胃肠激素和胃黏膜pH值在体外循环心脏手术中的变化

目的:探讨体外循环(cardiopulmonary bypass,CPB)中血乳酸,胃黏膜pH值,胃肠激素变化.方法:20例心脏直视手术患者,分别在麻醉前、CPB前、CPB 15-min、开放升主动脉后5min、停止CPB 20 min和术后3 h,测定红细胞压积,血乳酸(Lae),计算胃黏膜pH值(pHi).放射免疫法测定降钙素基因相关肽(CGRP)、胃泌素(GAS)和胃动素(MOT)浓度.结果:GAS和MOT在CPB15 min浓度均显著高于CPB前(89.72±21.59 vs 57.20±13.26.271.35±45.61 vs 196.93±42.56,均P＜0.05),相反,CGRP在CPB中浓度与CPB前相比明显降低(63.17±20.26 vs 115_37±29.04,P＜0.05).尽管体外循环期间血Lac浓度高于CPB前,pHi低于CPB前,但与体外循环前相比差异无显著性.结论:CPB过程中随时间延长,血清中MOT和Gas显著增高,CGRP显著降低,pHi下降是CPB术后发生胃肠道并发症的潜在的危险因素.     

奥美拉唑治疗重型颅脑损伤并发应激性溃疡疗效观察

将35例行开颅手术的重型颅脑损伤患者随机分为治疗组与对照组,分别给予奥美拉唑及西米替丁、1次/d,监测开颅术后即刻及术后6 d内每日胃黏膜内pH(pHi)值、胃液pH值、血浆胃泌素水平、GCS评分及应激性溃疡出血变化.发现治疗组术后pHi高于对照组;术后第3天开始,治疗组血浆胃泌素水平较对照组降低;治疗组发生应激性溃疡例数明显少于对照组.认为奥美拉唑对重型颅脑损伤患者发生应激性溃疡具有一定的预防作用.     

大鼠应激性溃疡模型复制及埃索美拉唑的干预效果

目的复制大鼠应激性溃疡动物模型并进行预防性治疗。方法 24只大鼠随机分成3组,每组8只。实验前埃索美拉唑组灌胃埃索美拉唑2.4 mg/kg,模型组灌胃生理盐水1 ml/d,共3 d,正常对照组不做任何处理。采用冷藏法制作应激性胃溃疡大鼠模型。对比3组胃黏膜的溃疡程度并测定胃内p H值变化。结果正常对照组胃黏膜表面光滑,呈粉白色,无任何溃疡面。其他两组均有不同程度胃溃疡,以模型组溃疡程度最严重,沿着胃黏膜褶皱凸起的部位有多发的条索状出血带及点状出血,呈咖啡色,黏膜水肿、糜烂、溃疡严重;与模型组比较,埃索美拉唑组胃溃疡程度明显减轻(P0.05)。与正常对照组比较,模型组胃内p H值降低(P0.05);与模型组比较,埃索美拉唑组胃内p H值有一定程度增加。结论冷应激可用来复制大鼠胃溃疡模型,埃索美拉唑对胃溃疡具有预防作用。     

埃索美拉唑与奥美拉唑对胃食管反流病24小时胃内pH效果比较

维持胃内pH >4是有效治疗胃食管反流病 (GERD)的关键。 4 0mg埃索美拉唑是第一个光学异构体质子泵抑制剂 (PPI) ,已被证实较 2 0mg奥美拉唑有更显著的抑酸效果。此项研究的目的在于比较每天 1次埃索美拉唑 4 0mg与奥美拉唑 4 0mg对症状性GERD病人胃酸的影响。在这项开放交叉研究中 ,130例症状性GERD病人接受每天 1次埃索美拉唑 4 0mg或奥美拉唑 4 0mg连续 5d的治疗。在每个疗程的第 1天和第 5天进行 2 4h胃内pH监测。接受埃索美拉唑 4 0mg的病人第 1天和第 5天的 2 4h胃内pH >4的时间显著长于奥美拉唑 4 0mg(第 1天 :4 8.6 %比 4 0 …     

