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。     

Cardiac Surgery with Cardiopulmonary Bypass in Low-Weight or Preterm Neonates: A Retrospective Study Analyzing Early Outcome

Background: Most outcome studies in congenital cardiac surgery for “low weight” neonates include patients undergoing surgery without cardiopulmonary bypass (CPB). The primary objective of our study was to identify risk factors for in-hospital mortality in neonates weighing less than 3 Kg and undergoing surgery with CPB. In addition, we compared the effect of early surgery with CPB (before 37W-gestational age (GA)) for congenital heart disease to delayed surgery until a corrected GA of 37 weeks in an attempt to promote weight gain. Methods: Retrospective single-center study including all patients operated between 1997 and 2017. Uni- and multivariable analysis were used to analyze outcome. Results: 143 patients were included. The median weight was 2.7 Kg and 49 (34.3%) weighted <2.5 Kg. 80% of the patients were Risk stratification STAT categories ≥3. 114 patients (80%) were operated without delay (usual timing, median age 9 days), whereas 29 patients (20%) entered a delayed strategy (median age 30 days). In-hospital mortality was 21.7%. By multivariate analysis, dysmaturity, preoperative positive ventilation, post-operative ECMO requirement or resuscitation, and any residual lesion were predictors of in-hospital death. In-hospital mortality in the usual timing group and the delayed group were 21.1% and 24.1%, respectively (p = 0.71). In-hospital mortality for neonates operated prior to 37W-GA (n = 10) was 27.3%. Conclusions: Predictors of in-hospital mortality in neonates less 3 Kg requiring CPB surgery did not differ from those unveiled in other contemporary studies. Our data demonstrates that a strategy of delaying surgery in selected patients resulted in similar clinical outcome.     

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。     

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。     

200例婴幼儿法乐四联症体外循环经验

目的：总结深低温低流量灌注结合中深度血液稀释的体外循环方法在２００例婴幼儿法乐四联症的临床应用效果。方法：鼻咽温降至１７～２０℃（平均１８．８９±２．５６℃），动脉灌注流量２０～５０ｍｌ·ｋｇ－１／ｍｉｎ（平均３７．６±１３．０ｍｌ·ｋｇ－１／ｍｉｎ），稀释后血红蛋白４４～１１０ｇ／Ｌ（平均６８．７±１２．６ｇ／Ｌ）。结果：采用此种体外循环方法，术后肺部并发症明显降低，术后早期死亡率由１０．２％降至３．５％。结论：此种体外循环方法，适用于婴幼儿紫绀型心血管病手术，术后并发症少，临床效果满意，可在临床推广。     

代谢相关基因在体外循环心脏手术中表达谱的变化

目的:探讨体外循环心脏手术中外周血单个核细胞代谢相关基因表达水平改变及基因芯片技术在此过程中的应用。方法:在体外循环下心内直视手术的住院患者19例。于术前1天、麻醉后开胸前、体外循环开始、体外循环结束及手术结束后分别抽取静脉血,分离外周血单个核细胞,提取标本总核糖核酸(RNA),逆转录合成并标记单链互补脱氧核糖核酸(cDNA),与HC10001基因芯片进行杂交。结果:统计结果发现,HC10001基因芯片的10 000个杂交基因中约有20%的基因在手术前、后或手术中有不同程度的表达差异;其中与代谢相关的葡萄糖异构酶基因的表达变化十分显著,心脏脂肪酸结合蛋白基因的表达量也有较大的变化。结论:通过表达谱基因芯片的初步筛选,发现葡萄糖异构酶和心脏脂肪酸结合蛋白基因表达量在手术前与麻醉、体外循环、手术操作后相比都存在差异,提示它们可能参与了体外循环心脏手术中的病理生理反应,对手术过程中患者肌体的供氧及脏器保护提供了分子生物学方面的依据,对今后手术中的麻醉和体外循环药物的选择具有一定的参考价值。     

Benefits and Risks of Maintaining Normothermia during Cardiopulmonary Bypass in Adult Cardiac Surgery: A Systematic Review

Cardiopulmonary bypass is associated with significant morbidities, and the ideal temperature management during cardiopulmonary bypass remains uncertain. This review assessed the benefits and risks of maintaining normothermia during cardiopulmonary bypass in adult cardiac surgery. A total of 6731 patients from 44 randomized controlled trials in 14 countries, comparing normothermic (>34°C) and hypothermic (≤34°C) cardiopulmonary bypass in cardiac surgery (>18 years of age), were identified from MEDLINE (1966 to August 10, 2009), EMBASE (1988 to August 10, 2009), and Cochrane controlled trials register and subject to meta‐analysis. Two investigators examined all studies and extracted the data independently. Mortality after normothermic and hypothermic bypass was not significantly different (1.4% vs. 1.9% respectively, relative risk [RR] 1.38, 95% confidence interval [CI] 0.94–2.04, I²= 0%, P= 0.10). Hypothermic bypass was, however, associated with an increased risk of allogeneic red blood cells (RR 1.19, 95% CI 1.07–1.34, I²= 0%, P= 0.002), fresh frozen plasma (RR 1.54, 95% CI 1.06–2.24, I²= 7.7%, P= 0.02), and platelet transfusion (RR 2.53, 95% CI 1.26–5.06, I²= 44%, P= 0.009). The risk of stroke, cognitive decline, atrial fibrillation, use of inotropic support or intra‐aortic balloon pump, myocardial infarction, all‐cause infections, and acute kidney injury after cardiac surgery was not significantly different between the two groups. The differences in the bypass time and targeted perfusion temperature were not significantly related to the risk of mortality and stroke. The current evidence suggests that maintaining normothermia during cardiopulmonary bypass in adult cardiac surgery is as safe as that of hypothermic surgery, and associated with a reduced risk of allogeneic blood transfusion.     

