再次阻断温血灌注在心脏复跳中的应用体会

自2001年5月起,我院对4例心脏手术中发生心脏复苏困难患者及时采取再次温血停跳处理,效果满意。现报告如下。1临床资料本组心脏手术中发生心脏复苏困难患者4例,其中AVR3例,VSD PH(重)1例。上述患者手术均在中度低温CPB下进行,阻断升主动脉后,经主动脉根部灌注4:1氧合血全钾停跳     

重症心脏瓣膜病心肌保护的临床研究

为探讨不同心肌保护方法对重症心脏瓣膜病患者心脏直视术中的心肌保护效果。将40例重症瓣膜病患者随机分为实验组和对照组。实验组（n=20）采用中浅低温氧合血停搏液先行主动脉根部顺灌或冠状动脉直接灌注停跳心脏＋冠状静脉窦持续逆灌＋开放前温血灌注心肌保护；对照组（n=20）采用冷血停搏液间断灌注心肌保护。观察两组围手术期心肌酶、心肌超微结构及临床血液动力学变化。结果显示，术后各时点实验组CK、CK—MB、eTnI水平均显著低于对照组，实验组心肌超微结构改变轻微，术后自动复跳率高，正性肌力药物用量少。因此，含血停搏液多种灌注方法结合可为重症心脏瓣膜病患者术中提供更好的心肌保护。     

顺-逆-温灌注技术在重症心脏瓣膜疾病术中的心肌保护作用

比较30例大左室瓣膜置换术的灌注方法,以探讨体外循环中应用不同停搏液对心肌的保护作用。1　资料与方法1.1　病例:30例患者的左室舒张末径均>6 5 mm,心功能 ～ 级,左室肥厚伴劳损或伴脏器功能损害。随机分为两组,每组15例, 组采用顺逆温灌技术; 组采用冷血顺灌,两组间病程、性别、年龄、左室及瓣膜病变程度、心功能等方面均无显著性差异(P均>0 .0 5 ) ,有可比性。见表1。1.2　心肌停搏液灌注方法: 组于升主动脉阻断后先从主动脉根部灌注4∶1高钾冷血停搏液(K 2 2 m mol/ L,即氧合血与含钾停搏液以4∶1比例混合,灌注管置于4℃冰水中) ,灌…     

老年人工生物瓣膜置换过程中紫外线照射充氧血首次灌注对心肌的保护

背景:动物实验表明将紫外线照射充氧血添加于心停搏液中有一定的心肌保护作用,故推测其对体外循环心内直视手术患者的心肌也有保护作用.目的:课题提出使用紫外线照射充氧血行首次冠状动脉顺行灌注,观察其在老年患者人工生物心脏瓣膜置换体外循环过程中是否对心肌有保护作用.设计、时间及地点:生化水平的随机对照试验,于2006-10/2008-04在贵州省人民医院心脏外科完成.对象:选择贵州省人民医院心脏外科收治需择期行人工生物瓣膜置换的风湿性心脏瓣膜病老年患者46例,按随机数字表法分为2组,每组23例.方法:紫外线照射充氧血组于麻醉后通过锁骨下静脉按10 m/kg放血行紫外线照射充氧(同时经另一静脉途径输入等量生理盐水,术前经过计算,体外循环过程中血红蛋白低于70g/L者,用库血代替自体血行紫外线照射充氧),升主动脉阻断后,将紫外线照射充氧血作为心停搏液组成成分进行首次冠状动脉顺行灌注,之后每30 min常规以4:1冷血/晶体灌注.对照组首次冠状动脉顺行灌注使用不含紫外线照射充氧血的4:1冷血/晶体外,其他处理同治疗组.主要观察指标:于升主动脉阻断前,升主动脉开放后5,10 min从冠状静脉窦取血2 mL,测定超氧化物歧化酶活性及丙二醛浓度.在升主动脉阻断前,停体外循环后4,24,48 h时从中心静脉取血2 mL,测定肌酸激酶同工酶活性及肌钙蛋白I质量浓度.结果:开放升主动脉后,紫外线照射充氧血组冠状静脉窦血清丙二醛浓度低于对照组(P＜0.05),超氧化物歧化酶活性显著高于对照组(P<0.05).紫外线照射充氧血组停体外循环后4-48 的血清肌酸激酶同工酶活性及肌钙蛋白I质量浓度显著低于对照组(P< 0.05).结论:体外循环过程中首次冠状动脉顺行灌注紫外线照射充氧血能提高心肌细胞超氧化物歧化酶活性,减少丙二醛产生,减轻心肌缺血再灌注损伤.降低心肌损伤标志物水平,对老年人工生物心脏瓣膜置换患者具有较好的心肌保护作用.     