康复新液联合埃索美拉唑治疗慢性糜烂性胃炎合并胃黏膜隆起胃镜切除98例临床观察

[目的]探讨康复新液联合埃索美拉唑治疗慢性糜烂性胃炎合并胃黏膜隆起胃镜下电切术后的临床治疗效果。[方法]回顾性分析我院收治98例慢性糜烂性胃炎合并胃黏膜隆起胃镜下电切术后患者,随机分2组,治疗组50例,采用康复新液联合埃索美拉唑治疗;对照组48例,采用埃索美拉唑医治,对照2组疗效。[结果]根据患者病情分析,治疗组总有效率为92.00%;对照组总有效率为81.25%;治疗组明显高于对照组,差异有统计学意义(P0.05)。[结论]康复新液能有效修复胃黏膜,能快速减缓症状,增进糜烂及胃黏膜隆起电切术后人工溃疡面的愈合,避免复发,是医治慢性糜烂性胃炎合并胃黏膜隆起电切术后的有效药物,值得在临床中普遍推行。     

不同质子泵抑制剂与PCI手术患者血小板抑制率的相关性研究

目的：研究不同质子泵抑制剂(PPI)对经皮冠状动脉介入治疗(PCI)手术患者血小板抑制率的影响。方法: 本研究纳入符合入选标准2014年1月-2016年4月解放军第一七五医院心内科住院的冠心病患者210例,均为需行PCI手术治疗的病人。所有入选者均予负荷量阿司匹林 氯吡格雷口服24h后采取静脉血标本,然后用血栓弹力图仪(TEG)检测并自动计算出二磷酸腺苷(ADP)诱导的血小板抑制率,并将入选者随机分为三组,每组70例,分别给予雷贝拉唑、埃索美拉唑、泮托拉唑口服以保护胃粘膜、预防消化道出血。所有入选者经负荷量双联抗血小板治疗后均继续予阿司匹林 氯吡格雷常规量维持治疗,1周后采用上述方法复查血小板抑制率。结果：雷贝拉唑组、埃索美拉唑组、泮托拉唑组的患者双联抗血小板治疗24 h后与7 d后的血小板抑制率分别为（64.7±16.5 vs 63.9±15.2,63.2±13.6 vs 62.1±14.5,62.5±15.3 vs 61.6±14.9）;不同PPI组患者双抗治疗24 h后或7 d后的血小板抑制率比较均未见统计学差异（P>0.05）;同一PPI组患者双抗治疗7 d后比24 h后的血小板抑制率略有降低,但比较均未见统计学差异（P>0.05）;共出现43例（20.5%）氯吡格雷抵抗现象,而不同PPI组患者的氯吡格雷抵抗情况比较未见统计学差异（P>0.05）。结论：雷贝拉唑、埃索美拉唑及泮托拉唑对氯吡格雷抗血小板作用的影响无明显差异,均可作为PCI术后患者双联抗血小板治疗的胃黏膜保护剂。     

埃索美拉唑在预防长期服用小剂量阿司匹林引起胃黏膜损伤中的临床疗效

目的 比较不同药物对预防长期服用小剂量阿司匹林患者胃黏膜损伤的临床疗效.方法 107例长期服用小剂量阿司匹林患者,随机分为对照组、法莫替丁组、铝碳酸镁组、奥美拉唑组和埃索美拉唑组,对照组单独应用阿司匹林治疗,其余各治疗组在应用阿司匹林治疗的基础上,分别加服法莫替丁20 mg 2次/d;铝碳酸镁500 mg 3次/d;奥美拉唑20 mg 1次/d和埃索美拉唑20 mg 1次/d治疗.3个月后,对各组患者上消化道症状及胃黏膜损伤发生率进行比较.结果 各治疗组与对照组相比,上消化道症状及胃黏膜损伤的发生率明显减少,差异有统计学意义(P<0.05);其中埃索美拉唑组发生率明显低于其余各治疗组,差异有统计学意义(P<0.05).结论 埃索美拉唑对预防长期应用小剂量阿司匹林引起的胃黏膜损伤有显著疗效.     

