冠状动脉搭桥术后康复护理研究进展

文章指出了康复护理的重要性,并从饮食、运动、心理、药物、社会支持方面归纳了冠状动脉搭桥术后康复护理研究现状.在此基础上,对促进冠状动脉搭桥术后患者早期康复及早日回归家庭与社会,提高护理质量,建立完整、连续的康复体系的研究前景进行了展望.     

非体外循环冠状动脉旁路移植手术的护理配合

[目的]总结非体外循环冠状动脉旁路移植（OPCAB）手术的护理配合.[方法]对31例病人行OPCAB手术,同时加强术前准备及术中护理配合.[结果]31例病人手术均顺利,病人均康复出院,手术效果满意.[结论]加强 OPCAB手术的护理配合是手术成功的保证.     

冠状动脉搭桥手术患者的健康教育

目的探讨健康教育对冠状动脉架桥患者的影响。方法对同期行冠状动脉搭桥手术的患者100例,随机分为2组:即健康教育组及对照组,据住院天数、术后并发症、家属患者满意率进行分析比较。结果健康教育组住院天数明显缩短,术后并发症少,患者及家属满意率明显高于对照组。结论开展对冠状动脉搭桥手术患者围手术期的健康教育很有必要,值得推广。     

Is the evidence from first time off-pump coronary artery bypass graft surgery transferable to re-operative off-pump surgery?

On-pump coronary artery surgery remains the gold standard treatment for multi-vessel disease. The technique of off-pump surgery has evolved since its first use; however, currently less than 20% of all cases worldwide are performed this way. This poor uptake has been both the cause and the effect of widespread scepticism regarding the validity of the data on the technique, as well as criticism regarding the conversion-related adverse outcomes, graft patency and completeness of revascularisation. Consequently, there has been focus on patient selection from subgroups most likely to benefit from the technique. Re-operative patients, by virtue of their advanced age, complex co-morbidities and the technical challenges of re-operation, fall into this category. In this review, the authors will discuss the outcomes of off-pump surgery in comparison to on-pump, explore the potential beneficial effects of off-pump in re-operative surgery and formulate a decision-making strategy in patients undergoing reoperative coronary artery surgery.     

乳化异氟醚对离体大隐静脉舒张功能影响的研究

目的探讨乳化异氟醚对离体大隐静脉桥舒张功能影响。方法取材于临床冠状动脉旁路移植术剩余的成人新鲜大隐静脉。采用器官槽法,分别检测用重碳酸盐缓冲液(KH液)、1 mmol/L乳化异氟醚、含30%脂肪乳的重碳酸盐缓冲液和HTK液浸泡血管环1h后,再用7μmol/L indomethacin和300 nmol/L LNNA作用后,检测30 nmol/L U46619及不同浓度A23187引发的血管收缩舒张反应。结果 U46619引发的血管环预收缩强度,各组间差别无显著性差异(P0.05);A23187引起的内皮源性舒张,重碳酸盐缓冲液(KH液)及含1 mmol/L乳化异氟醚,脂肪乳3组间无显著性差异(P0.05),HTK液组与其余3组间有显著性差异(P0.01);电镜下,HTK液组对内皮损伤最轻,其余3组损伤基本一致。结论 1 mmol/L乳化异氟醚对血管内皮无明显损伤作用,不影响大隐静脉舒张功能;HTK液对血管内皮有明显保护作用,对大隐静脉舒张功能有明显影响。     

