体外循环手术中血小板单采对血液的保护作用

目的　探讨在体外循环心脏手术中血小板单采对血液的保护作用 ;方法　选择 2 0例行心脏瓣膜手术患者 ,随机分为实验组和对照组 ,实验组采用血小板单采技术 +常规体外循环 ,对照组只采用常规体外循环 ,其他血液保护措施两组相同 ;结果　①实验组血小板采集量均在患者血小板总数的 2 0 %以上 ;②实验组术中血液制品 (全血和血浆 )用量较对照组明显减少 ,差异有显著性 ;③两组间Hb及Hct各时点变化趋势一致 ;④围手术期患者血小板计数的动态变化两组差异不大 ,而实验组恢复较快 ;⑤实验组术后血小板聚集功能明显优于对照组 ,差异有显著性 ;⑥实验组术后凝血酶原恢复时间明显较对照组快 ,差异有显著性 ;⑦实验组术后各分时段引流量较对照组明显减少 ,差异有显著性。结论　体外循环术中血小板单采能够保护血小板免遭体外循环的破坏 ,明显减少术后出血 ,起到良好的血液保护作用。     

体外循环中盐酸戊乙奎醚对肺损伤的保护作用

目的:研究盐酸戊乙奎醚时体外循环(CPB)炎症因子的影响及对肺损伤的保护作用.方法:24例择期首次行心脏瓣膜置换术患者,随机分为盐酸戊乙奎醚组(A组)和对照组(C组),每组12例.分别于诱导切皮前(T1)、转流30 min(T2)、停CPB 1 h(T3)、4 h(T4)、24 h(T5)抽取动脉血,测定红细胞压积和动脉血气分析,计算呼吸指数RI,测定血浆TNF-α、IL-6浓度.结果:两组间血浆IL-6、TNF-α水平和RI值在CPB前T1时差异无统计学意义(t≤1.82,P＞0.05).两组T2-5各时点TNF-α、IL-6均高于T1(F≥6.21,P＜0.05),A组T2-5各时点TNF-α、IL-6浓度明显低于C组同时点值(t≥2.41,P＜0.05),两组T3-T4时点RI均高于T1时点(F≥5.87,P＜0.05),A组中T3,T4时点RI较C组同时点明显降低(t≥2.38,P＜0.05).结论:盐酸戊乙奎醚能有效地抑制CPB心脏直视手术围术期炎症因子的释放,改善肺功能.     

Monitoring lung mechanics and airway pressures during differential lung ventilation (DLV) with emphasis on weaning from DLV

Fifteen polytrauma patients with asymmetric pulmonary contusion were treated with differential lung ventilation (DLV) for a mean of 106 hours (range 24–298, median 83). The differential time constant (Tc), compliance (Ct), inspiratory and expiratory airway resistance (Raw_insp, Raw_exp) and peak-airway pressure (Paw_peak) were monitored to evaluate the function of each lung. Values measured after starting DLV were compared to those obtained prior to stopping DLV in order to analyse whether these parameters had returned to symmetrical values when recommencement of conventional mechanical ventilation was considered on clinical parameters and also whether these could be useful criteria for weaning from DLV. The significant difference in Tc of the contused lung compared to the contralateral lung after starting DLV is mainly determined by altered Ct resulting from contusion. During DLV improvement of Ct resulted in identical Tc of both lungs prior to stopping DLV. Changes in the Raw_insp contributed little to changes in Tc. Identical Tc prior to stopping DLV coincided with identical Paw_peak on symmetrical ventilator settings. These data suggest that when less advanced monitoring equipment is available, the differential Paw_peak might be used as a measure of differential lung mechanics in asymmetrical pulmonary contusion.     

氧浓度对体外循环后肺损伤影响的实验研究

目的：观察体外循环(CPB)前后吸入不同浓度氧气对肺脏缺血／再灌注损伤的影响。方法：建立大鼠体外循环模型，体外循环时间为120min。根据机械通气期间吸入氧浓度的不同分100％氧通气组(n=8)和50％氧通气组(n=8)。实验过程记录血压和心率的变化，并进行血气分析。CPB后60min实验结束时取肺组织。测定并计算丙二醛(MDA)、髓过氧化物酶(MPO)和组织含水量。结果：体外循环前后血压和心率相对稳定。体外循环过程中红细胞压积(HCT)和转流量两组没有明显差异。100％氧通气组的PaO2在CPB结束后5min和CPB后60min均低于CPB前，而50％氧通气组没有明显变化，而且CPB后肺组织中MDA和MP0较低．肺组织含水量也低于100％氧通气组。结论：体外循环前后吸入高浓度氧可加重氧化性肺损伤，应使用接近生理水平的较低浓度的氧气以减轻肺损伤。     

