparable groups, P and C. In the C group, heparin was neutralized with an initial fixed dose of protamine, 1.67 mg protamine per milligram total heparin (n = 8). In the P group, protamine dose was determined for residual heparin concentration (n = 12). In the P group, blood heparin concentrations at 60 minutes after the establishment of cardiopulmonary bypass, just after cardiopulmonary bypass and first protamine administration were 2.35 +/- 0.14, 2.31 +/- 0.17 and 0.13 +/- 0.08 U/ml, respectively. Concentrations reached zero with the second protamine administration. The requirement of transfusion (659 +/- 224 vs. 1559 +/- 323 ml, p = 0.0314), pulmonary vascular resistance index just after the protamine administration (190 +/- 22 vs. 286 +/- 18 dyne.s.cm-5.m2, p = 0.0137) and the IL-8 levels (just after protamine: 26.9 +/- 5.1 vs. 43.5 +/- 5.9 pg/ml, p = 0.0499, 12 hours after cardiopulmonary bypass: 37.1 +/- 12.1 vs. 86.8 +/- 20.0, p = 0.0435) in the P group were significantly lower than those in the C group. These data suggested that heparin level monitoring in whole blood may be useful to determine the optimal dose of protamine resulting in the decrease of a requirement of blood components in open heart surgery and attenuating in transient pulmonary hypertension and excess protamine-induced inflammatory reactions.     

Evaluation of patients at risk for protamine reactions

Patients with neutral protamine Hagedorn and protamine-zinc insulin-dependent diabetes, a history of fish allergy, or prior vasectomy have been reported to be at an increased risk for protamine reactions after cardiopulmonary bypass because of prior sensitization. We prospectively evaluated cardiac surgical patients with prior vasectomies and fish allergies and retrospectively evaluated a cohort of 3245 consecutive cardiac surgical patients requiring cardiopulmonary bypass over a 2-year period for protamine-containing insulin use and clinical evidence of adverse reactions after protamine administration for heparin reversal after cardiopulmonary bypass. Clinical reactions to protamine did not occur in six patients with fish allergies or 16 patients with prior vasectomies. There was one reaction (0.6%) in 160 patients with neutral protamine Hagedorn insulin-dependent diabetes. The incidence of clinical reactions in the other patients was 2/3085 (0.06%). The incidence of clinical reactions in the patients with neutral protamine Hagedorn insulin-dependent diabetes is not significantly different from that in other patients. We conclude that prior neutral protamine Hagedorn insulin use, a history of fish allergy, or prior vasectomy does not represent a contraindication to protamine administration after cardiopulmonary bypass.     

Clinical role of blood heparin level monitoring during open heart surgery

Protamine has been used for neutralizing heparin and its dosage is decided by the initial fixed dose of heparin. Adequate protamine neutralization is very important to reduce complications. To attenuate excess reactions, in particular, whole blood heparin concentration during and after cardiopulmonary bypass was measured using Hepcon®, and the efficacy of optimal protamine dose in open heart surgery was evaluated. Twenty patients were randomly divided into two comparable groups, P and C. In the C group, heparin was neutralized with an initial fixed dose of protamine, 1.67 mg protamine per milligram total heparin (n = 8). In the P group, protamine dose was determined for residual heparin concentration (n = 12). In the P group, blood heparin concentrations at 60 minutes after the establishment of cardiopulmonary bypass, just after cardiopulmonary bypass and first protamine administration were 2.35 ± 0.14, 2.31 ± 0.17 and 0.13 ± 0.08 U/ml, respectively. Concentrations reached zero with the second protamine administration. The requirement of transfusion (659 ± 224 vs. 1559 ± 323 ml, p = 0.0314), pulmonary vascular resistance index just after the protamine administration (190 ± 22 vs. 286 ± 18 dyne·s·cm^?5·m², p = 0.0137) and the IL-8 levels (just after protamine: 26.9 ± 5.1 vs. 43.5 ± 5.9 pg/ml, p = 0.0499, 12 hours after cardiopulmonary bypass: 37.1 ± 12.1 vs. 86.8 ± 20.0, p = 0.0435) in the P group were significantly lower than those in the C group. These data suggested that heparin level monitoring in whole blood may be useful to determine the optimal dose of protamine resulting in the decrease of a requirement of blood components in open heart surgery and attenuating in transient pulmonary hypertension and excess protamine-induced inflammatory reactions.     

肾功能不全者心脏手术后的疗效分析

目的：分析合并肾功能不全心脏病人行体外循环心内直视手术的疗效。方法：４３例术前心功能Ⅱ级７例,Ⅲ级１８例,Ⅳ级１８例病人,行先天性心脏病手术５例,瓣膜替换术３６例,冠状动脉搭桥术２例。术前肾功能不全为轻度者３４例,中度５例,重度４例。结果：术后肾功能正常１８例,轻度不全４例,中度７例,重度１４例。     

Heparin reversal in off-pump coronary artery bypass surgery: complete,partial, or no reversal?

