体外循环术后精神障碍的临床分析

目的:探讨体外循环(CPB)术后精神障碍的临床特征、病因和防治。方法:回顾性分析641例CPB心脏直视手术后并发各种类型的精神障碍31例临床资料。结果:本组CPB术后精神障碍发生率为4.83%(31/641),主要表现为抑郁状态14例(45.16%)。谵妄状态11例(35.48%)。经过治疗26例治愈,5例死亡。结论:CPB导致的脑损害是精神障碍的主要原因,应积极预防和综合治疗。     

体外循环术后成人呼吸窘迫综合征的研究进展

心脏直视术后肺功能的改变与体外循环（ｃａｒｄｉｏｐｕｌｍｏｎａｒｙ ｂｙｐａｓｓ,ＣＰＢ）的应用有关,ＣＰＢ后成呼吸窘迫综合征（ａｄｕｌｔ ｒｅｓｐｉｒａｔｏｒｙ ｄｉｓｔｒｅｓｓ ｓｔｎｄｒｏｍｅ,ＡＲＤＳ）的发生率为０．２５％￣１．３％,死亡率在４０％以上,最高达９１．６％＾「１」。随着分子生物学、免疫学和药理学等学科的迅速发展。体外循环后ＡＲＤＳ的发生机理得到了进一步的认识,其预防和治疗措施     

开塞露肛注治疗体外循环术后尿潴留

20 0 0年 7月至 2 0 0 2年 5月 ,我院施行体外循环手术10 2 7例 ,术后都给予 5小时至数日 (多为 15～ 36小时 )导尿。对于拔除尿管后 6～ 8小时有尿意而不能自行排出者 ,我们给予诱导 (听流水声、腹部热敷、按摩、协助站立及蹲位等 )方法协助排尿 ,但仍有 115例 (男 88例 ,女 2 7例 )经以上处理无效而发生尿潴留 ,发生率为 11.2 %。方法与结果 :给予开塞露 2 0～ 30 ml肛注。患者取侧卧位 ,剪开开塞露封口 ,挤出一滴润滑尖端及肛周 ,轻轻插入 ,将全部挤入肛管 ,忍耐 5分钟。在便意急迫时 ,取便于用力的排便姿势 ,同时嘱患者做排便动作。本组…     

体外循环相关性肺损伤及其预防

肺损伤是体外循环术后常见的并发症之一。近年来 ,动物实验和临床对体外循环相关肺损伤的机制及其预防进行了大量的研究 ,旨在防止体外循环引起的肺损伤 ,保护肺功能。本文就近年来这方面的研究作一综述     

体外循环术后患者的心理状态分析及护理对策

目的：通过对体外循环术后患者心理状态调查,并分析其原因,及时给予相应的护理措施,从而使患者更积极主动的配合治疗,增进康复速度,减少住院时间.方法：使用精神症状评定量表筛选2009年10月至2010年10月心胸外科体外循环术后出现精神障碍的86例病人,在给予药物治疗的同时针对患者精神障碍的不同类型选择个体化的护理措施.结果：被调查对象均有不同程度和类型的焦虑、恐惧、情绪低落等精神症状,部分患者存在幻觉、被害妄想等精神病性症状.结合抗焦虑、镇静、催眠等药物治疗的同时,选择个体化的护理措施,取得了良好的临床效果.     

中医心理卫生保健预防精神障碍的基本原则与方法

中医早在《内经》就提出“未病先防，既病防变”的预防医学思想，重视和畅情志，摄养心身，性命双修，创造了一套具有民族特色且行之有效的心理卫生原则和方法。应用如豁达法、松弛法、节怒法、平心法、自悦法等许多自我控制或调节情绪的方法，对预防精神障碍的发生起到了积极的作用。     

体外循环后全身毛细血管渗漏综合征

体外循环后全身毛细血管渗漏综合征表现为术后早期全身性水肿、胸腹腔渗液、低血氧等。目前认为该病的发病机制为体外循环诱发全身炎症反应，导致毛细血管内皮受损，以及体外循环期间胶体渗透压和静水压平衡改变，使大量液体渗漏到组织间隙。     

