Plasma carnitine concentrations in patients undergoing open heart surgery.

Carnitine is an essential cofactor for fatty acid (FA) metabolism, the predominant source of ATP in the normal aerobic heart. During myocardial ischemia, FA metabolism is impaired and tissue carnitine levels are depleted. Since the heart cannot synthesize carnitine, plasma carnitine could play an important role in maintaining myocardial carnitine levels during reperfusion. The purpose of this study was to determine the incidence of abnormal plasma carnitine concentrations in open heart surgery. Blood samples were obtained from eleven patients before, immediately after, and two hours after cardiopulmonary bypass (CPB). Total and free carnitine levels were significantly reduced immediately after CPB (p<0.01) and remained depressed until two hours after CPB (p<0.01 vs. pre CPB), while acyl carnitine levels were unchanged over the course of this study. These depressed free carnitine levels might affect cardiac metabolism in the heart after open heart surgery. Carnitine supplement might be a useful adjunct in the therapy after open heart surgery.     

Preoperative autologous blood donation in patients undergoing open heart surgery

We examined the possibility to avoid the homologous blood transfusion in patients undergoing open heart surgery by predonation of 200 ml or 400 ml on the day before operation. Between March 1999 and December 2001, 117 patients underwent scheduled open heart surgery. In these patients, preoperatively collected autologous blood on the day before operation amounted 200 ml or 400 ml. We divided these patients into 3 groups according to the necessity of homologous blood, no transfusion (group A, n = 77), intraoperative transfusion (group B 1, n-29) and postoperative transfusion (group B 2, n = 11). In 65.8% of patients the homologous blood transfusion could be avoided. Preoperative, intraoperative and postoperative factors were compared in the 3 groups. Especially, old age, female, body weight and preoperative hemoglobin value were significantly different between 3 groups. Postoperative Svo2 and postoperative hemoglobin value were significantly different between 3 groups. The purpose of this study was to evaluate that the predonation of 200 ml or 400 ml on the day before operation may be to avoid the homologous blood transfusion and that preoperative, intraoperative and postoperative factors in regard to homologous blood transfusion.     

心内直视术病人心率变异性的变化

目的　探讨麻醉和手术创伤对心脏自主神经系统的影响。方法　 2 0例心内直视术病人 ,采用静吸复合全麻 ,麻醉诱导药为安定、依托咪酯、芬太尼、阿曲库铵和琥珀胆硷。麻醉维持用 ( 0 .5～ 1.0 ) %异氟醚吸入 ,辅以芬太尼、阿曲库铵间断静注。手术过程中采用体外循环控制性降温 ,手术时间 ( 2 4 0± 5 0 )分 ,体外转流 ( 95± 4 3 )分 ,主动脉阻断 ( 72± 3 9)分 ,最低温度 ( 2 7± 2 .5 )℃。结果　未发现依托咪酯、芬太尼和异氟醚等麻醉药物对心率变异性造成的明显影响。体外转流开始后 ,L F、HF和TP明显下降 ,伴随体温降低 ,L F、HF和 TP进一步下降。升温复跳后 L F、HF和 TP下降更为明显 ,并持续至术毕 ,而 L F/HF在整个手术过程中无明显变化。结论　心脏手术中 ,体外循环、低温、主动脉阻断及药物等因素可导致心率变异性下降 ,而选择合理的麻醉药物和剂量 ,可以降低麻醉药物对心率变异性的影响     

Preoperative intraaortic balloon pumps in high-risk patients undergoing open heart surgery