重症心脏瓣膜病心肌保护的临床研究

为探讨不同心肌保护方法对重症心脏瓣膜病患者心脏直视术中的心肌保护效果。将40例重症瓣膜病患者随机分为实验组和对照组。实验组(n=20)采用中浅低温氧合血停搏液先行主动脉根部顺灌或冠状动脉直接灌注停跳心脏+冠状静脉窦持续逆灌+开放前温血灌注心肌保护;对照组(n=20)采用冷血停搏液间断灌注心肌保护。观察两组围手术期心肌酶、心肌超微结构及临床血液动力学变化。结果显示,术后各时点实验组CK、CK-MB、cTnI水平均显著低于对照组,实验组心肌超微结构改变轻微,术后自动复跳率高,正性肌力药物用量少。因此,含血停搏液多种灌注方法结合可为重症心脏瓣膜病患者术中提供更好的心肌保护。     

一种新的心脏停跳复苏动物模型

本实验采用阻断奇静脉、下腔静脉及上腔静脉,同时阻断升主动脉,灌注冷钾停跳液保护心肌的方法,成功地建立了一种新的心脏停跳复苏动物模型。结果表明:模型的心脏复苏成功率高(100%),复苏后心血管功能容易维持稳定,主要实验参数容易控制,临床相关性好,易于复制,可满足不同时间心停后脑复苏研究的需要。对于探讨复苏后脑损伤的机制及进行实验性治疗具有一定的价值。     

心脏瓣膜置换术中心脏不复跳1例体外循环处理分析

体外循环(CPB)广泛用于心脏直视手术,一般升主动脉开放后,冠脉循环恢复,心脏自动复跳,但是特殊情况下会遇到心脏复苏困难者,需要经过一定处理方能复跳[1]。对心脏瓣膜置换术中心脏不复跳1例体外循环处理分析如下。1病历摘要女,17岁,32kg,身高145cm,术前Hct0.42,术前诊断二尖瓣关闭不全,三尖瓣关闭不全,2006-05在全麻下行二尖瓣置换、三尖瓣成形术。体外循环过程:国产膜肺,常规预充,经升主动脉、上下腔静脉插管建立体外循环,血流降温,鼻咽温29.5度阻断升主动脉,人工心肺机经主动脉根部灌注4:1(4份血:1份晶体)停跳液,每25~30min灌注一次,心…     

停跳和不停跳行心脏直视手术对心肌保护作用的对比研究

目的：探讨浅低温体外循环(CPB)下温血停搏液持续灌注和不停跳行心内直视手术对心肌的保护作用。方法：18只同种健康山羊采用单盲法随机分为冷晶体间断灌注组(Ⅰ组)，温血停搏液持续灌注组(Ⅱ组)，不停跳组(Ⅲ组)3组，每组6只；分别在CPB的不同时刻测定心肌组织丙二醛(MDA)含量及静脉血心钠素(ANP)含量，并切取心肌组织在电镜下观察超微结构的改变。结果：Ⅰ组MDA和ANP在CPB期间逐渐升高，恢复正常灌注后升高更明显：Ⅱ组、Ⅲ组MDA和ANP虽也有所升高，但较Ⅰ组低，且恢复正常灌注后无升高趋势。心肌超微结构也显示Ⅰ组改变明显，而Ⅱ组、Ⅲ组则基本不变。结论：温血停搏液持续灌注和不停跳行心内直视手术可有效避免心肌的缺血和再灌注损伤，有良好的心肌保护作用。     

脱中性粒细胞温血心脏停搏液连续灌注在心脏手术中心肌保护的研究

目的 :研究体外循环期间常温血脱中性粒细胞心脏停搏液微流量连续灌注对心脏瓣膜置换术中心肌的保护作用。方法 :临床随机选取体外循环时间在 60min以上的风湿性心脏瓣膜病人 2 0例 ,随机分为实验组和对照组 (每组 10例 ) ,分别检测不同时间点血浆心肌肌钙蛋白I(cTnI)水平和血浆MDA水平的变化。结果 :①两组病人在CPB前cTnI含量组间差异无显著性 ,而在主动脉阻断后及主动脉开放后各时间点差异显著 ,对照组cTnI值高于实验组 (P <0 .0 5 ) ;②两组病人在体外循环前及主动脉阻断 3 0min时MDA的含量组间差异无显著性 ,而在主动脉开放各时间点组间差异具有显著性 (P <0 .0 5 ) ,对照组高于实验组。结论 :实验研究证实 ,脱除心脏停搏液中的中性粒细胞后 ,可减轻中性粒细胞介导的心肌损伤 ,有利于心肌保护     

