非标准状态下脉压变异率评估患者容量反应性的研究进展

容量反应性是目标导向液体治疗(GDFT)的核心,脉压变异率(PPV)反映每搏输出量随呼吸的变化,能够准确评估患者的容量反应性。然而,PPV监测依赖于心肺相互作用,测量时有严格的条件限制。PPV测量的标准状态要求患者接受机械通气,潮气量至少为预测体重(PBW)8 ml/kg,同时不合并自主呼吸、低肺顺应性、心律失常、胸腔开放、腹内高压和高呼吸频率等,不完全满足上述测量条件时测得的PPV则为非标准状态下PPV。临床上多数患者不满足PPV测量的标准状态,因此如何保证非标准状态下PPV应用的有效性成为当前临床研究的热点。本文综述了PPV的原理以及非标准状态下PPV的临床应用等内容,为临床合理使用PPV监测提供参考。     

目标导向液体治疗在B型主动脉夹层患者冠状动脉搭桥手术中的疗效分析

目的 探讨目标导向液体治疗在B型主动脉夹层患者冠状动脉搭桥手术中的疗效。方法 收集2019年6月至2022年6月于河北医科大学第一医院接受冠状动脉搭桥手术治疗的82例B型主动脉夹层患者的临床资料,按照治疗方法的不同将其分为观察组(n=50,采用目标导向液体治疗)与对照组(n=32,采用常规液体治疗)。比较两组患者术前30 min(T₀)、麻醉诱导后15 min(T₁)、术中l h(T₂)、术中2 h(T₃)、术毕(T₄)时脑氧饱和度(rSO₂)、中心静脉血氧饱和度(ScvO₂)、容量负荷指标[心排血量(CO)、每搏量变异度(SVV)]、血流动力学指标[平均动脉压(MAP)、心率(HR)、心排血指数(CI)、中心静脉压(CVP)]、血乳酸(LAC)水平及术后并发症发生情况。结果 两组患者手术时间、术中低体温、术中出血量比较,差异均无统计学意义(P﹥0.05)。T₂～T₄时,观察组患者CO、rS...     

目标导向容量治疗对冠状动脉旁路移植术患者全身炎性反应和早期预后的影响

目的探讨围术期目标导向容量治疗(goal—directed therapy,GDT)对体外循环(cardiopulmonary bypass,CPB)下冠状动脉旁路移植术(coronary artery bypass grafting,CABG)患者全身炎性反应和早期预后的影响。方法择期行体外循环下CABG的患者60例,随机分为G、C两组,每组各30例。G组患者在脉搏指数连续心排血量(pulse—indicated continuous cardiacoutput,PICCO)监测指导下行GDT;C组患者根据平均动脉压(MAP)、中心静脉压(CVP)、心率(HR)、尿量等指标进行液体治疗。分别于麻醉诱导前(T_0)、转流结束时(T_1)、术毕(T2)、术后6小时(T_3)、24小时(T_4)等5个时间点采取动脉血,测定白细胞介素(IL)—6、肿瘤坏死因子(TNF)—α及Toll受体4(TLR4)的浓度,并行血气分析监测Lac及氧合指数(OI)值。结果与T_0比较,T_1~T_3时两组患者IL—6、TNF—α、TLR4以及血乳酸(Lac)的浓度均明显升高,OI值明显降低(P0.05);T_1~T_3时G组IL—6、TNF-α、TLR4以及Lac的浓度均明显小于C组,而OI明显大于C组(P0.05);G组患者气管导管留置时间、ICU停留时间和术后总住院时间均明显短于C组(P0.05)。结论 GDT可减轻体外循环下CABG患者围术期的全身炎性反应,有利于改善患者的早期预后。     

目标导向液体治疗对脑膜瘤切除术患者脑氧代谢的影响

目的比较目标导向液体治疗(GDFT)与常规输液方法对脑膜瘤切除术患者围术期脑氧代谢的影响。方法择期行仰卧位脑膜瘤切除术患者28例,随机分为两组:GDFT组(G组,n=15)和常规输液组(C组,n=13)。G组补偿性扩容量于麻醉诱导前30min内补充,术中以胸腔内血容积指数(ITBI)在800～1000ml/m2范围内为导向目标。采集动脉血与颈内静脉球部血检测血氧饱和度(SaO2、SjvO2)血氧分压(PaO2、PjvO2)、血氧含量(CaO2、CjvO2)、脑氧摄取率(CERO2)及乳酸含量(aLac、jvLac)。结果与诱导前比较,术中两组CaO2与CjvO2明显下降,而aLac与jvLac明显上升(P<0.05),且术中C组aLac和jvLac明显高于G组(P<0.05)。结论脑膜瘤切除术围术期以ITBI实施GDFT,能稳定心指数,维持有效循环血容量,从而保证脑灌注、改善微循环,降低脑乳酸生成率,不影响脑氧供需平衡。     