BACKGROUND: The use of the preoperative intraaortic balloon pump (IABP) in patients with severe left ventricular dysfunction or unstable angina with critical coronary anatomy is becoming more frequent as surgical casemix changes. The aim of this study was to determine the impact of preoperative IABP use on survival in high-risk patients having open heart surgery. METHODS: Prospectively collected data for 645 consecutive patients were reviewed. Patients receiving an IABP were identified and grouped as follows: group A (preoperative IABP for high-risk nonemergent cases), group B (preoperative IABP for emergent cases), and group C (intra/postoperative IABP). Risk-adjusted hospital mortality rates in these three groups was compared using the modified Parsonnet score for preoperative risk stratification. RESULTS: IABPs were used in 101 cases (16%). The predicted versus actual hospital mortality rate was 20% versus 5.7% in group A, 32.1% versus 47.6% in group B, and 12.6% versus 22.2% in group C (group A vs group B, p = 0.0014; group A vs group C, p = 0.012). IABP-related morbidity occurred in 3% of cases (all in group C). CONCLUSIONS: Risk-adjusted mortality was significantly lower in high-risk cases with preoperative IABPs compared with emergent cases and intraoperative/postoperative IABPs. We encourage the use of preoperative IABPs in selected high-risk patients.     

Preoperative evaluation of patients with liver cirrhosis undergoing open heart surgery

Objective  Clinical outcomes after open heart surgery in patients with liver cirrhosis are not satisfactory. For evaluating hepatic function, the Child-Pugh classification has been widely used. It has been reported that open heart surgery can be performed safely in patients with mild liver cirrhosis. In this study, we examined the clinical outcomes after open heart surgery in patients with liver cirrhosis and evaluated the usefulness of the Child-Pugh classification. Methods  There were 12 liver cirrhosis patients who underwent open heart surgery between January 2002 and December 2006 at our institution. The severity of cirrhosis was graded according to the Child-Pugh classification. We reviewed clinical outcomes, such as postoperative mortality and morbidity, and tried to determine the risk factors. Finally, we assessed the usefulness of the Child-Pugh classification. Results  Six patients were classified as having Child class A, and the other six patients were classified as B. The overall mortality of group A was 50%, and that of group B was 17%. Postoperative major morbidities occurred in half of the patients of Child class A and in all of the patients of Child class B. Patients who experienced major morbidities had markedly lower levels of serum cholinesterase (106 ± 46 vs. 199 ± 72 IU/l; P = 0.02) and lower platelet level (7.5 ± 2.9 vs. 11.9 ± 3.6 × 104/μl; P = 0.04). Conclusion  The mortality and morbidity rates were high even in the Child class A patients. The Child classification may be an insufficient method for evaluating hepatic function. We have to assess other factors, such as the serum cholinesterase level or the platelet count.     

Early postoperative candida colonization in alimentary canal in patients undergoing open heart surgery

AIM: To examine the frequency and factors predisposing to candidiasis in the digestive tract in the early postoperative period after open heart surgery. METHODS: One hundred patients undergoing open heart surgery were enrolled in this study. Patients were divided into 2 groups in regard to Candida spp. colonization. Group A means increased Candida spp. colonization after open heart surgery (31/100). Group B indicates unchanged Candida spp. colonization after open heart surgery (69/100). Samples were obtained from both oral and anal mucosa in 3 different periods of operation: 1) preoperatively (stage 1), 2) at the end of the first hour in the intensive care unit (stage 2), 3) 24 hours after operation (stage 3). Findings were compared with both preoperative and intraoperative parameters. For fungal isolation Sabourauds dextrose agar and blood agar were used. RESULTS: In Group A (31), there was a significant relationship between the samples in stage 1 and 2 (p=0.031), and also a significance between stage 1 and 3 (p=0.048). Comparison between Candida positive and negative groups (Group A and B) did not reflect any statistical significance (p>0.05). CONCLUSIONS: Candida colonization in the alimentary canal in the early postoperative period after open heart surgery is due to individual preoperative features. However, early postoperative Candida colonization in the digestive tract is not a risk factor for sepsis unless the patient has an additional risk factor leading to prolongation of length of stay in the intensive care unit.     

