体外循环技术在非心脏手术中的临床应用

目的探讨体外循环技术在非心脏手术中的临床应用体会。方法7例非心脏手术中,在体外循环下行左侧局部晚期肺癌扩大根治术3例,颈动脉瘤破裂血管移植1例,肝叶切除或肝移植 右房癌栓清除2例,大块急性肺动脉栓塞取栓术1例。结果7例病人全部康复出院。1例肝癌和1例右颈动脉瘤破裂出血患者因凝血功能障碍延迟至第3d关胸。另1例肝癌术后出现心包积液、伤口不愈合,行心包引流和伤口二期缝合后痊愈。7例均获随访,平均11(6~16)月。2例肺癌均存活15月后死亡,另1例肺癌术后6月仍存活。2例肝癌分别生存14月、13月后死于全身衰竭。其余患者恢复正常工作。结论体外循环技术在非心脏手术的应用,为某些急重症、疑难病人提供了重要救治手段。     

Minimizing Systemic Inflammation During Cardiopulmonary Bypass in the Pediatric Population

Cardiopulmonary bypass (CPB) is known to cause a systemic inflammatory response. Inflammation includes several cascade activations: complement, cytokine, and coagulation. The early phase is triggered by blood contact with the synthetic bypass circuit and the late phase by ischemia‐reperfusion and endotoxemia. Systemic inflammatory response syndrome (SIRS) is constant following cardiac surgery; however, a compensatory anti‐inflammatory response is also constant and the clinical manifestations (varying from uncomplicated SIRS to shock and multiple organ dysfunction) depend on the balance between the two responses. When overexpressed, the inflammatory response may significantly increase a patient's risk. Minimization of systemic inflammation is a major concern and several strategies aiming to inhibit the inflammatory response are described. None of them is satisfactory, but the “control” of the inflammatory response extent is likely to require a multimodal approach. This review aims to describe the strategies proposed to reduce CPB‐related systemic inflammation.     

血凝酶在体外循环后的止血效果

目的研究注射用血凝酶(巴曲亭)于体外循环结束后应用的止血效果.方法174名在体外循环下行心脏手术的患者随机分为3组,在体外循环结束后分别予不同止血药物:实验组57例应用巴曲亭,空白对照组62例不应用任何止血药物,立止血组55例应用立止血.定时记录各组的血细胞分析指标(RBC、Hb、PLT、WBC)和凝血功能指标(PT、APTT、FIB);记录术后引流量、需要输血的患者数目、发生不良反应的患者例数.结果巴曲亭组和空白对照组相比,给药前的血细胞分析和凝血功能均无显著性差别(P＞0.05),给药后的血细胞分析(除WBC外)和凝血功能有显著差别(P＜0.05).巴曲亭组和立止血组相比,给药前后的血细胞分析和凝血功能、术后12、24、36 h的引流量、术后需要输血的人数均无显著差别.巴曲亭组和对照组及立止血组相比,在不良反应方面均无显著差别.结论巴曲亭的应用可以减少红细胞和血红蛋白的丢失,减少血小板的破坏,增强凝血功能,减少术后引流及输血的需要.巴曲亭和立止血的临床效果相似,而且不增加不良反应.巴曲亭在体外循环后应用具有有效性和安全性.     

Comparison of Two Miniaturized Cardiopulmonary Bypass Systems Regarding Inflammatory Response

Cardiopulmonary bypass (CPB) is a known mediator of systemic inflammatory response. Extracorporeal circulations are undergoing continuous modifications and optimizations to achieve better results. Hence we aim to compare the inflammatory response associated with two recent miniature extracorporeal circulation systems during normothermic CPB. We measured plasma levels of cytokines including interleukin (IL)‐1β, IL‐6, IL‐10, tumor necrosis factor‐α, migration inhibitory factor (MIF), receptor for advanced glycation endproduct, and cluster of differentiation 40 ligand in 60 consecutive patients during the first 24 h after CPB. The patients were prospectively randomized to one of three trial groups: patients in group A were operated with the minimal extracorporeal circulation circuit (MECC, Maquet, Rastatt, Germany), group B operated with the extracorporeal circulation circuit optimized (ECC.O, Sorin, Italy), and group C operated with a conventional extracorporeal circuit (CECC, Maquet). Arterial blood samples were collected at intervals before, 30 min after initiation, and after termination of CPB. Further samples were collected 6 and 24 h after CPB. IL‐10 levels were significantly raised in the CECC group as compared with either of the mini ECC‐circuits with a peak concentration at 6 h postoperatively. Human MIF concentrations were significantly higher in the CECC group starting 30 min after CPB and peaking at the end of CPB. The overall reduction in cytokine concentrations in the mini‐ECC groups correlated with a lower need for blood transfusion in MECC and a shorter mechanical ventilation time for ECC.O. Normothermic CPB using minimally invasive extracorporeal circulation circuits can reduce the inflammatory response as measured by cytokine levels, which may be beneficial for perioperative preservation of pulmonary function and hemostasis in low risk patients.     