小儿法乐四联症体外循环术后灌注肺的治疗

本文总结7例4～12岁小儿四联症体外循环下根治术后并发灌注肺的4例治愈经验。体外循环心内直视手术时可因多种原因损伤肺血管床,使微血管壁通透性增加,液体渗出,肺泡萎陷,肺内分流增加,通气/血流比失调,表现为进行性低氧血症,呼吸衰竭及血痰。在四联症病人肺内侧支循环多,体外循环心脏血流阻断时间较长等因素更易诱发灌注肺。灌注肺一旦发生,起病急,进展快,预后差,应积极采取预防及治疗措施,本组经验包括:术前注意及时纠正胸、肺疾患,改善心肺功能,术中定期肺内充气,保证优良左心引流,体外循环系统采用微孔过滤器防止微栓栓塞及缩短体外循环和手术时间。术中、术后若有明显呼吸困难、发绀、血痰、低氧血症,用呼吸器仍难以改善且血压低,即应考虑有灌注的存在,尽早采取:1.保持气道通畅,适时吸去血痰:2.适当采用呼气末正压(PEEP)辅助呼吸;3.输用微孔过滤器过滤的新鲜血:4.控制液体入量,纠正低旦白,减少水肿;5.肝素治疗;6.应用激素:7.纠正水、电、酸碱失衡:8.适当用血管扩张剂减轻循环阻力,佐以强心、利尿、抗感染及全身支持疗法。应用 PEEP 时应注意血容量充足,以免产生低血压、低心排综合症,避免长期缺氧酸中毒而诱发严重心律紊乱,及防止其它并发症如急性肾功能衰竭等而致死亡。     

精神障碍病人的康复治疗

精神疾病的康复治疗也随着医学模式的改变而不断增添新的内容,且日益受到人们的重视,其不断完善、发展及推广应用,为精神病治疗学开拓了一个较为光明的前景。1康复治疗的进程社会精神卫生服务,在我国已有40余年的历史,我国政府对精神疾病的防治和康复工作给予了极大的重视。195     

丙泊酚治疗老年急性术后精神障碍临床观察

将32例急性术后精神障碍(POP)的老年患者(年龄69~84岁,A SAⅡ~Ⅲ级)随机分为观察组和对照组各16例。观察组用注射泵持续静脉注射丙泊酚0.4m g/(kg.h),对照组注射咪唑安定0.05 m g/(kg.h),治疗时间均为12h。比较两组R am say镇静评分、治疗有效率、药物起效时间和停药后清醒时间,监测呼吸、循环相关参数,随访肝肾功能。结果观察组达到5分镇静程度者(14例)明显多于对照组(6例),P<0.01,精神状态改善率(94%)明显高于对照组(63%),平均起效时间和平均清醒时间明显短于对照组(P<0.01);两组用药后HR、Bp、SpO2、RR比用药前均明显下降(P<0.05),心电图及其他监测指标无异常。证实丙泊酚可用于治疗老年急性POP,其特点为提高睡眠质量,改善精神症状,副作用小。     

体外循环后血管麻痹综合征的诊治

目的 总结体外循环后血管麻痹综合征的诊断及其治疗经验。方法 1999年1月至2002年4月共发生6例体外循环后血管麻痹综合征，结合有关献，对体外循环后血管麻痹综合征的临床表现和治疗经验进行总结。结果 在体外循环后早期，6例均出现的以严重低血压伴血液动力学高排低阻为特征的现象。2例由于认识水平有限，治疗欠佳，逐步出现全身多脏器功能障碍，最终导致死亡。4例确诊后，立即开始大剂量收缩血管药物治疗，成功抢救后平顺出院。结论 体外循环后血管麻痹综合征的发生率不高，但是处理不当其后果是严重的，因此，在临床工作中对它要有充分的认识，做到判断准确、治疗及时。     

体外循环心脏术后消化系统并发症的防治进展

体外循环心脏术后消化系统并发症虽然发生率不高,但病死率却极高.体外循环期间多种因素导致消化系统血液供应减少、组织损伤、炎性介质大量释放,从而引起包括胃肠道出血、消化性溃疡、缺血性肠炎、胰腺炎、胆囊炎、肝衰竭等在内的消化系统并发症.严密观察患者临床表现并早期诊断予以干预,对患者的预后有重要帮助.本文就近年来体外循环心脏术后消化系统并发症的机制、危险因素及诊断治疗的进展予以综述.     