重症高龄冠状动脉旁路移植术的体外循环管理

目的 同顾性总结20例冠状动脉搭桥手术(CABG)患者的体外循环(CPB)方法、心肌保护、血液保护措施.方法 20例重症的CABG患者.CPB采用中度低温,心肌保护采用4:1(血:晶体)高钾(20mmol/L)含镁(20mmol/L)冷血停搏液正灌或与逆灌联合,开升丰动脉前温血灌注;CPB中维持充足的灌注流最(2.4～2.8L/m2·min)和较高的平均动脉压(MAP60～90mmHg);预充白蛋白20g.CPB中应用超滤、悬浮红细胞、氨甲环酸氯化钠、速尿.结果 全组病例在开放升主动脉后自动复跳16例占80%,电击除颤复苏4例,占20%.除一例术前心功能Ⅳ级,术后低心排夕匕亡外,其余均痊愈出院.结论 提高术中体外循环管理技术和加强术中心肌保护是至关重要的.开升丰动脉前温血灌注为有效的心肌保护方法,对重症患者具有实用性.     

影响心肺复苏成功因素的临床分析

目的 :研究影响心搏骤停患者复苏成功的因素。方法 :就本院急诊中心收治的 14 8例非创伤性心搏呼吸骤停患者进行回顾性分析。结果 :14 8例中 ,院内心搏骤停患者 5例 ,经复苏存活 2例 ;14 3例院外心搏骤停患者经送来医院 ,复苏存活仅 2例 ( 1 4% )。结论 :应尽早除颤 ,积极治疗原发病 ,在救治过程中时间乃是制约成败的关键因素 ,故应大力加强心肺复苏的普及     

Association of Drug Therapy with Survival in Cardiac Arrest: Limited Role of Advanced Cardiac Life Support Drugs

OBJECTIVE: To generate hypotheses regarding the association of standard Advanced Cardiac Life Support (ACLS) drugs with human cardiac arrest survival. METHODS: This observational cohort study was conducted over a two-year period in the wards, intensive care units, and EDs of two tertiary care hospitals. Included werc adult patients who suffered cardiac arrest either inside or outside the hospital and who required epinephrine according to standard ACLS guidelines. Six standard ACLS drugs (given while CPR was in progress) were assessed for association with survival from resuscitation to one hour and to hospital discharge by univariate and multivariate logistic regression analyses. RESULTS: In the 529 patients studied, initial cardiac rhythm had no impact on the association between drug administration and survival. The time of drug administration (quartile of ACLS period) was associated with resuscitation for atropine (p < 0.05) and lidocaine (p < 0.01). The odds ratios (95% CIs) for successful resuscitation, after multivariate adjustment for potential confounders, were: a respiratory initiating cause, 3.7 (2.1 -6.4); each 5-minute increase in CPR-ACLS interval, 0.5 (0.4-0.7); each 5-minute duration of ACLS. 0.9 (()1.8- 1.0; atropine, 1.2 (1.0-1.3); bretylium. (0.4 (0.1-1.1); calcium 0.8 (0.2-2.4); lidocaine, 0.9 (0.7-1.1); procainamide. 21.0 (5.2-84.0) d sodium bicarbonate 1.2 (1.0-1.6). All other potential confounding variables entered into the model were not significantly associated with resuscitation. CONCLUSION: Initiating cause of arrest, time to ACLS, and duration of ACLS were important correlates of survival. Other than procainaimide, standard ACLS drugs had relatively little association with survival, but timing of administration may be an important factor. Further research using definitive large randomized controlled trials is warranted to assess the role of drug therapy in improving cardiac arrest survival.     