目标导向液体治疗对胰-肾联合移植患者预后的影响

目的探讨目标导向液体治疗对胰-肾联合移植患者预后的影响。方法选取胰-肾联合移植患者100例,男85例,女15例,年龄18～64岁,ASAⅢ或Ⅳ级。根据治疗方法随机分为两组:传统液体治疗组(C组)和目标导向液体治疗组(G组),每组50例。C组术中维持CVP 8～12 mmHg, MAP80 mmHg。G组术中根据目标导向液体治疗原则使SVV13%,CI2.5 L·min~(-1)·m~(-2),MAP80 mmHg。记录术中补液总量、尿量。记录麻醉前(T_0)、麻醉后10 min(T_1)、肾脏再灌注后10 min(T_2)、胰腺再灌注后10 min(T_3)、术毕即刻(T_4)的MAP。记录术毕的CVP值和血浆脑钠肽(BNP)。监测术前、术后第1、3、5、7天的血淀粉酶、空腹血糖、血肌酐清除率。记录术后外源性胰岛素使用时间、术后首次肛门排气时间和住院期间并发症的发生情况。结果与C组比较,G组术中补液总量、尿量明显增多(P0.05),T_2—T_4时MAP明显增高(P0.05),术后第1天血淀粉酶和空腹血糖明显降低(P0.05),术后第7天血肌酐清除率明显升高(P0.05),术后胰岛素使用时间和首次肛门排气时间明显缩短(P0.05)。术毕两组CVP、BNP、住院期间并发症发生率差异无统计学意义。结论与传统液体治疗比较,目标导向液体治疗有利于维持胰-肾联合移植术中循环稳定、改善移植器官灌注、加快移植器官及肠道功能恢复。     

目标导向液体治疗联合甲氧明对创伤性脑损伤患者围术期的影响

目的评估目标导向液体治疗(GDFT)联合甲氧明对创伤性脑损伤(TBI)手术患者围术期的影响。方法选择2019年1—12月收治的24 h内入院的TBI手术患者60例,男42例,女18例,年龄18~64岁,BMI<28 kg/m²,ASAⅡ—Ⅳ级。采用随机数字表法分为两组:GDFT联合甲氧明组(GM组)和GDFT组(G组),每组30例。两组均以每搏量变异度(SVV)为目标导向进行补液。GM组于麻醉诱导后持续泵注甲氧明1.5~4.0μg·kg^-1·min^-1至术毕;G组泵注等容量生理盐水。记录晶体输注量、胶体输注量、总输液量、红细胞输注量、血浆输注量、总输血量、尿量和出血量。记录麻醉诱导后(T₀)、切开硬脑膜时(T₁)、切开硬脑膜后1 h(T₂)、术毕(T₃)、术后12 h(T₄)的HR和MAP。记录术中去甲肾上腺素使用例数。T₀—T₄时采集桡动脉及颈内静脉球部血样行血气分析,记录颈内静脉球部血氧饱和度(SjvO₂)和颈内静脉乳酸(jvLac)浓度,计算动静脉血氧含量差(Da-jvO₂)及脑氧摄取率(C_ERO₂)。T₀—T₄时采集颈内静脉球部血样,采用ELISA法检测血清S100β蛋白和神经元特异性烯醇化酶(NSE)浓度。分别于术前、术后1、3、5、7 d评估格拉斯哥昏迷量表(GCS)评分。出院前采用格拉斯哥预后评分(GOS)评估术后早期生存质量。记录住院时间以及术后切口及颅内感染、脑积水、脑梗死、脑脊液漏、心肌梗死、肺炎等并发症的发生情况。结果与G组比较,GM组晶体输注量、胶体输注量、总输液量明显减少;T₁—T₃时MAP明显升高;术中去甲肾上腺素使用率明显降低;T₁—T₄时SjvO₂明显升高,Da-jvO₂、C_ERO₂明显降低;T₃时jvLac浓度明显降低;T₄时S100β蛋白、NSE浓度明显降低;术后3、5、7 d GCS评分明显升高(P<0.05)。两组红细胞输注量、血浆输注量、总输血量、尿量、出血量、不同时点HR、出院前GOS评分、住院时间以及术后并发症发生率差异无统计学意义。结论目标导向液体治疗联合甲氧明用于创伤性脑损伤手术患者,可以优化临床输液方案,稳定血流动力学以及改善脑组织氧供需平衡,从而改善患者预后。     