埃索美拉唑治疗高危老年溃疡性上消化道出血的研究

目的观察大剂量与常规剂量埃索美拉唑治疗高危老年溃疡性上消化道出血的有效性。方法以2010年6月至2013年8月在我院老年医学科住院的96例溃疡性上消化道出血的高危（Rockall评分〉5分）老年患者为研究对象,将其随机分为治疗组和对照组,2组患者均在内镜下成功的止血,2组患者的一般治疗方案相同,治疗组采用1次静滴埃索美拉唑80 mg后（30 min）,接着以8 mg/h的速度持续静脉泵入埃索美拉唑,71.5 h后改为口服埃索美拉唑40 mg（1次/d）,持续观察至第30天;对照组静滴埃索美拉唑80 mg（1次/d）,3 d后改为口服埃索美拉唑40 mg（1次/d）,持续观察至第30天,观察2组的再出血率、死亡率、平均住院日及平均住院费用。结果与对照组相比,治疗组的再出血率、死亡率、平均住院日及平均住院费用均有明显的降低（P均〈0.05）。结论对高危的老年溃疡性上消化道出血患者而言,静脉大剂量使用埃索美拉唑是有效、合理的。     

埃索美拉唑对健康志愿者抑制胃泌酸的药效学研究

目的　比较埃索美拉唑与雷贝拉唑对健康志愿者抑制胃泌酸的效果及安全性。方法　 36名健康志愿者随机分为两组 ,分别口服埃索美拉唑 4 0mg或雷贝拉唑 10mg ,每日 1次 ,连续 5d ,经过14d的洗脱期后 ,交叉口服雷贝拉唑 10mg或埃索美拉唑 4 0mg ,每日 1次 ,连续 5d。分别于服药首日及第 5天连续测定 2 4h胃内 pH ,并以PCR方法鉴定细胞色素 (CYP) 2C19基因型。 结果　埃索美拉唑组服药后首日最初 4、2 4h和第 5天 2 4h胃内pH >4 .0的时间百分比分别为 5 8.9%、73.7%和 84 .2 % ,显著高于雷贝拉唑组 (32 .1%、5 4 .8%和 76 .2 % ,P <0 .0 0 1) ;胃内 pH中位值分别为 4 .2 9、5 .6 0和 6 .38,亦显著高于雷贝拉唑组 (2 .88、4 .2 6和 5 .77,P≤ 0 .0 0 1)。服药后首日及第 5天pH >4 .0超过 16h的志愿者埃索美拉唑组百分率分别为 6 3.9%和 88.9% ,亦显著高于雷贝拉唑 (33.3%和 6 1.1% ,P <0 .0 5 )。36名志愿者中 2 8名CYP 2C19基因型为强代谢型 ,8名为弱代谢型。两药对强代谢型或弱代谢型者胃泌酸的抑制差异无显著性 (P >0 .0 5 )。服药期间两组均未发生明显不良反应。结论　埃索美拉唑和雷贝拉唑均具有较强的抑制胃酸分泌效应 ,但在抑酸速度、抑酸强度和维持时间方面 ,4 0mg埃索美拉唑优于 10mg雷贝拉唑。两药     

埃索美拉唑预防氯吡格雷相关性胃黏膜损伤的研究

目的探讨埃索美拉唑是否可以预防氯吡格雷导致的胃黏膜损伤。 方法120只SD大鼠随机分为3组,每组40只,分别给予生理盐水、氯吡格雷、埃索美拉唑联合氯吡格雷灌胃。分别于给药后7 d、14 d、21 d和28 d处死大鼠,使用HE染色对胃黏膜进行组织病理学观察,使用Guth法对胃黏膜损伤进行评分。 结果埃索美拉唑可显著降低胃黏膜损伤的发生率(65.0% vs 42.5%,P＝0.044)。用药后7 d开始,单用氯吡格雷组小鼠胃黏膜出现明显损伤,损伤评分在14 d达到高峰(6.85±0.99),而联合用药组在各时间点胃黏膜损伤的程度均较单用氯吡格雷组更轻微(P<0.01),且损伤程度随用药时间延长无显著变化。 结论氯吡格雷可导致胃黏膜损伤,且损伤程度在14 d达到高峰,而埃索美拉唑可有效预防氯吡格雷相关性胃黏膜损伤。     