Diabetes Does Not Affect Ventricular Repolarization and Sudden Cardiac Death Risk in Patients with Dilated Cardiomyopathy

Background: We studied the effects of diabetes on ventricular repolarization parameters and sudden cardiac death in patients with dilated cardiomyopathy (DCM).
Methods: We enrolled 132 consecutive patients in New York Heart Association (NYHA) heart failure functional classes II or III and left ventricular ejection fraction <40% without evidence of coronary artery disease. In 45 patients (34%), diabetes was diagnosed according to standard criteria (study group), and the remaining 87 (66%) had no diabetes (controls). All patients underwent a 5-minute high-resolution electrocardiogram recording for determination of QT variability (QTV) index and were followed for 1 year thereafter.
Results: At baseline, the two groups did not differ in age, gender, left ventricular ejection fraction, NYHA functional class, or plasma brain natriuretic peptide levels. Similarly, QTV index did not differ between the study group (−0.51 ± 0.55) and controls (−0.48 ± 0.51; P = 0.48). During follow-up, 18 patients (14%) died of cardiac causes. Of the 18 deaths, eight were attributed to heart failure, and 10 to sudden cardiac death. Mortality was higher in the study group (10/45, 20%) than in controls (8/87, 10%) (P = 0.03). The same was true of the heart failure mortality (6/45 [13%] vs 2/87 [2%], P = 0.01), but not of the sudden cardiac death rate (3/45 [7%] vs 7/87 [8%], P = 0.78). By multiple variable analyses, diabetes predicted total and heart failure mortality, and a high QTV predicted sudden cardiac death.
Conclusions: Diabetes appears to increase the risk of heart failure in patients with DCM without affecting ventricular repolarization parameters and sudden cardiac death risk.     

自体心包膜移植后受体心电活动的变化

背景：自体心包膜移植治疗已广泛应用于临床,主要涉及心血管修补重建、眼表疾病的治疗等领域;但其对心脏本身在缺血损伤下的保护作用却研究甚少。探索自体心包膜带瓣移植的安全性及其对缺血损伤后心肌的保护作用具有重要意义。 目的：观察心脏接受自体心包膜移植后对心电活动的影响及其对缺血心肌的保护作用。 方法：以荣昌肉猪和SD大鼠为研究对象,2种动物分别分为3组：移植组、心肌梗死组及心肌梗死＋移植组,心肌梗死组及心肌梗死＋移植组动物结扎冠状动脉前降支建立心肌梗死模型,移植组及心肌梗死＋移植组动物以自体心包膜组织带瓣移植建立移植模型。 结果与结论：①猪心电图监测室上性早搏常见;移植组室性早搏偶见,监测过程中未见室性心动过速和室性颤动。与心肌梗死组相比,心肌梗死＋移植组室性早搏减少,超声心动图检查示心功能改善（P 〈0.05）。②移植组大鼠心电图监测未见室性颤动;心肌梗死组、心肌梗死＋移植组均见非致死性室性颤动。与心肌梗死组相比,心肌梗死＋移植组心功能改善,心肌凋亡指数降低,Bcl-2蛋白表达升高,Caspase-3蛋白表达降低（P 〈0.05）。提示自体心包膜带瓣移植未诱发恶性室性心律失常,其安全性相对较高;并在一定程度上减少缺血损伤后室性早搏个数、促进心功能恢复,其可能与抑制缺血区域细胞凋亡有关。     

经皮穿刺急诊体外循环心肺复苏的实验与临床研究

目的探讨经皮穿刺插管快速建立急诊体外循环(ECPB)心肺复苏(CPR)的方法与疗效,方法自行研制经皮穿刺体外循环插管及鼓泡式氧合器、动脉滤器、泵管、管道连接的一体化无菌密闭系统。先将15只犬随机分为有搏动经皮穿刺插管组(A组)5只,无搏动绛皮穿刺插管组(B组)5只,无搏动切开插管组(C组)5只,通过动物实验探讨经皮穿刺插管方法建立急诊体外循环的可行性及对心肺复苏的影响。后将6例心脏停搏常规复苏8min无效患者进行床边经皮穿刺急诊体外循环方法的研究及对心肺复苏疗效的观察,结果无论在动物或人体上均快速建立了ECPB．使CPR的自主循环恢复率(ROSC)显著提高。结论经皮穿刺周围大血管插管能快速建立急诊体外循环,使CPR的ROSC显著提高。     