新生儿呼吸衰竭机械通气撤机时的肺力学研究

目的探讨新生儿机械通气撤机时肺力学指标的范围及临床意义。方法通过Bicore-CP 100呼吸功能监测仪测定32例机械通气撤机时的新生儿在CPAP模式、脱机拔管前及拔管后20 min等条件下的肺力学指标范围,根据拔管48 h内是否重新插管并分为撤机成功组与失败组。结果成功组的呼吸力学范围为:气道阻力(Rawmean)(93.7±14.3)cmH2O/(L.s)、呼吸系统顺应性(Crs)(0.65±0.09)ml/(cmH2O.kg)、患者呼吸功(WOBp)(1 589±133.2)g.cm/(min.kg);失败组为:Rawmean(98.6±15.5)cmH2O/(L.s)、Crs(0.57±0.08)ml/(cmH2O.kg)、WOBp(1 782±148.6)g.cm/(min.kg)。Crs与WOBp两组差异有显著性。Crs(0.65±0.09)ml/(cmH2O.kg),脱机成功率95.4%。撤机后拔管前两组平均WOB为(1 768±186.4)g.cm/(min.kg),Crs为(0.624±0.11)ml/(cmH2O.kg),脱机成功率为81.25%。结论肺力学的检测对新生儿呼吸机的撤离具有指导作用,特别是呼吸系统顺应性和呼吸功的检测更具有实质意义。     

The cerebroprotective effects of pentoxifylline and aprotinin during cardiopulmonary bypass in dogs

OBJECTIVE: The purpose of this study was to investigate the cerebroprotective effects of pentoxifylline (PNX) and aprotinin in dogs using cardiopulmonary bypass (CPB). MATERIALS AND METHODS: Eighteen clinically healthy dogs were divided into three groups: Group 1 (control, n = 6), Group 2 (PNX, n = 6), and Group 3 (aprotinin, n = 6). PNX was administered at a dose of 300 mg/day in Group 2 three days before the operation and during the operation. Half a million IU aprotinin were added to the prime solution and 500,000 IU were transfused via a central venous jugular catheter preoperatively in Group 3. Blood samples were taken from the central jugular vein before and after CPB and interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-alpha), and S100beta protein were measured. Gliosis was investigated histopathologically in cerebral cortex biopsy samples under light microscopy. RESULTS: The preoperative results of IL-6, TNF-alpha, and S100beta protein values were found to be significantly higher (p < 0.001) when compared with postoperative values. This significant difference was observed in the same parameters between Groups 1 and 2, and 1 and 3 (p < 0.001). There was no significant difference between Groups 2 and 3. Comparison between pre- and postoperative levels of IL-6 and TNF-alpha for Group 2 and Group 3 revealed statistically significant differences (p < 0.001), whereas S100beta protein levels did not. Histopathological examinations showed significant differences between the control group and PNX and aprotinin, and between aprotinin and PNX groups (p < 0.001). CONCLUSION: PNX and aprotinin might be useful in order to reduce postoperative cerebral damage in patients undergoing cardiac surgery with CPB.     

乌司他丁对小儿体外循环术后肺损伤的保护作用

目的探讨乌司他丁（Ulinastatin,UTI）对小儿体外循环（cardiopulmonary bypass,CPB）术后肺损伤的保护作用。方法先天性心脏病择期手术患儿27例被随机分为对照组（C组）和试验组（U组）。C组不给药,U组于麻醉诱导后、CPB开始时和主动脉开放时分别给予乌司他丁总量的1／3（15000万U／kg）。于麻醉诱导后（T1）、CPB结束即刻（L）以及CPB术后1h（T3）、12h（T4）和24h（T5）测动脉血浆中IL-8和中性粒细胞弹性蛋白酶（Neutrophil Elastase,NE）水平。于CPB术后1h、2h及4h测动脉血气,并监测CPB术后肺功能指标肺泡．动脉氧分压差（PA-aO2）、氧合指数（OI）。结果CPB结束即刻和术后1h时间点U组NE水平均显著低于C组对应值（P〈0．05）。CPB术后1h时U组IL-8显著低于C组（P〈0．05）。CPB术后1h U组的OI、PA-aO2显著低于C组（P〈0．05）。结论乌司他丁可通过抑制IL-8和NE的过度释放,对小儿CPB诱发的肺损伤起一定的保护作用。     