不停跳冠状动脉旁路移植术对糖尿病患者术后早期结果的影响

目的探讨糖尿病对冠状动脉旁路移植术的手术病死率和并发症发生率的影响作用.方法回顾分析1995年10月-2004年1月958例择期行冠状动脉旁路移植术的患者,其中191例并发糖尿病.糖尿病和无糖尿病患者按是否应用体外循环进一步分为四组,对四组患者术前、术后资料进行对比分析.结果糖尿病组应用体外循环患者手术病死率为5.6%,糖尿病组不停跳冠状动脉旁路移植术患者为2.1%.结论糖尿病是影响冠状动脉旁路移植术预后的危险因素,不停跳冠状动脉旁路移植术能显著减少糖尿病患者的手术病死率和并发症发生率.     

Coronary surgery of the beating heart. First year of experience in a series of 317 non-selected coronary patients

From May 1999 to May 2000, 317 unselected patients, representing 92.7% of all coronary artery surgery procedures, underwent open heart surgery of the beating heart by median sternotomy with the aid of a cardiac stabilising device. The main preoperative characteristics were: mean age = 66.1 years; men = 78.9%; left main stem disease = 31.8%; mean left ventricular ejection fraction = 54.1%; mean Parsonnet index = 16.9. These 317 patients were compared with a group of 303 patients who underwent coronary bypass surgery the year before by the same surgical team with cardiopulmonary bypass (CPB) and cardiac standstill. Seven hundred and eighty-six distal anastomoses were carried out in the beating heart group (2.48 grafts per patient) compared with 2.91 in the CPB group: p < 0.001). There were 10.1% single bypass, 37.5% double bypass, 47.3% triple bypass and 5% quadruple bypass procedures. A cardiopulmonary bypass was required in 13 patients (4.1%). The mortality at 30 days was 3.1% versus 4.6% in the CPB group (p = NS). The need for blood transfusion was reduced by nearly 40% in the beating heart group (23.7% versus 39.9%, p < 0.001). The incidence of cerebrovascular complications was reduced from 3% in the CPB group to 0.6% in the beating heart group (p = 0.06). The peak postoperative troponine I levels were much lower in the beating heart group (2.5 versus 6.4 ng/ml, p < 0.001). The authors conclude that surgery on the beating heart is feasible in most patients. Compared with conventional surgery under CPB, there seems to be less requirement for blood transfusion and a tendency to reduce the cerebral risk. Nevertheless, a large prospective randomised trial is required to validate the potential advantages and limitations of this technique with respect to conventional surgery and to determine the optimal indications of surgery on the beating heart.     

Effect of cardiopulmonary bypass on cytokine network and myocardial cytokine production

BACKGROUND: In addition to the well-investigated proinflammatory cytokine expression, there is an ever increasing interest in the field of anti-inflammatory response to cardiopulmonary bypass (CPB). Evidence suggests that myocardium serves as an important source of cytokines during reperfusion and application of CPB. The effect of coronary artery bypass graft (CABG) without CPB on myocardial cytokine production has not as yet been investigated. HYPOTHESIS: Cardiopulmonary bypass can cause long-term disturbance in pro- and anti-inflammatory cytokine balance, which may impede a patient's recovery following surgery. Therefore, the effect of CPB on the balance of the pro-/anti-inflammatory cytokines network and myocardial cytokine outflow was assessed throughout a longer period after surgery. METHODS: Twenty patients were scheduled for CABG with CPB and 10 had off-pump surgery. Blood samples were taken before, during, and over the first week following surgery. Coronary sinus blood samples were collected during surgery. The ratio of pro- and anti-inflammatory cytokines was calculated and the cytokine concentration of peripheral and coronary sinus blood were compared in both groups. RESULTS: Pro-/anti-inflammatory cytokine ratio decreased early after CPB followed by a delayed and marked increase. A more balanced ratio was present following off-pump surgery. Coronary sinus levels of certain cytokines exceeded the concentration of systemic blood in the course of CPB but not during off-pump operation. CONCLUSION: Patients show pro-inflammatory predominant cytokine balance at a later stage after CPB in contrast to those without CPB. The heart produces a remarkable amount of cytokines only in the course of surgery with CPB.     

