S100蛋白与心脏外科手术后的脑损伤

心脏手术后使用血清标记物辅助诊断脑损伤是十分有必要的。S100蛋白是脑损伤的早期标志,对判断CPB术后脑损伤的时间和程度有很大帮助。现就S100蛋白在心脏外科手术中的变化及其对CPB术后脑损伤诊断的意义作一综述。     

Spinal Anesthesia with an Indwelling Catheter Reduces the Stress Response in Pediatric Open Heart Surgery

Background: Extreme stress and inflammatory responses to open heart surgery are associated with increased morbidity and mortality. Based on both animal and adult human data, it was hypothesized that spinal anesthesia would be more effective at attenuating these responses than conventional high dose intravenous opioid techniques in infants and young children undergoing open heart surgery.

Methods: A prospective randomized controlled clinical trial was performed in 60 children aged up to 24 months undergoing open heart surgery. Patients were randomly assigned to receive either high-dose intravenous opioid or high-dose intravenous opioid plus spinal anesthesia. Spinal anesthesia was administered via an indwelling intrathecal catheter.

Results: Spinal anesthesia significantly reduced the stress responses as measured by plasma norepinephrine and epinephrine concentrations (both P < 0.05). Spinal anesthesia reduced plasma lactate concentrations (P < 0.05), but increased fluid requirements during the first postoperative day (P < 0.05). There were no differences in other cardiovascular parameters.     

婴幼儿体外循环心脏手术少用血的探讨

为探讨深度血液稀释及剩余机血回输在婴幼儿心脏手术应用的安全性。选择２０例婴幼儿室间隔缺损修补术者，随机均分为对照组（Ａ组）和观察组（Ｂ组）。Ａ组采用中度血液稀释（ＨＣＴ０．２０～０．２５），体外循环结束后不回输剩余机血；Ｂ组应用深度血液稀释（ＨＣＴ０．１５～０．２０）和剩余机血回输方法。结果Ｂ组围术期异体库血用量较Ａ组减少６０％，病儿全部顺利康复。作者认为，深度血液稀释及机血回输是减少体外循环心脏手术库血用量切实有效的方法，只要加强围术期综合管理，对婴幼儿也是安全可行的。     

应用血液保护综合措施减少体外循环心脏手术库血用量

为证实血液保护（ｂｌｏｏｄｃｏｎｓｅｒｖａｔｉｏｎ）综合措施的临床效果，本文对３３３例体外循环心脏直视手术病人围术期库血用量进行了统计分析。１３４例采取血液保护综合性措施者为实验组，其余的１９９例列为两个对照组，即１９９３年对照组（对照组Ⅰ，ｎ＝１２１）和１９９４年对照组（对照组Ⅱ，ｎ＝７８）进行比较。结果显示，实验组的围术期总体平均输血量（４５８±３６９ｍｌ）和输血＞１０００ｍｌ病人数（１２例，９％）明显少于对照组Ⅰ（１４３４±６７３ｍｌ，Ｐ＜０．００１；９８例，８１％，Ｐ＜０．００１）和对照组Ⅱ（１４１６±６５４ｍｌ，Ｐ＜０．００１；６０例，８３％，Ｐ＜０．００１）。实验组有２４例（１８％）病人于围术期未输库血，而对照组所有的病人均输了库血。这些结果表明，体外循环心脏手术期间采取上述综合措施能有效地减少库血需要量，从而降低因输血而引起的疾病的危险性。     

心脏手术体外循环中心包血回输对凝血系统功能的影响

目的探讨心脏手术体外循环（CPB）中心包血回输对凝血系统功能的影响及作用。方法将24例行二尖瓣置换术患者随机分为心包血回输组和心包血不回输组，每组12例。分别于术前5min、肝素化后10min、CPB30min和CPB结束时采集体循环血；CPB结束时同时采集心包血。用酶联免疫吸附分析（ELISA）法检测组织因子（TF）、D-二聚体（D—D）的血浆含量。结果两组体循环D—D和TF在CPB30min、CPB结束时分别较本组术前明显增高（P〈0．05）。心包血不回输组体循环D—D和TF在CPB30min、CPB结束时较心包血回输组明显降低，两组比较差异有统计学意义（P〈0．01）。两组心包血D—D和TF较同时循环血中D—D和TF明显升高（P〈0．05），全血激活凝血时间（ACT）缩短。结论直视心脏手术CPB中心包血可激活凝血系统，TF通过外源性凝血途径激活凝血系统。     

慢性肾功能不全病人行体外循环心脏直视手术围术期处理

探讨慢性肾功能不全病人行体外循环心内直视手术的危险性。方法：１９９３年３月到１９９７年６月间对术前诊断为氮质血症期１８例,肾功能不全代偿期４例,尿毒平期１例共２３现人,在心脏手术围术期均给予积极治疗。结果术后早期肾功能指标较术前差,围术期腹透４例,血透１例治疗后,肾功能指标有所改善。２０例昨出院３例死亡。结论术前肾功能不全病人绝大多数可以安全地渡过肾功能衰竭关,达到改善症状及提高生活质量的目的。     