The effects of cardiopulmonary bypass on androgen hormones in coronary artery bypass surgery

The effects of testosterone on coronary vasomotor regulation have been described by several recent reports. Here we investigated changes in serum androgen levels during and after cardiopulmonary bypass (CPB) in patients who had undergone coronary artery bypass surgery. Serum luteinizing hormone, free testosterone and dihydroepiandrestenedione sulphate (DHEA sulphate) levels were evaluated in 38 male coronary artery bypass surgery patients using a chemical immunoassay technique. All hormone levels were corrected to account for haemodilution. Serum-free testosterone level decreased significantly during weaning from CPB (from 15.7 +/- 4.2 nmol/l to 6.2 +/- 2.8 nmol/l), and an even greater decrease was observed in the first post-operative day (5.4 +/- 3.1 nmol/l). On the seventh post-operative day, free testosterone levels reached a normal value (11.8 +/- 5.5 nmol/l), although they were still significantly lower compared with the pre-operative value. There were slight alterations in serum DHEA sulphate levels, although the only significant decrease occurred from the first to the seventh day post-operation (from 4.7 +/- 2.2 mumol/l to 3.7 +/- 1.8 mumol/l, respectively). Serum luteinizing hormone levels were decreased during weaning from CPB (from 4.8 +/- 2.1 mIU/ml to 3.9 +/- 1.8 mIU/ml), but increased rapidly to the pre-operative value (5.5 +/- 2.5 mIU/ml) at the first post-operative day. These results show that CPB affects serum luteinizing hormone, free testosterone and dihydroepiandrestenedione sulphate levels. The free testosterone level decreases significantly both during and after CPB surgery.     

The effect of oxygenator choice on hypotension during cardiopulmonary bypass

Cardiopulmonary bypass (CPB) exposes blood to artificial surfaces, which induces a systemic inflammatory activation.This may contribute to hypotension during CPB. A perceived difference between two membrane oxygenators was noted. Data were collected on 222 consecutive patients; four were excluded from the analysis due to having emergency operations. One hundred and twelve (51%) patients received the Apex oxygenator whilst 106 (49%) received the Quadrox. There was no difference between the two groups in the primary outcome; 90/112 patients (80%) in the Apex group and 77/106 (73%) in the Quadrox group (p=0.18, OR: 0.65; 95% CI: 0.34, 1.22) received meteraminol due to marked hypotension during CPB. There was also no difference in the secondary outcomes, length of stay in ICU (22.8 versus 22.7 hours, (OR 0.79, 95% CI: 0.42, 1.48, p=0.16) and length of stay in hospital (8.5 days versus 8.0 days (OR: 0.83, 95% CI: 0.48, 1.45; p=0.52). The choice of oxygenator between the Apex and Quadrox does not have an effect on hypotension in cardiac surgery.     

氨茶碱对心肌的保护作用

目的探讨氨茶碱在体外循环(CPB)心脏瓣膜置换术中的心肌保护作用及其可能机制。方法将择期行心脏瓣膜置换术的30例风湿性心脏瓣膜病患者随机分为氨茶碱组和对照组,每组各15例。氨茶碱组麻醉诱导后静脉滴注氨茶碱(5 mg/kg)。分别测定CPB转流前及术后不同时期血浆肌钙蛋白Ⅰ(cTnI)、心肌环磷酸腺苷(cAMP)和髓过氧化物酶(MPO)以及主动脉血/冠状静脉窦血中性粒细胞(PMN)比值等;同时观察血流动力学等临床指标。结果两组患者各临床指标差异均无统计学意义;升主动脉开放后两组cTnI均比CPB前升高,但氨茶碱组显著低于对照组;升主动脉开放后30 min,两组cAMP均降低,但氨茶碱组心肌cAMP含量显著高于对照组,MPO活性及主动脉血,冠状静脉窦血PMN比值显著低于对照组。结论在CPB心脏瓣膜置换术中,氨茶碱具有一定的心肌保护作用;其机制可能与升高心肌cAMP、抑制白细胞对心肌组织的浸润有关。     

