急性等容血液稀释对血液动力学及氧代谢的影响

目的 研究术前急性等容血液稀释对血液动力学和氧代谢的影响。方法 20例肝癌切除术病人,随杨分为血液稀释组（I组,n=10)和对照组（Ⅱ组,n=10)。I组于全麻后采血,将血红蛋白稀释到80－90g/L,同时输入两倍于采血量的晶胶体溶液。在稀释前后各时点监测血液动力学、氧代谢以及动脉血乳酸等参数。结果 I组于血液稀释后,心脏指数（CI）和每搏指数（SI）维持稳定,氧输送量（DO2）降低（P＜0．01）,但仍高于临界氧输送值。结论 在吸入高浓度氧的情况下,中度血液稀释无明显的心血管代偿反应,不引起氧输送不足。     

常温不停跳冠脉搭桥对血液动力学及氧代谢的影响

目的；比较研究常温心脏不停跳和低温体外循环心脏停跳手术对血液动力学及移植血管功能的影响。方法：35例冠脉搭桥手术病人分为心脏不停跳组（20例）和体外循环心脏停跳组（15例）。经Swan-Ganz漂移导接BaxterCCO监测仪监测血液动力学，Doppler测定移植血管血流量，并测定全身及心肌炎的氧供需。结果：（1）搭桥后，心脏不停跳组CI显著升高，MPAP、SV、HR无明显变化；心脏停跳组CI无明显变化，SV降低，HR和MPAP增加。搭桥后两组CO较手术前无统计学差别；（2）搭桥后两组病人CaO2和Cv^-O2均显著下降，VO2、O2ER和VO2I呈增加的趋势，但无统计学意义；（3）搭桥后两组病人移植血管的血流量无明显差异，移植血管支配区域心肌的MDO2、MVO2和MDO2／MVO2也无明显差异。结论：常温不停跳搭桥手术对血液动力学的影响较小，而对全身氧供需的平衡及移植血管功能的影响与体外循环心脏停跳搭桥手术相似。     

急性等容血液稀释对组织氧供氧耗的影响

目的：通过观察急性等容血液稀释（ＡＮＨＤ）时组织ＤＯ２、ＶＯ２的变化，寻找ＡＮＨＤ的生理极限。方法：１０只健康成年杂种犬，用戊巴比妥钠、维库溴铵静脉麻醉后行气管内插管，控制呼吸。每只犬进行三个水平即中度（ＨＤ１）、深度（ＨＤ２）、极深度（ＨＤ３）ＡＮＨＤ，然后回输自家血，测定血流动力学指标，动脉及混合静脉血气，动脉血乳酸等，以观察ＡＮＨＤ时ＤＯ２、ＶＯ２的变化。结果：ＨＤ１（ＨＣＴ＝１９．４３％±１．９７％），ＨＤ２（ＨＣＴ＝１４．７３％±０．９９％）时，ＤＯ２分别降低４２％和５２％，ＥＲＯ２分别升高４０％和８８％，ＣＩ升高４１％和４８％，而ＶＯ２只降低４．８％和５．２％，动脉血乳酸末升高。ＨＤ３（ＨＣＴ＝９．５０％±０．８８％）时，ＤＯ２降低７３％，ＥＲＯ２升高２００％，ＣＩ降低，ＶＯ２降低３５％，动脉血乳酸显著增加。回输自家血后，ＤＯ２、ＶＯ２及血乳酸均恢复。结论：中、深度ＨＤ时，ＤＯ２减少，ＶＯ２可通过增加ＥＲＯ２和ＣＩ代偿；极深度ＨＤ时ＶＯ２降低显著，出现无氧代谢，ＨＤ达极限。     

控制性降压对急性等容血液稀释安全性的影响

目的：通过观察犬急性等容血液稀释（ＨＤ）合并控制性降压（ＩＨ）时机体ＤＯ２、ＶＯ２及血乳酸浓度（ＬＡＣ）的变化，探讨ＩＨ对ＨＤ安全性的影响。方法：１２只健康成年杂种犬，静脉麻醉后气管内插管，探讨呼吸。分别进行ＨＤ至ＨｃｔＩＩＧＵＯ ０．３５、０．３０、０．２５、０．２０、０．１５、０．１０，以尼卡地平行控制性降压使ＭＡＰ下降３０％，测定血流动力学指标、动脉及混合静脉血气、血ＬＡＣ等，以观察不同Ｈｃ     

非停跳冠脉搭桥术中患者血液动力学和氧代谢的变化

本研究拟观察非停跳冠状动脉搭桥术中血液动力学和氧代谢的变化。 资料与方法 择期行非停跳冠状动脉搭桥术的多支病变患者20例,年龄55-76岁,NYHA心功能Ⅰ-Ⅱ级,左室射血分数均大于40％。     