心脏直视手术中参附注射液的心肌保护作用

目的观察参附注射液对体外循环下心内直视手术患者心肌损伤标志物的影响。方法30例择期心脏手术患者随机分成参附组和对照组,每组15例。两组麻醉诱导方式相同,参附组在麻醉诱导前静脉输入参附注射液2 ml/kg。分别在术前、心脏再灌注5、10、30、60及120 min测定肌酸磷酸激酶同功酶(LDH)、乳酸脱氢酶(CK-MB)、心肌钙蛋白(cTnI),并进行组间比较。结果两组患者所测心肌损伤标志物在开放升主动脉后显著升高,但参附组明显低于对照组。结论参附注射液能减轻体外循环期间心肌缺血-再灌注损伤,对心肌有一定保护作用。     

旁气流通气监测法观察心内直视手术患者通气功能变化

目的：应用旁气流通气监测法（ＳＳＳ）观察心内直视手术患者通气功能的变化。方法：心内直视手术患者２４例，按病种不同分为四组：室间隔缺损组（ｎ＝６）；室缺合并肺动脉高压组（ｎ＝６）；法鲁氏四联症组（ｎ＝６）及瓣膜置换组（ｎ＝６），采用ＳＳＳ监测围术期的通气功能及气道力学的变化。结果：室缺组、室缺肺高压组潮气量、分钟通气量、顺应性逐渐下降，气道峰压、平台压逐渐升高，其中室缺肺高压组在停体外循环后１０分钟时与诱导后比较差异显著（Ｐ＜０．０５），顺应性环亦有相应变化。法四组、瓣膜组潮气量、分钟通气量、顺应性无明显变化，气道压轻度升高，但均无统计学意义。结论：ＳＳＳ可及时准确地反映呼吸功能和气道力学参数，发现异常情况，以便迅速纠正。     

心内直视手术麻醉与体外循环期间血浆降钙素基因相关肽的变化

目的：研究麻醉、心内直视手术及体外循环期间降钙素基因相关肽（ＣＧＲＰ）的变化及其与前列环素代谢产物（６－ｋｅｔｏ－ＰＧＦ１α）变化的关系。探讨ＣＧＲＰ在心肌保护的意义。方法：应用放免法对１５例心内直视手术患者的血浆ＣＧＲＰ和６－ｋｅｔｏ－ＰＧＦ１α浓度分别在麻醉前、麻醉平稳后、转机前、转机中、转机后、术毕和术后第二天七个时间点进行动态观察。结果：（１）ＣＧＲＰ在转机中显著升高（Ｐ＜０．０５），转机后达峰值，并持续至术毕及术后第二天（上述均Ｐ＜０．０１）；（２）６－ｋｅｔｏ－ＰＧＦ１α在转机前及转机中显著升高，于转机后及术毕降低但仍显著高于基础值（上述均Ｐ＜０．０１）；（３）ＣＧＲＰ与６－ｋｅｔｏ－ＰＧＦ１α的变化规律不一致，两者无显著相关性（ｒ＝０．０１２，Ｐ＞０．０５）。结论：ＣＧＲＰ对体外循环期间的缺血，缺血后再灌注心肌细胞具有代偿性保护作用，这种作用与前列环素无明显关系。     

针刺对体外循环心内直视术患者血管通透性的影响

目的 评价针刺对体外循环心内直视术患者血管通透性的影响.方法 择期行体外循环心内直视术患者32例,年龄18～60岁,体重指数19～28 kg/m2,ASA分级Ⅱ或Ⅲ级,心功能NYHA分级Ⅰ或Ⅱ级,随机分为2组(n=16):对照组和针刺组.针刺穴位取双侧内关穴、列缺穴和云门穴,参数为:AM2/100 Hz疏密波,刺激强度2～4 mA,刺激波宽0.2～2.0ms,刺激时间从麻醉诱导前30 min持续至术毕.于术前和术毕时,收集尿液,采用ELISA法测定尿微量白蛋白浓度.于术前24 h和术后24 h时,抽取中心静脉血样,测定丙氨酸转氨酶、门冬氨酸转氨酶的活性和总胆红素、尿素氮、肌酐的浓度.结果 与对照组比较,针刺组术毕尿微量白蛋白浓度降低(P＜0.05).两组患者肝、肾功能各指标比较差异无统计学意义(P＞0.05).结论 针刺可降低体外循环心内直视术对患者血管通透性的影响.     