The importance of pulmonary artery circulation during cardiopulmonary bypass

This study sought to determine changes in transpulmonary difference in blood cells and alveolar-arterial oxygen (A-aO2) gradient when pulmonary artery circulation was obstructed in patients undergoing coronary artery bypass grafting (CABG) with cardiopulmonary bypass (CPB). Eighteen patients were divided into group A (control group; X-clamp placed on aorta, n = 9) and group B (pulmonary ischaemia group; X-clamp placed on aorta and pulmonary artery, n = 9). Haematological parameters were compared before CPB and up to 90 min after declamping. A-aO2 gradient differences were compared before and 2 h and 6 h after declamping. A transpulmonary increase in leucocyte levels normalized after 60 min in group A but remained higher in group B. A transpulmonary increase in neutrophils normalized after 60 min in group A and 90 min in group B. Increased lymphocyte levels normalized after 30 min in group A and 90 min in group B. A-aO2 gradient was determined as: group A (294.8 +/- 74.3) and group B (321.2 +/- 73.3) before X-clamping; group A (132.7 +/- 22.7) and group B (236.6 +/- 41.5) 2 h after declamping; and group A (72.2 +/- 22.7) and group B (189.4 +/- 88.9) 6 h after declamping. When pulmonary artery circulation was obstructed during the X-clamping period, leucocyte, neutrophil and lymphocyte sequestration within both lungs increased, and an increased A-aO2 gradient was observed because of tissue damage. To prevent post-operative complications, precautions to maintain normal pulmonary artery circulation are recommended.     

体外循环心脏手术中辅助复温致手掌烫伤1例

报告1例体外循环心脏手术中辅助复温致手掌低温烧伤患者的致伤过程和护理体会。患者在低温体外循环下行心脏手术,术中为配合体外循环复温,将用敷料包裹的水温45℃的温水瓶放于患者双手掌行辅助复温,导致其低温烧伤,经及时发现、积极对症处理后痊愈。提示护理人员应加强对低温烧伤的认识,在局部加热时,控制温度,缩短观察间隔时间,间断加热,以防止低温烧伤的发生。     

L-精氨酸对体外循环中胰岛素抵抗及炎性反应因子的影响

目的探讨左旋精氨酸（L—Arg）对体外循环（CPB）下机体在缺血再灌注损伤后胰岛素抵抗的缓解作用。方法40例CPB下行心脏瓣膜置换术患者随机分成对照组和治疗组,分别于麻醉前（TO）、CPB15min（T1）、开放升主动脉后15min（T2）和停CPB后2h（T3）测定血浆血糖、胰岛素、血浆肿瘤坏死因子α（TNF—α）、白细胞介素6（IL-6）、白细胞介素8（IL-8）水平,计算胰岛素敏感指数（ISI）和胰岛素抵抗指数对数LgMOHA。结果两组组间比较显示T2、T3各指标较体外循环前T0、T1升高,差异有统计学意义（P〈0．05）;两组T1较体外循环前T0升高,差异有统计学意义（P〈0．05）。两组组间比较显示T1、T0各指标比较差异无统计学意义;两组T2、T3各指标比较有统计学意义（P〈0．05）。TNF-α、IL-6、IL-8与ISI相关分析显示具有负相关关系,TNF-α、IL-6、IL-8与Lg—HOMA相关分析显示具有正相关关系。结论CPB期间存在明显的胰岛素抵抗现象;L—Arg可改善术中胰岛素抵抗的程度。     

体外循环术中高血糖对术后认知功能的影响

目的研究体外循环（CPB）心脏手术中高血糖症与术后认知功能障碍的关系。方法本院86例CPB下行心脏瓣膜置换术（CVR）或冠状动脉旁路移植术（CABG）的非糖尿病成年患者,在术前及术后6周用标准化神经系统检查进行认知功能评分,并在术中监测患者血糖水平,按照术中出现高血糖（〉200mg／dL）与否分为A、B两组,比较两组患者的术前术后认知功能评分,分析术中高血糖与术后认知功能障碍的关系。结果术中出现高血糖的患者,与术中未出现高血糖的患者比较,术后认知功能评分显著降低,认知功能障碍发生率明显增加（P〈0．01）。结论在接受体外循环手术的患者中,术中高血糖是术后出现认知功能障碍的独立毹险因素。     