冠状动脉搭桥患者围术期血浆15-F2t-isoprostane含量变化及临床意义

目的　分析常温心脏手术中血浆游离 15 F2 t isoprostane浓度变化及其与术后早期心功能的关系。方法　选择 30例在常温体外循环 (CPB)下行冠状动脉搭桥术患者 ,根据术后有 (组 )、无 (组 )应用正性肌力药物分为两组。 CPB中采用间断温血灌注 ,分别于麻醉诱导后、阻升主动脉后 30 min以及开放升主动脉后 10、30和 12 0 min抽取中心静脉血样 ,采用有高度特异性的兔血清抗体用酶标放射免疫法测量血浆中游离 15 F2 t isoprostane含量。术中至术后 6 h进行连续心排量测量。结果　 15 F2 t isoprostane血浆含量于阻升主动脉后 30 m in、开放升主动脉后 10 min显著升高 ,开放升主动脉 30 m in以后开始下降。组 患者血浆 15F2 t isoprostane含量的升高呈递减趋势 ,至开放升主动脉后 30 min恢复正常 ;相反 ,术后需两种以上正性肌力药物支持以维持心脏指数 (CI) >2 .2 L· m in- 1· m- 2的患者 (组 )血浆 15 F2 t isoprostane含量至开放升主动脉后 30 m in均显著高于正常。术后 CI与开放升主动脉后 10和 30 min时血浆游离 15 F2 t isoprostane含量呈良好的负相关性 (r=- 0 .95 ,P<0 .0 1)。结论　术中 15 F2 t isoprostane血浆含量与术后心功能的恢复密切相关。     

Physical, psychological and social recovery patterns after coronary artery bypass graft surgery: a prospective repeated measures questionnaire survey

AIM: This study examined the physical, psychological and social recovery patterns of Hong Kong Chinese patients who have undergone CABG surgery over a period of six months. BACKGROUND: Recovery from coronary artery bypass graft (CABG) surgery is a dynamic process and the associated physical, psychological and social effects could lead to failure to recuperate leading to hospital re-admission and morbidity. DESIGN: A prospective repeated measures design was used for this research. Patients were interviewed in person 5 days before surgery and at 1 week after discharge, and by telephone at 3 and 6 months after discharge. Physical recovery dimension was assessed by three categories of the Sickness Impact Profile (ambulation, sleep-rest, body movement and care). Social recovery dimension was assessed by three categories of the Sickness Impact Profile (SIP) (home management, social interaction, and recreation and pastimes). Psychological recovery was assessed using the Centre for Epidemiologic Studies-Depression (CES-D). RESULTS: Sixty-eight patients participated in this research. The mean physical SIP-dimension score and depression level at discharge was the highest then gradually decreased at 6 months after CABG. The SIP-physical and SIP-social and depression level differed significantly across the four-assessment time within-group. There were no gender differences in physical and social recovery and depression levels. Patients who had poorer physical and social recovery had more depression at one week and three months after CABG surgery. CONCLUSION: Patients should be prepared for discharge after CABG surgery. Cultural factors may have influenced the similar recovery patterns between genders. These factors contributing to early recovery must be further examined. RELEVANCE TO CLINICAL PRACTICE: Because of the large number of patients who undergo CABG worldwide, and because of healthcare cost related to this intervention, it is important for both patients and healthcare providers to have realistic expectations about the recovery process and to recognise deviations from the norm. The results provided some insights into the Hong Kong Chinese patients' recovery from CABG surgery that would guide the development of culturally appropriate pre-operative and discharge teaching for this group of patients.     

The relationship between quality of life,sense of coherence and self-esteem in persons after coronary artery bypass graft surgery

We examined the contribution of Antonovsky's sense of coherence in explaining the variance of quality of life (QOL) in 84 patients 1-2 years following coronary artery bypass graft surgery. The hypothesis was: after controlling for variables related to poor health vulnerability, perceived support, self-esteem, and chronic illness trajectory instability and work, the addition of sense of coherence will significantly add to the explained variance of quality of life. The first two variables explained 49% of the variance of the QOL scale. Adding perceived social support, self-esteem and sense of coherence increased explained variance to 64%, 69%, and 75%, respectively. These findings supported our hypothesis.     