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。     

乌司他丁对体外循环下心脏手术围术期炎症反应的影响

目的:探讨体外循环心脏手术中胰蛋白酶抑制剂乌司他丁对围术期体温、全身炎症反应综合征(SIRS)评分、外周血白细胞计数和中性粒细胞百分比的影响。方法:300例择期体外循环冠状动脉(冠脉)旁路移植术或瓣膜置换术患者,随机分为实验组与对照组各150例。实验组于麻醉诱导后、肝素化后以及鱼精蛋白中和后,分别给予乌司他丁各100万单位,对照组则给予等量生理盐水。2组分别于手术开始前、手术结束即刻、术后8 h、16 h、24 h、48 h和72 h记录体温(膀胱温)、评估SIRS评分、采集静脉血行血常规检查。结果:两组体温、SIRS评分和白细胞计数均在术后8小时达到高峰,随后逐渐下降,但至术后72 h仍显著高于手术前水平(P<0.01);中性粒细胞百分比自手术结束即刻显著上升,至术后72小时仍未有下降趋势,显著高于手术前水平(P<0.01)。在术后8 h、16 h、24 h、72 h四个时间点,实验组体温显著低于对照组(P<0.01);在术后8 h、16 h、24 h、48 h四个时间点,实验组SIRS评分、白细胞计数和中性粒细胞百分比显著低于对照组(P<0.01),差异有统计学意义。并发症发生率与死亡率在两组间没有统计学意义(P>0.05)。结论:乌司他丁可显著降低体外循环心脏手术围术期体温、SIRS评分、外周血白细胞计数和中性粒细胞百分比。     

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.     

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。     

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.     

无创正压通气在体外循环术后急性呼吸衰竭患者中的应用

目的:临床回顾性研究无创正压通气(NPPV)在体外循环术后出现急性呼吸衰竭患者中应用的安全性和有效性。方法:回顾2010-01至08我院在全麻体外循环下行心脏手术的患者(年龄>16岁)450例,术后全部顺利拔管,其中24例拔管后出现急性呼吸衰竭给予NPPV治疗,为NPPV组;拔管后未出现急性呼吸衰竭的患者426例为对照组。比较NPPV治疗前、治疗后1 h的氧分压/吸入气体氧含量(PaO2/FiO2)、心率、呼吸次数和动脉血酸碱度(pH),并用患者围手术期的临床特征作为参数来分析NPPV失败的预测因素。结果:NPPV治疗平均(12.33±11.97)h,NPPV治疗后1 h与治疗前比较,PaO2/FiO2明显升高,呼吸次数、心率明显减低(P均<0.01),差异均有统计学意义。所有患者均无NPPV相关并发症。NPPV失败的相关危险因素包括:NPPV治疗后1 h的PaO2/FiO2<200(P=0.043)、第一次机械通气时间(P=0.039)和肺炎(P<0.0001),其中肺炎是NPPV失败的独立相关危险因素(比值比16.000;95%可信区间1.996～128.289)。结论:体外循环术后患者拔管后出现急性呼吸衰竭,NPPV可以有效改善肺部氧合,减低再次气管插管的需要,但要根据病因选择病例。     

左心辅助循环和完全体外循环下血细胞流变行为的对比实验研究

目的：研究左心辅助循环下微创冠状动脉旁路移植术（ＭＩＣＡＢＧ）血细胞流变行为的变化，并与体外循环下心脏手术后其相应的变化进行比较，以探讨其对减轻手术创伤的意义。　　方法：６条犬经左前外小切口在左心辅助循环下，用同种颈动脉在降主动脉或乳内动脉与钝缘支间做旁路吻合（实验组）。６ 条犬在体外循环下建立冠心病的动物模型（对照组）。手术停机后取血，运用布氏显微镜行活血分析。　　结果：左心辅助循环下ＭＩＣＡＢＧ术后血细胞流变学指标与术前相比无显著性变化。体外循环术后红细胞畸形率和白细胞活化率比术前显著增高，并显著高于ＭＩＣＡＢＧ术后的相应指标。　　结论：左心辅助循环下的ＭＩＣＡＢＧ对血细胞流变行为没有明显的影响。与体外循环下心脏手术相比左心辅助循环的方法可以减轻手术创伤。     

体外循环期间血浆ACTH与皮质醇浓度变化的研究

本实验用放射免疫测定方法，动态测定了２４例心内直视手术患者围术期的血浆ＡＣＴＨ与皮质醇浓度。结果发现：麻醉诱导后，ＡＣＴＨ及皮质醇的血浆浓度均稍有降低；转机后２０分钟，两激素浓度急剧下降，并且在转机４０分钟与６０分钟后，仍持续维持在较低水平；术后６小时，两激素血浆浓度明显高于术前对照值；术后第二天，两激素浓度基本恢复术前水平。本文认为：体外循环转机期间，机体存在明显的垂体一肾上腺皮质功能低下表现，因此转机中使用一定剂量的类固醇激素是合理的，本文并对体外循环期间影响垂体一肾上腺皮质功能的因素进行了讨论。     

Argatroban Anticoagulation for Cardiac Surgery with Cardiopulmonary Bypass in an Infant with Double Outlet Right Ventricle and a History of Heparin‐induced Thrombocytopenia

Heparin‐induced thrombocytopenia (HIT) is a life‐threatening complication of heparin therapy. Anticoagulation in pediatric patients with HIT is challenging as there are no approved heparin substitutes. We report the use of the anticoagulant argatroban for cardiac surgery with cardiopulmonary bypass in an infant with double outlet right ventricle and a history of HIT.     

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.