N-乙酰半胱氨酸对体外循环后肺微血管通透性的保护作用

目的 通过成年犬体外循环(CPB)相关肺损伤模型,研究探讨N-乙酰半胱氨酸(NAC)是否能减轻CPB相关肺损伤及保护肺微血管通透性的作用.方法 成年犬24只,随机分为3组(n=8),C组(CPB中用生理盐水),N1(CPB前用NAC),N2组(CPB中用NAC).通过监测CPB前(To)、CPB停机后维持30 min(T1)、60 min(T2)的呼吸指数(RI)及肺组织中MDA的含量,检测支气管肺泡灌洗液(BALF)的白细胞计数、总蛋白含量,肺微血管通透性指数(PMPI)、电镜观察肺泡上皮细胞形态学改变.结果 RI:CPB前3组差异无统计学意义,停机后(T1、T2),C组的RI升高幅度明显大于N1组、N2组(P<0.05),N1组低于N2组(P<0.05).MDA:CPB前3组差异无统计学意义,停机后(R1、T2),C组MDA的升高幅度高于N1组、N2组(P<0.05).BALF虹白细胞计数、总蛋白含量:C组显著高于N1组、N2组(P<0.05),N1组低于N2组(P<0.05).PMPI:C组显著高于NI组、N2组(P<0.05),N1组低于N2组(P<0.05).组织学检查:C组显示明显的肺部炎症改变,还可见内皮细胞间隙增宽.Ⅱ型肺泡上皮细胞胞质空泡化,板层体消失,线粒体肿胀;N1组、N2组相应改变明显减轻.结论 NAC可减轻CPB相关性肺损伤,并可降低肺微血管通透性,且CPB前NAC优于CPB中用NAC.     

Dynamic alveolar mechanics in four models of lung injury

Objective To determine whether pathological alterations in alveolar mechanics (i.e., the dynamic change in alveolar size and shape with ventilation) at a similar level of lung injury vary depending on the cause of injury.Design and setting Prospective controlled animal study in a university laboratory.Subjects 30 male Sprague-Dawley rats (300–550 g).Interventions Rats were separated into one of four lung injury models or control (n=6): (a) 2% Tween-20 (Tween, n=6), (b) oleic acid (OA, n=6), (c) ventilator-induced lung injury (VILI, PIP 40/ZEEP, n=6), (d) endotoxin (LPS, n=6). Alveolar mechanics were assessed at baseline and after injury (PaO₂/FIO₂ <300 mmHg) by in vivo microscopy.Measurements Alveolar instability (proportional change in alveolar size during ventilation) was used as a measurement of alveolar mechanics.Results Alveoli were unstable in Tween, OA, and VILI as hypoxemia developed (baseline vs. injury: Tween, 7±2% vs. 67±5%; OA: 3±2% vs. 82±9%; VILI, 4±2% vs. 72±5%). Hypoxemia after LPS was not associated with significant alveolar instability (baseline vs. injury: LPS, 3±2 vs. 8±5%).Conclusions These data demonstrate that multiple pathological changes occur in dynamic alveolar mechanics. The nature of these changes depends upon the mechanism of lung injury.Electronic Supplementary Material Electronic supplementary material to this paper can be obtained by using the Springer Link server located at .     

Intraoperative fluid balance during cardiopulmonary bypass: effects of different mean arterial pressures

INTRODUCTION: This study investigated whether two levels of mean arterial pressure (MAP) during cardiopulmonary bypass did influence per-operative fluid shifts. METHODS: Sixteen pigs underwent 60 minutes of normothermic cardiopulmonary bypass (CPB) followed by 90 minutes of hypothermic CPB. Eight animals had a MAP of 60-80mmHg by norepinephrine (HP group). Another 8 animals had a MAP of 40-45 mmHg by phentolamine (LP group). Blood chemistry, plasma/interstitial colloid osmotic pressures, plasma volume, fluid balance, fluid extravasation rate and tissue water content were measured or calculated. RESULTS: The plasma volume was significantly lower in the HP group compared with the LP group after 60 minutes of CPB. Net fluid balance was 0.18 (0.05) ml x kg(-1) x min(-1) in the HP group and 0.21 ml x kg(-1) x min(-1) in the LP group (P > 0.05) while fluid extravasation rate was 1.18 (0.5) and 1.13 (0.4) ml x kg(-1) x min(-1) in the HP group and the LP group during CPB (P > 0.05). CONCLUSION: Net fluid balance and fluid extravasation rate were similar in the animals with elevated and with lowered MAP during CPB.     

The coagulopathy of cardiopulmonary bypass

There have been numerous publications on the coagulopathy of cardiopulmonary bypass (CPB). This review provides an introduction to the history and main components of current CPB circuits and summarizes the current knowledge of pathogenesis, prevention, and treatment of the CPB coagulopathy. It encompasses an overview of intra- and postoperative monitoring of coagulation with special emphasis on the near-patient testing, its main complications, and the transfusion support, while taking into account the major changes in the technology used and supportive care provided since its inception.