急性非等容量血液稀释与控制性降压的联合应用

目的 研究术前急性非等容量血液稀释(ANIH)联合控制性降压(CH)对腹部手术患者血流动力学和氧代谢的影响.方法 60例择期行胃癌根治术患者随机分为两组:术前ANIH联合CH组(A组)和单纯CH组(C组),每组30例.A组于全麻插管后切皮前行ANIH;C组不行ANIH;术中两组患者均用硝酸甘油行CH,MAP控制在60～70 min Hg.观察气管插管后ANIH前(T0)、ANIH后CH前(T1)、CH后30 min(T2)、切除病灶后(T3)和术毕(T4)的MAP、HR、CVP、CO、外周循环阻力(SVR)及动脉血乳酸(Lac)浓度的变化,计算氧供(DO2)、氧耗(VO2)和氧摄取率(ERO2).结果 T1时A组MAP明显高于T0时及C组,T2、T3时两组MAP均明显低于T0、T1和T4时(P＜0.05).A组HR在T1时明显减慢,T2～T4时C组HR明显快于T0、T1时和A组(P＜0.05);T1～T2时A组CVP、CO、CI及ERO2均明显高于T0时及C组,T1～T4时A组SVR和DO2则显著低于T0时及C组(P＜0.05).T1～T2时A组Hct显著低于T0时和C组,T3、T4时两组Hct均明显低于T0时(P＜0.05).两组VO2及Lac在稀释前后无明显变化.结论 术前ANIH联合硝酸甘油CH不影响腹部手术时的机体氧代谢,可有效减少术中用血.     

不停跳冠脉搭桥术病人术中知晓及与脑电双频谱指数的关系

本研究旨在评价不停跳冠脉搭桥(Off-pump coronaryArtery Bypass,OPCAB)手术病人常规经验麻醉时脑电双频谱指数(BIS)监测麻醉意识状态的临床价值,同时探讨OPCAB手术常规经验麻醉意识水平的规律,为临床干预提供依据。     

成人非心脏手术急性等容血液稀释时氧代谢变化

目的探讨成人非心脏手术急性等容血液稀释(acute normovolemic hemodilution,ANHD)时氧代谢的变化。方法对24例成人非心脏手术患者施行中度ANHD,观察术中ANHD开始时(T0)、ANHD进行中Hb浓度最低时(T1)及手术结束时(T2)氧代谢的指标。结果与T0比较,术中T1时红细胞比容和血红蛋白明显降低(P<0.05);虽然T1时静脉血氧饱和度、动脉血氧浓度、混合静脉血氧浓度、单位组织供氧量明显下降(P<0.05),但动脉氧饱和度、动脉血氧分压、混合静脉血氧分压、动-静脉氧浓度差和单位组织耗氧量并无明显改变,且手术结束后各指标与ANHD之前比较均无差异。结论中度ANHD对组织氧合的影响并不显著,对成人非心脏手术患者是安全的。     

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。     

急性等容血液稀释对心肌钙蛋白和心肌酶的影响

目的 观察急性等容血液稀释（ANH）对心肌钙蛋白和心肌酶的影响,探讨急性等容血液稀释是否引起心肌损伤。方法 选择ASAⅠ～Ⅱ级,行择期肝切除术或双侧全髋置换术患者29例,随机分为血液稀释组（H组）和对照组（C组）。在麻醉前、输血前、术后4h和术后第一天采静脉血,测定肌酸激酶（CK）、肌酸激酶-MB（CK-MB）与心肌钙蛋白I（CTnI）。结果　（1）在输血前,H组血红蛋白比积（Hct）降低到20.33％±1.91％,C组降低到29.64％±1.78％,两者间差异显著（P<0.01）。（2）组间各相应时段的CK、CK-MB无显著性差异（P>0.05）。两组与基础值比较,CK于术后4h、术后第一天显著升高（P<0.01）;CK-MB于术后第一天显著升高（P<0.01）。（3）组间各相应时段和组内不同时段的Ctnl无显著性变化（P>0.05）;且一直处于低浓度（≤2.3ng·ml-1）结论 心肺等重要器官功能正常的病人,在术中吸入纯氧的条件下,等容血液稀释度Hct在约20％时,不会引起心肌的损伤。     

非体外循环与常规冠状动脉旁路移植术后心肌酶的动态变化

目的通过观察非体外循环冠状动脉旁路移植术(OPCAB)与常规冠状动脉旁路移植术(CCABG)患者术后心肌肌钙蛋白I(cTnI)和肌酸激酶同工酶(CK-MB)的动态变化,比较两种手术方式对心肌的损伤情况.方法102例不稳定型心绞痛患者,按不同的手术方式分为OPCAB组和CCABG组.OPCAB组:71例,行OPCAB;CCABG组:31例,行CCABG.两组分别于术前、术后4、12小时、1、3、5天测定cTnI和CK-MB.结果CCABG组行旁路血管移植2～5支(2.97±0.84支),OPCAB组1～5支(2.69±0.92支);两组均无围术期心肌梗死.两组术后早期cTnI和CK-MB均有升高,分别于术后5天和术后3天基本恢复至术前水平.术后4、12小时、术后1天OPCAB组cTnI值与CCABG组比较差别有显著性意义(P<0.01).结论有选择的施行OPCAB是一种安全和合理的手术方式,OPCAB的心肌损伤程度明显轻于CCABG.     