婴幼儿体外循环心脏手术中奥美拉唑对胃肠道保护作用的临床观察

目的探讨奥美拉唑对婴幼儿体外循环（CPB）心脏手术中胃肠道的保护作用。方法45例在CPB下行先心病手术患儿,（年龄≤3岁）随机分为3组:实验A组在CPB预充液中即给予奥美拉唑10 mg,实验B组于CPB结束时给予奥美拉唑10 mg,对照组注入等量生理盐水。3组均于术前、CPB 30 m in、CPB结束后、术后4 h、24 h进行胃液常规检查,并采集血液标本,ELISA法测定血清促胃液素。结果与CPB前比较:A组胃液pH于CPB结束后有明显升高,B组胃液pH于术后4 h有明显升高,C组胃液pH变化不明显。A、B、C 3组胃液红细胞计数及血清促胃液素与本组CPB前相比均有明显上升。与对照组（C组）相比:A组胃液pH于CPB结束后各时间点较对照组明显上升,而胃液红细胞计数则有明显下降,血清促胃液素于CPB 3 m in后较对照组有明显降低。B组胃液pH于术后4、24 h较对照组有明显升高,同时间点胃液红细胞计数与促胃液素则有明显降低。结论在CPB心脏手术中预充液中即加入奥美拉唑对胃肠道有明显的保护作用。     

Fibrinogen and fibrin degradation products in patients undergoing open-heart surgery

We have determined fibrinogen and fibrin degradation products (FgDP and FbDP respectively) by an ELISA method using specific monoclonal antibodies in 100 patients undergoing cardiopulmonary bypass (CPB) for valvular heart disease and in 60 patients undergoing aorto-coronary bypass surgery. Blood samples were taken pre-operatively and on post-operative days 1 and 5. Post-operative evolution was similar in both patient groups, with a significant increase in FgDP on post-operative days 1 and 5 with respect to baseline value (P less than 0.01). FbDP were also significantly higher on post-operative days 1 and 5 (P less than 0.001), especially the day after surgery in patients with valvular disease as compared with coronary patients (P less than 0.01). Our results indicate that fibrinolysis is more important than fibrinogenolysis after open-heart surgery, which may have pathophysiological implications.     

心肌肽素在心脏手术中对心肌的保护作用的临床研究

目的:考察心脏瓣膜替换术和冠状动脉旁路移植术(CABG)患者在体外循环停跳液中使用心肌肽素的安全性及对心肌的保护作用。方法:选择心脏瓣膜替换术患者44例(瓣膜替换组,又随机分为对照患者、用药患者各22例),CABG患者65例(CABG组,又随机分为对照患者33例、用药患者32例)。2组用药患者在麻醉后,静脉滴注心肌肽素1 mg/kg,30分钟给药完毕;第1次灌注时在停跳液中一次性加入心肌肽素2 mg/kg。2组对照患者给予相应的甘露醇。观察围术期血流动力学,心肌组织形态学,心肌酶学及肌钙蛋白含量的变化。结果:所有受试患者均顺利完成试验,未见明显不良反应,均康复出院。CABG组心肌组织形态学:用药患者在用药前心肌组织病变分值较对照患者显著升高(P<0.01),而用药后较对照患者显著降低(P<0.01);用药患者体外循环后心肌组织病变分值较体外循环前显著降低(P<0.01);而对照患者体外循环后心肌组织病变分值较体外循环前显著升高(P<0.01)。瓣膜替换组心肌组织形态学:体外循环前心肌组织病变分值用药患者虽高于对照患者,但无统计学意义;体外循环后用药患者显著低于对照患者(P<0.01);体外循环后对照患者心肌组织病变分值较体外循环前显著升高(P<0.01),用药患者虽有降低,但无统计学差异(P>0.05)。结论:心肌肽素在心脏瓣膜替换术和CABG患者体外循环停跳液中使用是安全的,而且对心肌有一定保护作用。     

No decrease in incidence of atrial fibrillation in patients undergoing off-pump coronary artery bypass grafting