无创评估容量反应性的临床应用进展

容量评估与干预是围术期患者安全管理的一项重要因素,可以影响患者最终转归。无创评估容量反应性具有简便、快速、创伤小、患者更易配合等特点,是进行个体化液体治疗的基础,近些年临床应用广泛。本文从基于心肺交互作用的评估指标、基于容量负荷的评估方法两方面对常用的无创评估容量反应性的方法进行阐述,为临床应用提供参考。     

常温不停跳冠状动脉搭桥术对机体氧供需的影响

目的：研究常温心脏不停跳冠状动脉搭桥术对机体氧供需平衡的影响。方法：16例冠心病患者，在咪唑安定，芬太尼，丙泊酸，维库溴铵及异氟醚静吸复合麻醉下，心脏不停跳行冠状动脉搭桥手术，术中监测ECG，SpO2及血液动力学指标。于冠脉血管吻合前后，分别取挠动脉及肺动脉血，测定血红蛋白（Hb)和动脉血氧饱和度（SaO2)，并计算全身氧供需平衡，结果：冠状动脉搭桥前后CaO,CvO2,DO2,VO2,O2ER,A-aDO2等均无明显变化（P＞0．05），CO搭桥后比搭桥前增加，但无显著性差异，结论：常温心脏不停跳冠状动脉搭桥手术对全身氧供需平衡没有明显影响。     

硝普钠在冠状动脉搭桥手术中对脑血流速度的影响

目的 研究硝普钠在冠状动脉搭桥手术中对脑血流速度的影响及在提高大脑供血供氧方面的意义。方法 选择ASAⅡ～Ⅲ级,择期行冠状动脉搭桥手术的患者24例。麻醉诱导后行桡动脉和颈内静脉穿刺置管,颈内静脉留置管放于颈静脉球部。分别在心肺转流(CPB)前(T_1)、CPB初期泵入硝普钠前(T_2)及泵入硝普钠10min后(T_3)三个时相监测下列指标:(1)使用彩色多普勒超声(TCD)测定大脑中动脉的血流速度(CBFV),并计算其搏动指数(PI)和阻力指数(RI);(2)动脉及颈静脉球部血气(SaO_2,SjvO_2),并计算出氧摄取率(COE);(3)平均动脉压(MAP);(4)中心静脉压(CVP)。结果 CPB期间应用硝普钠后,尽管MAP从(65.8±10.8)mmHg降为(47.5±4.8)mmHg(下降27.8％),但大脑中动脉的血流速度由(40.8±6.8)cm/s升高至(43.9±7.6)cm/s(上升7.6％)(P<0.01),搏动指数和阻力指数也有明显下降(P<0.01),而COE未见明显差别(P>0.05)。结论 体外循环期间硝普钠的血管扩张效应尽管在一定程度上降低MAP,但由于脑血管阻力降低、脑血流加速而增加全脑血流量,对脑代谢无不良影响。     

每搏输出量变异度对预测术中液体反应性的指导价值

背景 鉴于越来越多的研究表明中心静脉压(central venous pressure,CVP)等静态血流动力学指标在预测液体反应性方面的不准确性及不实时性,每搏输出量变异度(stroke volume variation,SVV)作为一个功能性血流动力学指标日趋受到重视. 目的 探讨SVV预测术中液体反应性的可靠性及指导价值,为目标靶向治疗提供依据. 内容 综述其基本原理、测量方法、影响因素、不同手术中的应用价值和局限等. 趋向 SVV预测液体反应性的价值日趋受到重视,很可能会替代CVP而成为新的容量预测指标.     

Reoperative coronary artery bypass grafting using a minimally invasive direct coronary artery bypass procedure

OBJECTIVE: Reoperative coronary artery bypass grafting with cardiopulmonary bypass tends to cause a higher mortality and morbidity than the primary operation. The purpose of this study was to discuss the effectiveness and safety of a minimally invasive coronary artery bypass procedure for patients who had previously undergone coronary artery bypass surgery. METHODS: We performed redo single coronary artery bypass grafting to the left anterior descending coronary artery in 9 patients and to the right coronary artery in 3 patients using minimally invasive cardiac surgery. The graft to the left anterior descending coronary artery was taken from the left internal thoracic artery in 5 patients, the right gastroepiploic artery in 3 patients, and from the saphenous vein in the other 1 patient. The graft to the right coronary artery was from the right gastroepiploic artery in all 3 patients. RESULTS: All grafts were patent. There was no major postoperative complication and no surgical or hospital death except one late death. CONCLUSIONS: In selected patients, we could safely and completely perform coronary artery bypass re-grafting to the left descending coronary artery or right coronary artery using a minimally invasive operation.     