体外循环术后的超声监测

目的探讨体外循环术后超声监测的临床意义。方法采用超声诊断仪对107例体外循环心内直视手术患者术后早期行心脏、胸腔及肝脏扫查．根据病情变化每天或间隔1～2d检查1～2次。结果经超声检查发现心包填塞7例(6．5％),心肌收缩力减弱引起的低心排血量综合征8例(7．5％),二尖瓣置换术后感染性心内膜炎并瓣周漏1例(0．9％),胸腔积液51例(48.7％),术后肝脏反而增大者5例(4．7％)。经采取适当治疗措施后大部分患者好转．3例死于心肌收缩力减弱引起的低心排血量综合征。结论超声监测为部分体外循环术后心肺并发症的早期诊断和正确处理提供了依据,特别是对心包填塞和心肌收缩力减弱引起的低心排血量综合征的鉴别诊断具有确诊价值,对观察术后心功能变化及指导临床用药具有重要意义。     

Central nervous system function after cardiopulmonary bypass

In a prospective study, an elderly group of patients (n = 63,47 male, 16 female, age 40–65 years) was examined beforeand after open-heart surgery under cardiopulmonary bypass: postoperatively,19 patients (30%) showed no clinical neuropsychiatric symptoms,whereas in 35 patients (56%) mild or transient neurologicalsigns and in nine (14%) severe neurological complications werefound. The postoperative EEG changes were characterized by a slightdelta-theta increase, an alpha decrease and a significant cantslowing of the dominant frequency from 9.7 to 9.3 Hz. In brainstemauditory evoked potentials no changes were found, and in somatosensoryevoked potentials (median nerve) the latency of the early corticalcomponent, N20, increased. Cardiovascular reflexes showed increasedchanges, similar to those found in autonomic neuropathies. Inthe neuropsychological test battery, the Visual retention test(Benton) and the Rorschach test showed slight postoperativeimprovement, whereas other psychometric variables (flicker fusionfrequency, reaction time) did not change. Despite an improvedoperative technique some minor clinical and neurophysiologicaldisturbances of the central nervous system remain. However,specific pre- or peri-operative risk factors for these postoperativedisturbances or complications could not be identified.     

Levosimendan for weaning from cardiopulmonary bypass after coronary artery bypass grafting

BACKGROUND: Although cathecholamines are well-established agents of myocardial support during weaning from cardiopulmonary bypass (CPB), there has been little experience with a new inotropic agent, levosimendan. Our aim was to present our experience with levosimendan usage in patients manifesting failure-to-wean from CPB after coronary artery bypass grafting (CABG) when conventional inotropic and intraaortic balloon counterpulsation (IABP) therapies proved to be insufficient. METHODS: Fifteen patients undergoing CABG received levosimendan as a loading dose of 12-24 microg/kg over 10 min, followed by a continuous infusion of 0.1-0.2 microg/(kg min) for 24h. Hemodynamic measurements were performed at baseline and at 1, 24 and 48 h postoperatively. RESULTS: Mean patient age was 63.2+/-2.2 years. CPB time was 149.7+/-19.5 min, while cross-clamp time was 67.8+/-10.5 min. All patients showed evidence of hemodynamic improvement with the start of levosimendan infusion and 14 patients (93.3%) were successfully weaned from CPB. Eight patients (53.3%) experienced significant increases in cardiac index and blood pressure leading to a lessening of the need for catecholamine support. Five patients (33.3%) were lost postoperatively in the ICU. CONCLUSION: Levosimendan appears to be useful in failure-to-wean from CPB after cardiotomy when conventional inotropic therapy proves inadequate.     

Factor XIIIA and clot strength after cardiopulmonary bypass.