Evaluation of oxygen extraction ratio as a physiologic transfusion trigger in coronary artery bypass graft surgery patients

BACKGROUND: Approximately 20 percent of all allogeneic blood transfusions are administered in connection with coronary artery bypass graft (CABG) operations. Transfusion practices vary across the country. The whole-body oxygen extraction ratio (O2 ER) reflects the adequacy of the patient's response to acute normovolemic anemia with an O2 ER of approximately 50 percent being shown to be an appropriate transfusion trigger. The present study monitored the O2 ER in patients undergoing CABG and determined if transfusion practices would have been different if an O2 ER > or = 45 percent were used as a transfusion trigger. STUDY DESIGN AND METHODS: Seventy patients with a postoperative Hct < = 25 percent were the test subjects. Arterial and mixed venous contents were determined before the operation, in the intensive care unit after the operation, and 12 hours after the operation. RESULTS: There were no deaths. Forty-one patients received allogeneic transfusion. These patients were older, weighed less, and had a preoperative Hct lower than the nontransfused patients. There were no significant differences between transfused and nontransfused patients with respect to postoperative Hct (21.0 +/- 0.4 vs. 22.2 +/- 0.4), cardiac index (2.5 +/- 0.1 vs. 2.7 +/- 0.1), O2 delivery (6.4 +/- 0.3 vs. 6.7 +/- 0.3), O2 consumption (2.5 +/- 0.1 vs. 2.5 +/- 0.1), and O2 ER (38.3 +/- 1.7 vs. 37.5 +/- 1.5). In the transfusion group, 7 of 21 patients had a postoperative O2 ER > or = 45 percent, while 3 of 35 in the nontransfused group had that result. CONCLUSION: The use of O2 ER as a transfusion trigger as part of a transfusion algorithm could lead to a reduction in allogeneic blood transfusion.     

高血压对非体外循环下冠状动脉搭桥术前后左心室舒张功能变化的影响

目的 探讨对伴有高血压的冠心病患者行非体外循环下冠状动脉搭桥术前后的左心室舒张功能变化特点。 方法 93例接受非体外循环下冠状动脉搭桥术的患者根据是否合并高血压病,分为高血压组(HP组,38例)和血压正常组(NBP组,55例),术前、术后分别采集过二尖瓣的舒张早期(E)和舒张晚期(A)峰速及二尖瓣侧壁瓣环的收缩期(Sm)、舒张早期(Em)和舒张晚期(Am)峰速。 结果 HP组术前室壁运动积分(WMI)及肺动脉收缩压低于NBP组(P＜0.05);NBP组患者的术前E/A和E/Em值显著高于HP组(P＜0.05),术后1个月E/Em值即可降至接近正常范围,而HP组患者的E/Em值术后3个月才接近正常;两组患者的左心室射血分数术前均降低,术后1个月恢复正常。HP组患者左心室舒张功能分级较集中于1级和2级,共33例(33/38,86.84%),而NBP组患者各级所占比重较分散,最多为3级,20例(20/55,36.36%),其次为2级,17例(17/55,30.91%)。 结论 NBP组患者的左心室舒张功能受损程度较HP组严重;合并高血压的患者左心室舒张功能恢复较慢,长期、稳定降压治疗是改善冠状动脉搭桥术预后的有效措施。     

Transfusion and postoperative pneumonia in coronary artery bypass graft surgery: effect of the length of storage of transfused red cells