The superiority of pulmonary function after minimally invasive direct coronary artery bypass

OBJECTIVE: We determined whether minimally invasive direct coronary artery bypass (MIDCAB) leads to excellent postoperative pulmonary function, and which contributes more to this--minithoracotomy or avoidance of cardiopulmonary bypass. METHODS: Pulmonary function 1 week before and 2 weeks after surgery was evaluated in 8 patients undergoing MIDCAB (Group M), 10 undergoing off-pump coronary artery bypass (Group O), and 12 undergoing conventional coronary artery bypass grafting (Group C). Parameters were adjusted by their predicted values and postoperative values were expressed as a ratio to preoperative ones. RESULTS: Only Group M maintained postoperative vital capacity and forced expiratory volume in 1 second close to the preoperative level and thus, showed significantly better recovery than Groups O and C. No significant difference was seen between Groups O and C. CONCLUSIONS: MIDCAB provides better recovery of pulmonary function early postoperatively than other procedures thanks to minithoracotomy rather than avoidance of cardiopulmonary bypass.     

应用Port-Access系统行微创冠状动脉旁路移植术21例体会

目的　介绍应用Port-Access系统进行微创冠状动脉旁路移植术的体会。　方法　采用左胸小切口 (6～ 7)cm ,经股静脉插静脉管 ,经升主动脉或股动脉插动脉管 ,主动脉内球囊阻断的方法 ,行微创冠状动脉旁路移植术。　结果　本组 2 1例无手术死亡 ,无重大并发症。　结论　应用Port-Access系统进行微创冠脉搭桥手术是一种安全可靠的手术方法 ,可以避免胸骨切开 ,减轻疼痛 ,利于患者后恢复。     

Minimally invasive coronary artery bypass grafting via a small thoracotomy versus off-pump: a case-matched study

Objective: The minimally invasive coronary artery bypass grafting (MICS CABG) operation performed via a small thoracotomy has not previously been examined in a direct comparison to sternotomy off-pump coronary artery bypass grafting (OPCAB). Methods: We matched, according to age, gender, left ventricular function, and median number of distal anastomoses, 150 patients who underwent MICS CABG via small left thoracotomy, and 150 patients who received sternotomy OPCAB. All operations were performed by the same surgeon. Results: There was no perioperative mortality (0/300). In the MICS CABG group, pump assistance was used in 28/150 (19%) patients, and conversion to sternotomy occurred in 10/150 (6.7%) patients. In the OPCAB group, conversion to on-pump occurred in 3/150 (2.0%) patients. There were four (2.7%) reoperations for bleeding and one (0.7%) for anastomotic revision in each group. The median hospital length of stay was 5 days for MICS CABG (average 5.4), and 6 days for OPCAB (average 7.2) (P = 0.02). New-onset atrial fibrillation occurred in 35 (23%) MICS CABG patients and in 42 (28%) OPCAB patients (P = 0.3). No wound infection occurred with MICS CABG versus six (4.0%) with OPCAB (P = 0.03). A self-limiting left pleural effusion developed in 22 (15%) MICS CABG patients and in six (4.0%) OPCAB patients (P = 0.002). The median time to return to full physical activity was 12 days in MICS CABG patients versus >5 weeks in OPCAB patients (P < 0.001). Conclusions: MICS CABG is a valuable alternative for patients in need of multivessel CABG. The operation appears at least as safe as OPCAB, and associated with shorter hospital length of stay, less wound infections, and faster postoperative recovery than OPCAB.     

微创冠状动脉旁路移植手术33例报告

目的探讨微创冠状动脉旁路移植手术(minimally invasive direct coronary artery bypass graft,MIDCABG)的可靠性及安全性. 方法 2001年3月～2003年9月,我院在全麻、非体外循环、心脏不停跳下进行了33例单支MIDCABG.14例采用左前外侧小切口,19例采用胸骨下段正中切口.31例行左乳内动脉至前降支旁路移植,1例使用大隐静脉行主动脉根部至前降支旁路移植,1例行胃网膜右动脉至后降支旁路移植. 结果全组无手术死亡.术中出血量(163±120)ml,术后引流量(193±169)ml,术后拔管时间(6.4±5.5)h,ICU时间(17.8±4.4)h.随访(14.7±7.4)月,无死亡. 结论 MIDCABG安全可靠,具有创伤小、出血量少、并发症少的优点.     