高龄患者冠状动脉搭桥手术的体外循环管理

目的总结高龄患者行冠状动脉搭桥手术体外循环(cardiopulmonary bypass,CPB)管理的经验。方法行冠状动脉搭桥手术患者48例,其中70岁以上者28例(高龄组),70岁者20例(非高龄组),回顾性比较两组的CPB差异。结果高龄组患者术前更易合并糖尿病,术前HCT较低(P<0.05)。高龄组体外循环时间(135.6±17.3)min,升主动脉阻断时间(101.3±40.2)min,术后改良超滤10例,与非高龄组相比较,差异有显著性;高龄组应用库血预充占82.1%(23/28),明显高于非高龄组的25%(P<0.01),升主动脉开放后,高龄组自动复跳24例(85.7%),非老年组自动复跳17例(85%),两组比较无差异;但高龄组有3例停CPB后需IABP辅助脱机。结论高龄并非心脏手术CPB的禁忌症,根据其患病特点,合理地行CPB管理,可以为高龄患者成功地进行冠状动脉搭桥手术提供重要保证。     

抑肽酶,潘生丁在体外循环中应用比较的研究

在体外循环心脏直视手术的２０只绵羊的动物实验模型中应用丝氨酸蛋白酶抑制剂──抑肽酶，并与潘生丁作比较，通过测定ＴＸＡ２及ＰＧＩ２的变化，血小板超微结构的改变，以及术中术后的观察，证实抑肽酶确能有效地保护血小板功能，减轻血小板的激活释放及损耗，维护正常健全的凝血机制，达到明显减少术中术后出血与渗血之目的。     

在体外及体外循环中抑肽酶对ACT的影响

选择健康献血员及心内直视手术病，观察抑肽酶对全血活化凝血时间的影响。结果：在体外肝素剂量与ＡＣＴ有显著线性相关。抑肽酶单狡应用并不使ＡＣＴ延，但与肝素合用可协同性延长ＡＣＴ值；在体外循环中抑肽酶延长ＡＣＴ的值更为显著，一般超过８００ｓ。结论：抑肽酶可与肝素协同性延长ＡＣＴ，体外循环中应用抑肽酶时应以ＡＣＴ大于８００ｓ作为肝素抗凝标准。     

体外循环心脏直视手术对血清白细胞介素-6及C-反应蛋白水平的影响

目的：观察不同剂量芬太尼对体外循环心肺转流（ＣＰＢ）心脏直视手术中病人血清白细胞介素－６（ＩＬ－６）和Ｃ－反应蛋白（ＣＲＰ）的变化。方法：２０例择期心脏手术病分人为Ａ、Ｂ两组：Ａ组芬太尼用量为４０μｇ／ｋｄ,Ｂ组为２０μｇ／ｋｇ。麻醉诱导、地方法及辅助用药均一致。观测麻醉前、ＣＰＢ后５分钟、ＣＰＢ结束后５分钟、手术结束、术后第１天及第３天六个时点ＩＬ－６及ＣＲＰ的浓度。结果：术中ＩＬ－６和ＣＲＰ均     

抑肽酶在体外循环心脏外科的临床应用

通过在体外循环心脏手术中应用抑肽酶的临床研究（对照组ｎ＝２０；抑肽酶组ｎ＝５０）结果显示：抑肽酶能有效地保护血小板的功能，避免血小板在体外循环转流时的活化释放及损耗，并减轻血小板数量的下降；抑肽酶还可抑制纤溶系统的激活，与肝素有协同作用，使ＡＣＴ延长，并可减少肝素及鱼精蛋白的用量，最终达到明显减少术后失血量（６３％）及术后输血量（５４％）与输血浆量（４２％）之目的。     