心脏不停跳下先心纠治术的临床分析

目的：探讨心脏不停跳下房室缺修补手术的优点，为心内直视房室缺修补手术提供一种安全可靠的方法。方法：106例房室缺患者，在体外循环心脏不停跳下行心内直视手术。其中室间隔缺损64例，房间隔缺损42例。结果：本组病例术中经过顺利，未出现室颤及空气栓塞。术后无神经系统并发症，于术后10-14d痊愈出院。结论：由于该方法不阻断升主动脉，保持冠状动脉持续血液供应，避免了主动脉阻断造成的心肌缺血缺氧性损害和再灌注损伤，对心肌和神经元保护有利。     

Hospital Variability of Out-of-Hospital Cardiac Arrest Survival

Background. Previous literature has identified patient andemergency medical services (EMS) system factors that are associated with survival of out-of-hospital cardiac arrest patients. Objective. To determine variability in rates of survival to discharge of resuscitated adult out-of-hospital cardiac arrest patients andto identify hospital-related factors associated with survival. Methods. This was a retrospective, observational study of all adult (21 years or older) out-of-hospital Utstein criteria cardiac-etiology arrests treated by Milwaukee County EMS during the period 1995–2005 andsurviving to hospital intensive care unit admission. The primary outcome measure was survival to hospital discharge. Logistic regression analysis was used to compare the odds of survival between hospitals, patient factors, andhospital factors. Results. 1,702 patients at eight receiving hospitals were included in the study analyses. Hospital survival rates ranged from 29% to 42%. Patient andcase factors associated with increased survival included younger age, male gender, nonwhite race, witnessed arrest in a public location, bystander cardiopulmonary resuscitation (CPR), a modest number of defibrillations, andinitial cardiac rhythm of ventricular tachycardia. The only hospital characteristic correlated with survival was the number of beds per nurse. Patients admitted to a hospital with a ratio of beds to nurse less than 1.0 were over 1.5 times more likely to survive. Conclusions. Survival to discharge of resuscitated adult out-of-hospital cardiac arrest patients may vary by receiving hospital. A hospital's ratio of beds to nurse andseveral patient/case f actors are correlated with survival. Further research is warranted to investigate how this may affect resuscitation care, EMS transport policy, andresearch design.     

心内直视手术后早期心跳骤停危险因素的预测及急救

分析了１２例行心内直视手术后２４ｈ内发生心跳骤停的患者。认为１．严重的心律失常，如多源性室性早搏，尤其是ＲｏｎＴ现象以及室性心动过速是导致心跳骤停的主要原因；２．缺氧、低血钾及其他意外是常见的诱发因素；３．各种抢救药品、物品、器械齐全是抢救成功的前提；４．良好的群体素质，准确、快速有效地现场抢救是成功的关键     

Cardiac output determined by ultrasound-Doppler: clinical applications

Summary. A non-invasive method for cardiac output determination (COD) based on ultrasound-Doppler technique was evaluated in patients with cardiac disease at rest and during exercise, including patients with heart transplants. The aortic blood flow velocity was measured with pulsed Doppler technique from the jugulum, placing the sample volume just above the aortic valve, and the area from a parasternal 2-D echocardiographic measurement of the aortic annulus diameter assuming a circular area. Cardiac output was calculated as the product of the systolic velocity integral, the aortic annulus area and the heart rate. A high correlation was found between this method and a simultaneously performed invasive cardiac output (COF) and stroke volume (SVF) determination by the direct Fick method (COD = 0.3+0.9 x COF, r= 0.96, SD_res= 0.5 1 min^-1 and SVD = 3.9+0.92 × SVF, r= 0.94, SD_res= 6.9 ml). However, looking just at the systolic velocity integral compared to stroke index determined with the Fick method we found a low correlation, especially in patients with heart transplants. We conclude that cardiac output can reliably be measured non-invasively with this method—also in patients with heart transplants. The systolic velocity integral alone can be used for assessing changes in stroke volume but for absolute values of stroke volume and stroke index flow area should also be determined.     

胸内、外心脏挤压平均动脉压变化及复苏效果比较

目的 :探讨胸内外心脏挤压术 (直接、间接挤压术 )时平均动脉压变化对心肺脑复苏的意义。方法 :6 8例病人在常规抢救基本相同的情况下 ,随机分两组 ,每组 34例 ,采用直接与间接心脏挤压术 ,同时予动脉置管惠普监护仪或表式血压表进行平均动脉压监测。结果 :直接挤压术平均动脉压及心肺脑复苏成功率均显著高于间接挤压组。结论 :直接挤压术可提高血液灌注压 ,增加心、脑的血、氧供应 ,在心肺脑复苏中有着十分重要的地位 ,值得采用