143例微创冠状动脉旁路移植术有效性和安全性的倾向性评分匹配研究

目的 对比微创冠状动脉旁路移植术(minimally invasive coronary artery bypass grafting,MICABG)和常规开胸搭桥围术期临床效果,分析MICABG的有效性和安全性.方法 收集2017年1月至2020年9月北京安贞医院单医疗组接受不停跳冠状动脉旁路移植术患者共543例,其...     

Reoperative minimally invasive axillocoronary artery bypass to the obtuse marginal branch

A 73-year-old man was admitted with unstable angina, having severe coronary artery disease involving 3 vessels. He had undergone coronary artery bypass grafting to the left anterior descending artery and the obtuse marginal branch using saphenous vein grafts in 1979. Computed tomography showed severe calcium deposition and atherosclerosis in the ascending and descending aorta. We conducted axillocoronary artery bypass to the obtuse marginal branch and left internal thoracic artery as an in situ graft to the left anterior descending artery without cardiopulmonary bypass. Grafts were satisfactory and clinical results good.     

微创冠状动脉旁路移植术处理前降支病变的围术期结果

目的研究胸腔镜辅助下经左胸小切口微创直视下冠状动脉旁路移植术(minimally invasive direct coronary artery bypass grafting,MIDCAB)处理前降支病变的围术期结果及其安全性。方法回顾性分析2014年5月至2018年10月在我院接受MIDCAB 92例患者的临床资料,其中男72例(78.26%),年龄42~78(61.29±7.48)岁,女20例(21.74%),年龄30~80(61.30±12.26)岁。分析围术期并发症发生率、血制品使用情况、左心功能变化情况、呼吸机使用时间、住ICU时间及住院时间等指标。结果2例(2.17%)患者中转正中开胸手术,5例(5.43%)术中输入血液制品,2例(2.17%)二次开胸止血,4例(4.34%)术后低氧血症,1例(1.08%)再次气管插管。呼吸机使用时间3~227(22.35±35.39)h,住ICU时间16~777(78.85±108.62)h,术后住院时间2~36(8.86±6.05)d。住院死亡1例(1.08%)。结论MIDCAB处理前降支病变具有较好的围术期结果,尤其适用于孤立性前降支病变,可缩短术后呼吸机使用时间、减少血液制品使用、缩短住ICU时间及住院时间。     

Hybrid revascularization feasibility in minimally invasive direct coronary artery bypass grafting combined with percutaneous transluminal coronary angioplasty in patients with acute coronary syndrome and multivessel disease

OBJECTIVES: We reviewed early and midterm outcome of 11 multivessel-disease acute coronary syndrome patients treated by hybrid revascularization, i.e., initial coronary angioplasty followed by minimally invasive direct coronary artery bypass grafting. We evaluated procedural efficacy and applicability. METHODS: Beginning in August 1997, hybrid revascularization was conducted in 11 multivessel-disease acute coronary syndrome patients--9 men and 2 women with a mean age of 70.3 +/- 9.3 years. Occlusion or stenosis of the target coronary artery was treated by interventional cardiologic techniques and minimally invasive direct coronary artery bypass grafting, and the early and midterm outcome evaluated. Coronary angiography was conducted in all cases at 2 weeks, 6 months, 1 and 3 years postoperatively to evaluate anastomosis and restenosis in treated coronary vessels. RESULTS: Initial intervention succeeded in patients with minimal residual stenosis. Subsequent minimally invasive direct coronary artery bypass grafting involved no complications. Coronary angiography early postoperatively, 6 months, 1 and 3 years later showed grafts patent without stenosis. Percutaneous transluminal coronary angioplasty was reconducted on restenotic lesions in 3 patients, 1 of whom required 3 procedures. CONCLUSIONS: Hybrid revascularization appears safe and effective in coronary revascularization, at least over the short term. Several patients underwent angioplasty for restenosis within 3 years after initial procedure. Overall acceptance of this hybrid method depends on long-term functional success of the 2 procedures. Its major limitation is restenosis of angioplasty sites and the need for repeat procedures.