Several clinical studies have reported that avoiding cardiopulmonary bypass reduces postoperative bleeding. The purpose of this study is to verify that protamine during off-pump coronary artery bypass surgery produces significant reduction of postoperative bleeding.Sixty consecutive patients undergoing off-pump coronary artery bypass surgery were prospectively randomized in three groups: Group A received 1 mg of protamine every 100 IU of heparin, Group B 0.5 mg of protamine every 100 IU of heparin, and Group C none. The three groups were analyzed for differences in preoperative cardiac function, pre-, intra-, and postoperative coagulation profile, intraoperative variables, and postoperative bleeding.In the three study groups, no statistically significant difference was found in preoperative cardiac function, pre- and intraoperative coagulation profile, and prothrombin time, activated partial thromboplastin time, platelet count in the first postoperative day. In Group A, total postoperative bleeding, use of packed red blood cells, and mild pericardial effusion prevalence at discharge were significantly lower only when compared to Group C, but they were not significantly different when compared to Group B.In off-pump coronary artery bypass surgery, heparin should be reverted with protamine, otherwise the postoperative bleeding risk might increase. Partial heparin reversal might not increase postoperative bleeding risk, but it may reduce dose-dependent protamine adverse effects.     

维生素K1对小儿心内直视手术围术期凝血机制的影响

目的 小儿心内直视手术中应用维生素K1（Vitamin K1,Vit K1)，观察其对凝血因子的作用。方法 30例心脏手术患者分为3组，A组：动脉导管未闭患者；B组：使用VitK1治疗；C组：未使用VitK1治疗。每组各10例，分别检测A组术前、术后、B组、C组术前24小时、麻醉后开胸前、鱼精蛋白中和后10分钟、术毕、术后6小时、1天、3天和5天的血浆凝血酶原时间（PT）、激活部分凝血活酶时间（APTT）、凝血酶时间（TT）、X因子活性，纤维蛋白原含量和红细胞压积。结果 鱼精蛋白中和后10分钟血浆凝血酶原时间、激活部分凝血活酶时间、凝血酶时间最长，X因子活性、纤维蛋白原含量最低。与C组相比，B组术后24小时内血浆凝血酶原时间明显缩短，X因子活性明显升高。结论 术前应用Vit K1可明显提高术后早期凝血因子水平，有利于减少术后出血的发生。     

体外循环期间纤溶系统的变化规律及其机制的探讨

目的　探讨体外循环 (CPB)心脏直视手术期间纤溶系统的动态变化规律 ,探讨纤溶系统激活的机制。方法　 2 0例心脏直视手术患者 ,分别于麻醉诱导后切皮前、体外循环开始后 8、3 0min、鱼精蛋白中和肝素后 10min、术后 2h采集血标本 ,检测组织型纤溶酶原激活物 (t PA)、纤溶酶原激活物抑制剂 (PAI)、纤溶酶活性 (PLm)、D 二聚体 (D dimer)的动态变化。结果　术中t PA活性与术前相比显著升高 ,术后 2h恢复正常。PAI活性术中术后与术前相比差异无显著性。体外循环期间t PA/PAI比值显著升高 ,术后 2h恢复正常。手术期间D 二聚体含量显著升高 ,术后 2h仍维持较高水平。PLm活性在体外循环期间及中和后显著升高。结论　体外循环期间纤溶系统被明显激活 ,其主要机制是t PA分泌增加 ,t PA、PAI间的平衡失调和纤溶酶原的激活。     

Hemodynamics of protamine administration. Comparison of right atrial, left atrial, and aortic injections

Protamine administration for heparin reversal after cardiopulmonary bypass on occasion is associated with mild to severe hemodynamic deterioration. The route of administration may modify these reactions. A prospective randomized study was done in 68 patients undergoing isolated coronary artery bypass grafting. The route of protamine administration was randomized in a balanced fashion between right atrium, left atrium, and aorta. The preoperative and operative characteristics of the three groups were similar. Hemodynamic measurements were recorded before cannulation, after removal of the venous drainage catheter, and 1 minute, 5 minutes, and 10 minutes after protamine administration. Hypotension occurred in 11 patients with no significant difference among the three groups. The hypotension was immediate in three patients in whom route of administration was the aorta. The overall hemodynamic changes observed for the three treatment groups were not significantly different. An analysis for type II error indicated that it was unlikely that an important difference had been missed. We conclude that the route of administration does not affect the hemodynamic changes associated with protamine administration. We did not observe a case of severe hemodynamic deterioration, so that we cannot assess the effect of route of administration on the severity of an anaphylactic reaction.