BACKGROUND: Various bioactive substances are released from white cell (WBC) granules into red cell (RBC) components in a time-dependent manner during blood storage. Some of these substances may have immunosuppressive effects and may contribute to transfusion-induced immunomodulation. RBCs transfused after prolonged storage may be associated with a higher incidence of postoperative infections than fresh RBCs. This hypothesis does not seem to have been investigated in a clinical study. STUDY DESIGN AND METHODS: The records of 416 consecutive patients undergoing coronary artery bypass graft operations at the Massachusetts General Hospital were reviewed. The association between the length of storage of the transfused RBCs, as well as the number of units of non-WBC-reduced allogeneic RBCs and/or platelets transfused, and the occurrence of postoperative pneumonia was calculated by logistic regression analyses adjusting for the effects of confounding factors. Among these were the numbers of days of intubation, days of impaired consciousness, and units of RBCs transfused. RESULTS: By Centers for Disease Control and Prevention criteria, pneumonia developed in 54 patients (13.0%). Among 269 patients given RBCs, the risk of pneumonia increased by 1 percent per day of increase in the mean storage time of the transfused RBCs (p<0.005). In an analysis of all patients, the risk of pneumonia increased by 5 percent per unit of non-WBC-reduced allogeneic RBCs and/or platelets received (p = 0.0584). CONCLUSION: After adjustment for the effects of the risk factors for pneumonia and the number of transfused RBCs, an association was observed between the length of storage of transfused RBCs and the development of postoperative pneumonia. This association should be investigated further in future studies of the outcomes of blood transfusion.     

Relationships between patient attitudes,subjective norms,perceived control,and analgesic use following elective orthopedic surgery

The theory of planned behavior guided this exploration of postoperative analgesic use among adults (N = 137) undergoing elective orthopedic surgery. Patients who had a more positive attitude toward taking pain medication and had positive subjective norms intended to take more medication than those who had a negative attitude and had negative subjective norms. Perceived control over taking pain medications was not related to intentions. Intentions to take analgesics did not relate to the actual amount of analgesics used, but did relate to the subjective report of medication use. The discrepancy in association between intentions, objective behavior, and subjective behavior raises issues for examining complex behavior using the theory of planned behavior. © 1997 John Wiley & Sons, Inc. Res Nurs Health 20: 97–105, 1997     

Length of storage of transfused red cells and postoperative morbidity in patients undergoing coronary artery bypass graft surgery

BACKGROUND: The transfusion of old red cells (RBCs) may be associated with reduced delivery of oxygen to tissues and an increased risk of transfusion complications. The association of postoperative morbidity with the length of storage of perioperatively transfused RBCs was studied in 268 consecutive patients receiving a blood transfusion for coronary artery bypass graft surgery. STUDY DESIGN AND METHODS: The postoperative length of hospitalization, the postoperative length of stay in the intensive care unit, and the length of endotracheal intubation after the day of the operation were used as surrogate measures of global postoperative morbidity. The length of storage of the oldest transfused RBC unit, the mean length of storage of the oldest and second oldest RBC units, and the mean length of storage of all RBC units transfused to each patient were tested for association with the three outcome variables. Multiple linear regression analysis and Cox proportional-hazard analysis were used to adjust for the effects of confounding factors that pertained to each patient's severity of illness and the difficulty of each operation. RESULTS: There were no significant associations after adjustment for the effects of confounding factors. CONCLUSION: This study did not corroborate the previously reported association between transfusion of old RBCs and increased morbidity. However, there is surprisingly little research on the clinical outcomes of the transfusions of old RBCs, and this hypothesis should be investigated further.     

Anxiety, depression and sleep in male patients undergoing coronary artery bypass surgery

The aim of this study was to examine the prevalence of depression and anxiety following coronary artery bypass surgery (CABG) and to see how those patients with depression and anxiety differ in sleeping pattern. The individual reaction to sleep loss was tested as a predictor of certain emotional symptoms in the follow-up period. Thirty-eight males, between 45 and 68 years, were interviewed prior to, and 1 month after, surgery, and received a questionnaire at the 6-month follow-up. Eighty per cent scored moderate anxiety prior to surgery and six patients were depressed. An anxiety-prone individual reactivity persisted in the same patients in 38.9% (n = 14) following CABG, with significantly more sleep disturbances, firedness, energy deficits, immobility, and lower degree of quality of life (QoL). Sad/depressed mood or cognitive/behavioural fatigue symptoms as reactions to sleep loss were predictors of sleep problems and daytime sequelae, whereas a higher postoperative NYHA class was predicted by cognitive/behavioural fatigue and dysphoria reactions. Being less refreshed by sleep on final awakening prior to surgery related to 44.5% of the variance in QoL outcome 6 months following surgery. In conclusion, an anxiety-prone individual reactivity is significantly associated with sleep disturbances. Reactions to sleep loss prior to surgery are associated with emotional distress after surgery.     