Reduced factor XIIIA levels and decreased clot strength have been associated with increased bleeding after cardiopulmonary bypass (CPB). The purpose of this study was to evaluate the relationship between hemostatic factors, including factor XIIIA, and clot strength before, during and after CPB. Factor XIIIA antigen, platelet counts, fibrinogen, factor V activity, tissue plasminogen activator and clot strength (by thromboelastograph) were measured at baseline, after 45 min of CPB, at the end of CPB and 4 h post-operatively in 34 patients. Baseline factor XIIIA antigen was 5.2 +/- 1.4 mg/l. On average, factor XIIIA levels dropped to 64% and clot strength to 77% of baseline values after 45 min on CPB and remained below baseline during the immediate post-operative period. Clot strength was significantly correlated (r = 0.81) with platelet count and fibrinogen but not plasma factor XIIIA levels. Addition of 10 mg/l recombinant factor XIII[a2] significantly increased clot strength. Postoperative bleeding at 2 h was inversely correlated with platelet count, factor XIIIA antigen and clot strength measured at the end of CPB. Maintenance of adequate platelet counts and factor XIIIA levels at the end of CPB may play a role in maintaining clot strength and reducing blood loss.     

心脏病体外循环术后急性呼吸窘迫综合征的诊断与治疗

目的：探讨心脏病体外循环术后急性呼吸窘迫综合征（ARDS）的诊断,发病机理和治疗原则,方法：对86例体外循环后急性进行性呼吸窘迫综合征和难以纠正的低氧血症及时作出诊断,给予呼吸机辅助机械通气,降低肺毛细血管楔压,血管外肺水含量和维护心功能等治疗措施,结果：2例合并严重肾功能衰竭,3例术后ARDS导致多器官功能衰竭死亡,其余均痊愈出院,且远期随访均无肺损伤后遗症,结论：早期及时的诊断和积极有效的治疗是降低ARDS死亡率和提高治愈率的关键。     

Serum enzymes after cardiac surgery using cardiopulmonary bypass

Electrocardiographic and enzyme studies were made on an unselected series of 172 patients admitted to the intensive-care unit after cardiac surgery using cardiopulmonary bypass. Fifty-eight patients had aortic valve, 22 patients multiple valve, 40 patients mitral valve, 27 patients congenital, and 25 patients ischemic disease. There were five hospital deaths. The following observations were made preoperatively and on the first, second, and third postoperative days: 13-lead electrocardiograms, serum glutamic oxaloacetic transaminase, lactic dehydrogenase, creatine phosphokinase, and alkaline phosphatase. At least one further electrocardiogram was recorded later in the hospital stay. In 88 of the patients, isoenzymes of LDH were measured. Details of surgical technique and the postoperative course were recorded in each patient.SGOT and LDH values were elevated in all groups but were highest in patients with aortic- and multiple-valve disease. LDH isoenzyme patterns were typical of myocardial damage in only a small number of patients with high total enzymes. There was no relationship between high enzyme levels and age, hemolysis during bypass, or postoperative complications, but a correlation between enzyme levels and cardiopulmonary bypass time was shown in patients in the aortic and congenital groups and between enzyme levels and aortic cross-clamping time in patients in the aortic and mitral groups.Twenty-seven out of 34 patients with a peak postoperative SGOT level equal to or greater than 200 units per milliliter showed electrocardiographic evidence of myocardial damage but only nine out of 138 patients with SGOT levels less than 200 units per milliliter showed such evidence. All but one patient in the aortic and multiple groups showing myocardial damage had an SGOT level equal to or greater than 200 units per milliliter, but SGOT levels in patients in the mitral, congenital, and ischemic groups showing myocardial damage were usually around 100 units per milliliter. Myocardial damage was more common in the aortic, multiple, and ischemic groups. In patients in the aortic group prolonged ventricular fibrillation during operation was associated with high postoperative enzyme levels but this was largely explained by faulty coronary perfusion in some patients.It is concluded that postoperative elevation of serum enzymes is, in part, an inevitable consequence of cardiopulmonary bypass but exceptionally high levels usually indicate myocardial damage. Routine recording of electrocardiograms, serum SGOT, and serum LDH levels on the first two postoperative days is recommended for all patients.