BACKGROUND: With the introduction of beating heart surgery, there has been a renewed interest in the incidence of postoperative atrial fibrillation (AF) in patients undergoing coronary artery bypass grafting (CABG). A small number of studies have reported markedly decreased incidences of postoperative AF in patients undergoing off-pump CABG. AIMS: The aim of the present study was to review the incidence of AF in patients undergoing off-pump CABG at Royal Melbourne Hospital. METHODS: A retrospective review was undertaken of 80 patients who had elective first-time CABG off-pump over a 16-month period. These patients were matched with 80 patients who underwent CABG with cardiopulmonary bypass (CPB). Data on preoperative and operative variables were collected. Incidences of postoperative AF in both groups were recorded. RESULTS: The incidence of AF in the off-pump group was 27 of 80 patients (34%) and in the CPB group it was 25 of 80 patients (31%; NS). Increasing age was a significant risk factor for developing postoperative AF, and beta-blockade was identified as a protective factor. CONCLUSIONS: Off-pump CABG does not decrease the incidence of postoperative atrial fibrillation. A randomised prospective trial has been commenced at Royal Melbourne Hospital to further investigate postoperative outcomes of off-pump CABG.     

常温和中低温体外循环对甲状腺素变化的影响

目的探讨常温及低温体外循环心脏直视手术对甲状腺素的影响。方法选择先天性心脏病患者80例,随机分为常温组及低温组,各40例,分别于术晨、体外循环结束时及术后6、12、24、48h抽取患者动脉血,测定血浆T3、T4和TSH。结果两组术前各项检查指标差异无统计学意义。常温体外循环下甲状腺素T3升高水平低于中低温,恢复时间比中低温明显缩短。结论常温体外循环心脏直视手术对甲状腺素的影响显著轻于低温组,因而术后机体的恢复优于低温方法。     

Off-pump coronary revascularization attenuates transient renal damage compared with on-pump coronary revascularization

STUDY OBJECTIVES: Cardiopulmonary bypass (CPB) represents a specific risk factor for renal damage during coronary revascularization. The purpose of this study was to compare the perioperative renal damage in patients undergoing on-pump and off-pump coronary surgery. DESIGN AND PATIENTS: The progress and extent of renal damage was prospectively studied in two groups of patients undergoing cardiac surgery without concomitant morbidity, undergoing elective coronary revascularization with (n = 12) and without (n = 10) CPB. Markers of glomerular function (creatinine clearance) and damage (microalbuminuria), and markers of tubular function (fractional excretion of sodium [FENa] and free water clearance) and damage (N-acetyl-beta-D glucosaminidase [NAG]) were evaluated. Measuring plasma concentrations of free hemoglobin assessed hemolysis. Plasma and urinary specimens were obtained at the following points: (1) baseline; (2) heparinization; (3) the end of CPB or completing graft for off-pump surgery; (4) skin closure; (5) the sixth hour in the ICU; and (6) the second postoperative day. Free water and creatinine clearances, FENa, and the urinary excretion of microalbumin and NAG were calculated for the corresponding time intervals. SETTING: University hospital. RESULTS: We found that off-pump coronary revascularization induced significantly less changes in microalbuminuria, FENa, free water clearance, NAG, and free hemoglobin as compared with operations with CPB. Markers returned to baseline within 2 days after the operation, and there was no clinical or laboratory evidence of overt renal dysfunction in both groups. CONCLUSION: Off-pump coronary surgery attenuates transient renal injury compared with traditional on-pump coronary artery bypass grafting.     

Simple active air evacuation procedure for right ventricular failure caused by intracoronary air embolism

In cardiac surgical cases such as valve replacement, right ventricular failure caused by intracoronary air embolism sometimes occurs after aortic declamping and during weaning from cardiopulmonary bypass (CPB). The details are reported of a de-airing method which involves simply rotating the arterial cannula towards the base of the heart, with no need for a particular circuit. This method was used in ten patients who, following open-heart surgery, suffered postoperative right ventricular failure due to air embolism in the right coronary artery that did not respond to other de-airing methods. The technique resolved the problem in all patients, who were quickly weaned from CPB and ultimately discharged. Rotation of the arterial cannula may represent a simple means of resuscitating patients who have suffered right ventricular dysfunction that is unrelieved by other, conventional methods.