心内直视手术患者心肺转流前后血浆肾上腺髓质素及炎性因子的变化

目的 观察心内直视手术患者心肺转流(CPB)前后血浆肾上腺髓质素(ADM)及炎性因子的变化.方法 心内直视手术患者30例,年龄18～36岁,分别于麻醉前(T0)、CPB开始10 min(T1)、主动脉开放(T2)、CPB后3 h(T3)、6 h(T4)及24 h(T5)抽取桡动脉血测定血浆ADM、肿瘤坏死因子α(TNF-α)、白细胞介素-6(IL-6)及白细胞介素-10(IL-10),记录CPB时间、主动脉阻断时间.结果 ADM浓度于T2～T5时明显增加(P＜0.01),TNF-a、IL-6和IL-10浓度亦显著增加(P＜0.05或P＜0.01);ADM浓度增高得较早,其净增加值与主动脉阻断和CPB时间无明显相关性.结论 CPB可导致ADM以及TNF-α、IL-6和IL-10等细胞因子水平增高,ADM的改变可能与CPB引起的细胞因子增高有一定关系.     

Hypotension after the release of aortic cross clamp in patients undergoing open heart surgery

One hundred consecutive adult patients under-going various elective open heart surgical procedures were included in this prospective study. An indwelling radial arterial cannula was used to measure mean arterial pressure (MAP). Systemic vascular resistance (SVR) during bypass was calculated using the formula SVR=MAP×80/pump flow dynes-sec-cm⁻⁵. Patients in whom vasodilators were used during cardiopulmonary bypass were excluded. Measurements were made just before the release of aortic cross clamp when the pump flows were normal; and 1,3,5 and 10 minutes following the cross clamp release. There were 60 males and 40 females with a mean age of 29.4±13.9 years and mean weight of 46±13 Kg. The MAP fell from 65±14 to 47±15 mm Hg (p<0.00001) and the SVR fell from 1699±511 to 1163±365 dynes-sec-cm⁻⁵ (p<0.00001) one minute after the release of aortic cross clamp. There was some recovery during the subsequent period, but the change continued to remain statistically significant upto 10 minutes after the release of aortic cross clamp. MAP and SVR decreased in all except 9 and 3 patients respectively at 1 minute. The mean temperature at the time of release of aortic cross clamp was 33.7±2.7°C. There was a poor correlation between the temperature and duration of bypass and extent of decrease in MAP and/or SVR. We conclude that there is a significant decrease in MAP (27%) and SVR (31%) after the release of aortic cross clamp and it persists for 10 minutes.     

七氟醚与丙泊酚麻醉对心内直视手术患者应激反应的影响

目的比较七氟醚吸入麻醉与丙泊酚静脉麻醉对心内直视手术患者CPB期间应激反应的影响。方法择期行心脏直视手术患者40例,ASAⅡ或Ⅲ级,随机均分为七氟醚组(S组)和丙泊酚组(P组)。记录诱导前(T0)、气管插管后5min(T1)、CPB后30min(T2)、CPB结束(T3)、术毕(T4)MAP、HR、BIS及血浆促肾上腺皮质激素(ACTH)和皮质醇(Cor)含量。结果与T0时比较,T1时两组MAP、BIS、ACTH、Cor均降低(P<0.05),T2～T4时ACTH、Cor均明显升高(P<0.01)。T2、T3时P组MAP、BIS、ACTH、Cor显著高于S组(P<0.05)。结论心内直视手术CPB期间七氟醚吸入麻醉较之丙泊酚静脉麻醉可显著降低机体应激反应。     

乌司他丁对心脏直视手术患者围术期血清呼吸指数和白细胞介素-6的影响

目的 探讨乌司他丁对心脏直视手术患者围术期血清呼吸指数(RI)和白细胞介素-6(IL-6)水平的影响.方法 28例择期瓣膜置换术患者随机均分为乌司他丁组(Ⅰ组)和对照组(Ⅱ组).分别测定中心静脉开放后(T1)、心肺转流(CPB)前即刻(T2),主动脉开放即刻(T3)、1 h(T4),2h(T5)、18 h(T6)6个时点血清RI和IL-6.结果 与T1时相比,T2时Ⅱ组IL-6明显升高(P<0.05),亦明显升高Ⅰ组(P<0.05).与T1时相比,T2、T4～T6时两组RI均明显升高(P<0.05),T5时Ⅱ组明显高于Ⅰ组(P<0.05).结论 乌司他丁能抑制IL-6释放,起到一定的肺保护作用.     