吸烟患者冠状动脉旁路移植术中血浆15-F2t-isoprostane浓度变化及其临床意义

目的观察体外循环冠状动脉(冠脉)旁路移植术中吸烟患者血浆15-F2t-isoprostane(15-F2tIsoP)的变化及其与术后心功能恢复的关系.方法选择30例吸烟冠心病患者及30例非吸烟冠心病患者,均在异丙酚、芬太尼复合麻醉及体外循环下行冠脉旁路移植术.分别于麻醉诱导后手术前(T0)、主动脉阻断后30 min(T1)、主动脉开放后10 min(T2)及30 min(T3)经中心静脉抽血,测血浆游离15-F2t-IsoP浓度.结果 T0时吸烟及非吸烟组血浆15-F2t-IsoP浓度差异无显著性.T1时两组血浆15-F2t-IsoP显著升高(与T0比较,P均<0.01),此时吸烟组15-F2t-IsoP的升高幅度显著高于非吸烟组(P<0.05).再灌注期(T2、T3)吸烟组血浆15-F2t-IsoP浓度下降速度较非吸烟组为慢,术后更多患者需血管活性药物支持.结论吸烟者体内抗氧化能力降低,增加了心脏手术后心功能障碍的发生率.     

冠状动脉旁路手术病人实施手术前后预防性康复护理的效果分析

[目的]探讨对冠状动脉旁路手术病人实施手术前后预防性康复护理的效果。[方法]将接受冠状动脉旁路手术的病人随机分为两组,干预组病人实施术前、术后预防性康复护理,对照组实施传统护理方式,对比分析手术后康复效果。[结果]实施术前、术后预防性康复护理的干预组病人康复效果好。并发症发生率明显低于对照组。[结论]对接受冠状动脉旁路移植手术的病人进行术前和术后预防性康复护理,在消除病人心理负担、缩短病人住院时间、减少并发症发生和促使病人出院的社会康复及功能康复等方面都有明显的效果。     

Effect of Benson and progressive muscle relaxation techniques on sleep quality after coronary artery bypass graft: A randomized controlled trial

ObjectiveThis study aimed to investigate the effect of Benson relaxation (BR) and progressive muscle relaxation (PMR) techniques on the sleep quality of patients undergoing coronary artery bypass graft (CABG) surgery.MethodThis study was a three-arm, parallel, randomized controlled trial. 120 patients who underwent CABG surgery at two academic hospitals in an urban area of Iran were randomly allocated into three groups (40 per group): the BR, PMR, and control groups. Patients in the BR and the PMR groups performed relevant exercises twice a day for four weeks. Sleep quality was measured before and immediately after the intervention using Pittsburgh Sleep Quality Index.ResultsWithin-group comparison in the BR (t = 3.51, p = 0.001) and the PMR (t = 4.58, p < 0.001) group showed that the overall sleep quality showed a significant improvement after the intervention when compared to baseline. The between-group comparison showed that both the BR and PMR groups showed significant improvements in subjective sleep quality (F = 3.75, p = 0.02), habitual sleep efficiency (F = 4.81, p = 0.01), and overall sleep quality (F = 5.53, p = 005) when compared to the control group after the intervention. However, no statistically significant differences were identified among the three study groups in terms of sleep latency, sleep duration, sleep disturbances, sleeping medication, and daytime dysfunction after the intervention (p > 0.05).ConclusionThe study showed that a four-week program of both PMR and BR can be effective in the overall improvement of sleep quality in patients following CABG. Further research is required to replicate the findings of the present study.