低温心肺转流期间干扰脑氧平衡主要因素的探讨

为了探讨低温心肺转流（ＣＰＢ）期间干扰脑氧平衡的主要因素，本研究对１６例心脏瓣膜置换术患者，在６个时点同步测定脑氧饱和度（ｒＳＯ２）颈静脉球血氧饱和度（ＳｊＯ２），鼻咽温（ＮＰＴ），血红蛋白（Ｈｂ）浓度及其他脑氧合参数，血流动力学和血气指标，并比较了ｒＳＯ２和ＳｊＯ２的相关性，结果表明，ｒＳＯ２与ＳｊＯ２变化显著相关性（ｒ＝０．８１，Ｐ〈０．００１），提示两种方法的观察效果是一致的。ＮＰＴ变化与ｒ     

Insufflation of Hydrogen Gas Restrains the Inflammatory Response of Cardiopulmonary Bypass in a Rat Model

Systemic inflammatory responses in patients receiving cardiac surgery with the use of the cardiopulmonary bypass (CPB) significantly contribute to CPB‐associated morbidity and mortality. We hypothesized that insufflated hydrogen gas (H₂) would provide systemic anti‐inflammatory and anti‐apoptotic effects during CPB, therefore reducing proinflammatory cytokine levels. In this study, we examined the protective effect of H₂ on a rat CPB model. Rats were divided into three groups: the sham operation (SHAM) group, received sternotomy only; the CPB group, which was initiated and maintained for 60 min; and the CPB + H₂ group in which H₂ was given via an oxygenator during CPB for 60 min. We collected blood samples before, 20 min, and 60 min after the initiation of CPB. We measured the serum cytokine levels of (tumor necrosis factor‐α, interleukin‐6, and interleukin‐10) and biochemical markers (lactate dehydrogenase, aspartate aminotransferase, and alanine aminotransferase). We also measured the wet‐to‐dry weight (W/D) ratio of the left lung 60 min after the initiation of CPB. In the CPB group, the cytokine and biochemical marker levels significantly increased 20 min after the CPB initiation and further increased 60 min after the CPB initiation as compared with the SHAM group. In the CPB + H₂ group, however, such increases were significantly suppressed at 60 min after the CPB initiation. Although the W/D ratio in the CPB group significantly increased as compared with that in the SHAM group, such an increase was also suppressed significantly in the CPB + H₂ group. We suggest that H₂ insufflation is a possible new potential therapy for counteracting CPB‐induced systemic inflammation.     

A Venous Reservoir for Cardiopulmonary Bypass in Newborns and Small Infants

A venous reservoir has been designed for cardiopulmonary bypass in newborns and small infants that prevents undesirable volume shifts and thus permits precise control of perfusion.     

Carotid Doppler Flow After Cardiopulmonary Bypass and Mild Hypothermia in Neonatal Piglets

Although the mechanisms of neurological disorders after cardiac surgery in neonates are still not fully understood, alterations in blood flow after cardiopulmonary bypass (CPB) may lead to cerebral injury. The aim of the study was the analysis of flow changes in the carotid artery of neonatal piglets after CPB. Ten neonatal piglets (younger than 7 days) were connected to the CPB and further management underwent three steps: (i) cooling to 32°C core temperature within 30 min; (ii) cardiac arrest under cardioplegic myocardial protection for 90 min; and (iii) rewarming to 37°C after cross‐clamp release (60 min of reperfusion). In summary, piglets were separated from CPB after a total duration time of 180 min. The blood flow was measured in the left carotid artery by an ultrasonic flow probe before CPB (baseline), immediately after CPB, 30 min, and 60 min after CPB. Additionally, the pulsatility index and the resistance index were calculated and compared. Finally, the relation of the carotid artery flow data with the corresponding pressure data at each time point was compared. After termination of CPB, the carotid artery mean flow was reduced from 28.34 ± 13.79 mL/min at baseline to 20.91 ± 10.61 mL/min and remained reduced 30 and 60 min after CPB termination (19.71 ± 11.11 and 17.64 ± 15.31 mL/min, respectively). Both the pulsatility and the resistance index were reduced immediately after CPB termination and increased thereafter. Nevertheless, values did not reach statistical significance. In conclusion, the carotid Doppler flow immediately after CPB and mild hypothermia in neonatal piglets was lower than before CPB due to reduced vascular resistance. Additionally, the pressure–flow relation revealed that immediately after CPB, a higher pressure is required to obtain adequate flow.