腺苷预处理对心脏直视手术心肌保护作用的临床研究

目的　探讨腺苷预处理对心脏直视手术的心肌保护效果。方法　将 30例择期心脏瓣膜置换术患者随机分成治疗组和对照组 ,治疗组在开心术前实施腺苷预处理。观察血清心肌肌钙蛋白T(cTnT)、磷酸肌酸激酶同工酶 (CK MB)、血浆丙二醛 (MDA)、心肌三磷酸腺苷 (ATP)、能量储备(EC)及心肌超微结构 (线粒体计分 )的变化。结果　主动脉开放后 30min ,治疗组cTnT为 ( 0 .42±0 .1 8) μg/L、CK MB为 ( 35.42± 1 5.87)U/L、MDA为 ( 4 .2 8± 0 .35)mmol/L升高值均明显低于对照组 [( 1 .1 6± 0 .32 ) μg/L、( 56.2 6± 1 6.36)U//L、( 6.37± 2 .46)nmol/L(P <0 .0 5) ];治疗组ATP含量( 1 5.86± 3.51 ) μmol/g干重和EC值 0 .4857± 0 .0 578均明显高于对照组 [( 6.2 5± 2 .79) μmol/g干重、0 .2 992± 0 .0 4 1 9(P <0 .0 1 ) ];治疗组线粒体计分 0 .860 2± 0 .2 381明显低于对照组 2 .740 6±0 .9792 ,(P <0 .0 1 )。结论　腺苷预处理对心脏具有明显的保护作用     

缺血预处理对心内直视手术患者的心肌保护效应:meta分析

目的 采用meta分析评价缺血预处理对心内直视手术患者的心肌保护效应.方法 检索PubMed、EMBASE、Highwire、CENTREN及其下属各临床注册试验数据中心、中国生物医学文献数据库和中国期刊全文数据库,收集全身麻醉下缺血预处理对心内直视手术患者的心肌保护效果的随机对照研究.采用Cochrane系统评价法评价所纳入文献的质量,评价指标包括:术后心源性死亡率、心肌梗死发生率、室性心律失常发生率和正性肌力药物使用率.采用RevMan 5.0软件进行Meta分析.结果 纳入12项研究,8项研究为高等质量文献,4项研究为中等质量文献,共626例患者.缺血预处理可降低心内直视手术患者术后室性心律失常发生率和正性肌力药物使用率(P＜0.05),而对术后心源性死亡率及心肌梗死发生率无影响(P＞0.05).结论 缺血预处理可降低心内直视手术患者术后室性心律失常的发生,而对术后心源性死亡和心肌梗死发生没有影响.     

氨基己酸对体外循环下心脏直视手术患者纤溶系统的影响

目的探讨氨基己酸对体外循环(CPB)下心脏直视手术患者纤溶系统的影响。方法40例心脏直视手术患者随机分为二组:氨基己酸组(A组)和对照组(B组),每组20例。A组在CPB 预充液中单次加入氨基己酸200 mg/kg,B组在CPB预充液中加入等量生理盐水。分别于切皮前即刻(T0)、CPB 8min(T1)、30min(T2)、鱼精蛋白中和肝素后10min(T3)、术后2 h(T4)时采集静脉血,测定血浆组织型纤溶酶原激活物(t-PA)、纤溶酶原激活物抑制剂(PAI)、纤溶酶(Plm)活性及D-二聚体(D- dimer)浓度,同时记录术后24 h内出血量及输库血量。结果与T0比较,B组血浆t-PA、t-PA/PAI活性在T1-3、Plm活性在T1,2、D-dimer浓度在T1-4时升高(P<0.05或0.01)。与B组比较,A组血浆t-PA活性、t-PA/PAI在T1-3、Plm活性在,T1,3、D-dimer浓度在T2-4时降低(P<0.05或0.01)。术后24 h出血量及输库血量A组少于B组(P<0.05)。结论CPB可激活纤溶系统;氨基己酸可抑制CPB引起的纤溶系统激活,减少术后出血和输库血量。