经肺动脉输注三磷酸腺苷治疗小儿心脏术后肺动脉高压

目的探讨经肺动脉输注三磷酸腺苷（ａｄｅｎｏｓｉｎｅｔｒｉｐｈｏｓｐｈａｔｅ，ＡＴＰ）对心脏术后合并肺动脉高压患儿的肺血管扩张效应。方法对１３例确诊为室间隔缺损合并重度肺动脉高压患儿术后早期经肺动脉输入３０～１５０μｇ／ｋｇ．ｍｉｎ的ＡＴＰ，观察用药前后血流动力学参数的变化。结果与用药前相比，低剂量输入（３０～５０μｇ／ｋｇ．ｍｉｎ）ＡＴＰ，在不明显降低平均体动脉压（ＭＢＰ）的前提下，特异性的降低肺动脉压力（Ｐ＜０．０５）及肺血管阻力（ＰＶＲ）（Ｐ＜０．０１）；中－高剂量（１００～１５０μｇ／ｋｇ．ｍｉｎ）的ＡＴＰ，在明显降低平均肺动脉压（ＭＰＡＰ）（Ｐ＜０．０１）的同时，ＭＢＰ亦明显下降（Ｐ＜０．０１），ＰＶＲ与体循环阻力（ＳＶＲ）呈现相似的减低趋势。结论利用ＡＴＰ半衰期短的特点，自肺动脉直接输注ＡＴＰ，在一定剂量下可出现选择性的肺血管扩张效应     

Cerebral and extracerebral release of protein S100B in cardiac surgical patients

Although several clinical studies have shown that increased serum concentrations of protein S100B predict ischaemic brain damage after cardiac surgery, S100B may also be released from the heart or other injured tissue. We therefore investigated the correlation between serum S100B levels and those of the specific cardiac marker troponin I in order to assess the cerebral vs. extracerebral origin of S100B. In 64 cardiac surgical patients, serial blood samples were drawn for the measurement of S100B and troponin I before surgery and for seven days after surgery. Neurological function was assessed before with the National Institutes of Health Stroke Scale and the Folstein Mini Mental Test. The data show that a sustained increase in serum S100B levels is associated with neurological dysfunction, as witnessed by a positive correlation between S100B values and the results of the neuropsychological tests. In contrast, the early postoperative increased levels of protein S100B derive from cardiac tissue, as shown by the positive correlation between S100B and cardiac troponin I levels.     

单纯钾停跳氧合血持续灌注不降温心脏直视手术(附160例报告)

应用钾停跳、氧合血持续灌注心肌保护、不降温体外循环行心脏直视手术１６０例，手术均顺利，术后无低心排综合征、无严重心律失常发生。全组死亡２例（１．２５％）。部分病例进行了ＬＤＨ１／ＬＤＨ２、ＣＫ－ＭＢ及血清乳酸测定，与低温体外循环组比较无统计学明显差异（Ｐ＞０．０５）。作者认为，此方法临床效果满意，值得进一步研究、推广应用。     

4∶1液与微量晶体心停跳液在心内直视术中心肌保护的比较

９０例接受４∶１血液心停跳液和微量晶体心停跳液心肌保护心内直视手术病人，按设计的项目进行比较。阻断主动脉期间，两组病人冠状循环均连续灌注（顺灌或逆灌）从氧合器中引出并降温达８～１０℃的血液（红细胞压积０．２５左右）心停跳液，灌注量与速度相似。Ａ组（头２５例）用４∶１血液心停跳液连续灌注保护心肌；Ｂ组（后６５例）以高浓度晶体血液心停跳液连续灌注保护心肌。结果见两组病人术中心肌电机械活动抑制、心脏复苏、复苏后血液动力学稳定性、开放主动脉前冠状静脉血气分析、术后１、３、５天乳酸脱氢酶Ａ（ＬＤＨ－Ａ）检查均无明显差异。Ｂ组所用晶体停跳液量为Ａ组的５％（Ｐ＜０．０００１）；术中红细胞容积稳定，灌注装置简单，容量负荷低，停跳液用药少，是一种更理想的心肌保护法。     

S100B blood levels correlate with rewarming time and cerebral Doppler in pediatric open heart surgery

BACKGROUND: Brain hyperthermia, accompanying the rewarming phase of cardiopulmonary bypass (CPB), has been involved in the genesis of postoperative brain damage. Blood S100B levels are emerging as a marker of brain distress, and could offer a reliable monitoring tool at different times during and after open heart surgery. METHODS: Thirty-two patients undergoing repair of congenital heart disease with CPB and deep hypothermic circulatory arrest (DHCA) were monitored by S100B blood levels and middle cerebral artery Doppler velocimetry pulsatility index (MCA PI) before, during, and after surgical procedure at five predetermined time-points. RESULTS: Both S100B and MCA PI significantly increased, MCA PI values exhibiting a peak at the end of surgery time-point (p > 0.05), while S100B blood levels were increased at the end of CPB (p < 0.05). Multivariate analysis, with S100B levels measured at the end of CPB as dependent variable, showed a positive significant correlation with MCA PI (p = 0.04), with the CPB and the rewarming duration (p = 0.03 and p = 0.009, respectively). CONCLUSIONS: The present results show a significant correlation between a biochemical marker of brain damage and an index of increased cerebrovascular resistance, with higher levels during the rewarming CPB phase in pediatric open heart surgery.     

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     

维生素K1对小儿心内直视手术围术期凝血机制的影响

目的 小儿心内直视手术中应用维生素K1（Vitamin K1,Vit K1)，观察其对凝血因子的作用。方法 30例心脏手术患者分为3组，A组：动脉导管未闭患者；B组：使用VitK1治疗；C组：未使用VitK1治疗。每组各10例，分别检测A组术前、术后、B组、C组术前24小时、麻醉后开胸前、鱼精蛋白中和后10分钟、术毕、术后6小时、1天、3天和5天的血浆凝血酶原时间（PT）、激活部分凝血活酶时间（APTT）、凝血酶时间（TT）、X因子活性，纤维蛋白原含量和红细胞压积。结果 鱼精蛋白中和后10分钟血浆凝血酶原时间、激活部分凝血活酶时间、凝血酶时间最长，X因子活性、纤维蛋白原含量最低。与C组相比，B组术后24小时内血浆凝血酶原时间明显缩短，X因子活性明显升高。结论 术前应用Vit K1可明显提高术后早期凝血因子水平，有利于减少术后出血的发生。     

心脏不停跳手术中心肌NF-кB转录活性、ICAM-1的表达及其临床意义

目的 探讨心脏不停跳与心脏停搏手术对心肌核转录因子κB(NF-кB)转录活性、细胞间黏附分子-1(ICAM-1)表达水平的影响及其临床意义.方法 将40例先天性心脏病患者随机分为两组,每组20例.组Ⅰ:行心脏不停跳心内直视手术;组Ⅱ:行常规体外循环手术(灌注冷晶体心脏停搏液).两组患者均于心内操作前、后取右心房壁心肌组织检测NF-кB转录活性、ICAM-1表达水平,用透射电子显微镜观察心肌超微结构;分别于术前、主动脉开放或心内操作完成后1、24、48和72h测定两组心肌肌钙蛋白I(cTnI)、肌酸激酶同工酶MB(CK-MB),并对其结果进行比较.结果 术后组ⅠNF-кB转录活性、ICAM-1表达水平较术前无显著变化,组ⅡNF-кB转录活性较术前升高(P＜0.01);术后NF-кB转录活性组Ⅱ显著高于组Ⅰ(P＜0.01).术后两组血清cTnI、CK-MB水平较术前均有不同程度升高(P＜0.01),主动脉开放后/心内操作完成后各时点,组Ⅱ均显著高于组Ⅰ(P＜0.01).透射电子显微镜观察,组Ⅰ术后心肌超微结构无明显变化,组Ⅱ心肌损伤变化显著.结论 心脏不停跳下心内直视手术术后短期内心肌NF-кB转录活性、ICAM-1表达水平无明显变化,减轻了心肌缺血-再灌注损伤及由NF-кB激活而引起的心肌炎性反应,有较好的心肌保护效果.     

Less Blood Damage in the Impeller Centrifugal Pump: A Comparative Study with the Roller Pump in Open Heart Surgery

Abstract: A centrifugal pump with an impeller (Nikkiso Centrifugal Pump, Model HPM15; Nikkiso Co. Ltd.) was applied to cardiopulmonary bypass (CPB) in 14 patients who underwent elective coronary artery bypass grafting. Serum hemoglobin level, platelet count, and serum p-thromboglobulin (pTG) level were measured during CPB. The results were compared with those obtained in a comparative roller pump (RP) group (n = 10). There was no difference in the time on CPB between the NP (109 min) and RP (121 min) groups. The serum pTG level (ng/ ml) was lower in the NP group than in the RP group (obtained 90 min after the initiation of CPB). The plasma-free hemoglobin level also was lower in the NP group than in the RP group (obtained 90 min after the initiation of CPB, 120 min after the initiation of CPB, immediately after the termination of CPB, 3 h after termination of CPB; p < 0.01). There was no significant difference in platelet depletion. The HPM15 pump showed excellent hemodynamic performance with less blood trauma compared with the roller pump in its clinical application to open heart surgery.