No release of cardiac troponin I during major orthopedic surgery after acute normovolemic hemodilution

Background : Normovolemic hemodilution is a well-accepted method for intraoperative blood salvage. However, some controversy exists concerning the possible risk of myocardial fiber injury as a consequence of the reduced oxygen content. Laboratory diagnosis of perioperative myocardial fiber injury is difficult, since biochemical markers are elevated postoperatively due to the surgical trauma. Cardiac troponin I (cTnI) is a new, highly sensitive and specific cardiac marker for the detection of myocardial injury. The aim of our study was to investigate whether normovolemic hemodilution in patients with major orthopedic surgery (13 hemodiluted patients, 15 controls) induces a release of cTnI.
Methods : cTnI as a highly specific and sensitive cardiac parameter, as well as total creatine kinase (CK), creatine kinase isoenzyme MB mass (CKMB mass) and myoglobin were measured after induction of anesthesia, after normovolemic hemodilution, prior to retransfusion of blood components, 3 h after surgery, and on the first and third postoperative days. Results: Prior to retransfusion of blood components the hematocrit was decreased to 25.4±1.2% (mean±SEM; range: 18%–34%) in the control group and to 20.2±0.8% (mean±SEM; range: 17%-24%) in the hemodilution group. Total CK, CKMB mass as well as myoglobin concentration increased significantly in both groups, reaching their maxima within the first day of surgery. In contrast, cTnI was below the detection limit of the assay (<0.5 μg/L) at any time.
Conclusions : We suggest that pre- and intraoperative hemodilution to a hematocrit of approximately 20% by maintaining normovolemia does not induce myocardial fiber injury in patients without preexisting cardiac diseases.     

尼卡地平对非心肺转流冠状动脉旁路移植术患者术中血流动力学和氧代谢的影响

目的 探讨尼卡地平对非心肺转流冠状动脉搭桥术(off-pump coronary artery bypass grafting,OPCABG)患者术中血流动力学和氧代谢的影响.方法 选择拟行OPCABG患者79例,年龄51～68岁,ASAⅢ或Ⅳ级,随机分为两组,近端血管吻合前分别持续泵注尼卡地平0.5 μg·kg-1·h-1组(N组,n=41)或硝酸甘油0.5 μg·kg-1·h-1组(G组,n=38).记录麻醉前(T0)和用药后10min(T1)、30min(T2)、60 min(T3)、90 min(T4)时的氧代谢、血流动力学等指标变化情况,包括SvO2、MAP、PaO2、CO、HR和肺血管阻力(PVR)、体循环血管阻力(SVR)、CI、氧摄取率(ERO2)、乳酸(Lac)等.结果 与T0时比较,T3,T4时两组患者氧耗明显降低,Lac浓度明显升高,且N组均明显低于G组(P＜0.05);T3,T4时G组PaO2、氧供明显降低,ERO2明显升高,N组PaO2、氧供明显高于,ERO2明显低于G组(P＜0.05).与T0时比较,两组T1～T3时PAP、T1～T4时PVR和SVR均明显降低,T3,T4时CI明显升高(P＜0.05),且T1～T4时N组PVR和SVR明显低于G组,T4时CI明显高于G组(P＜0.05).两组患者均顺利完成手术,术后均无严重并发症发生.结论 尼卡地平可有效改善OPCABG患者术中氧代谢并维持血流动力学稳定.     

非体外循环冠状动脉旁路移植术后早期血流动力学和心肌损伤的观察

目的观察非体外循环冠状动脉旁路移植术（OPCAB）后早期血流动力学变化及心肌损伤。方法选择20例择期OPCAB患者,连续监测血流动力学变化,并记录麻醉诱导后10min（T0）、血运重建后30min（T1）、2h（T2）、6h（T3）、12h（T4）、24h（T5）的血流动力学参数,同时测定血浆肌酸激酶同功酶（CK-MB）、心肌肌钙蛋白1（cTnI）和N端B型脑钠肽（NT—proBNP）浓度。吻合血管前和血运重建后30min分别取右心房心肌组织透射电镜观察超微结构的变化。结果围术期SBP和DBP无明显变化,但血运重建后HR增快（P〈0．01）、CVP、肺动脉楔压（PCWP）、平均肺动脉压（MPAP）和心指数（cI）升高（P〈0．01）,而体循环阻力（SVR）、体循环阻力指数（SVRI）、每搏数（SV）、每搏指数（SVI）和左室每搏功指数（LVSWI）降低,右室每搏功指数（RVSWI）仅在血运重建后2h降低（P〈0．01）。CK-MB和cTnI从血运重建后持续升高（P〈0．05）,尤以血运重建后24h为明显。NT-proBNP在血运重建后12h内无显著变化,但在血运重建后24h显著升高（P〈0．01）。透射电镜下见血运重建后肌丝结构较术前模糊,线粒体有变形,结构不清晰,嵴模糊。结论OPCAB血运重建后早期存在心肌损伤和左右心功能下降,以左心为著。     

The clinical outcome of off-pump coronary artery bypass surgery in the elderly patients

Objective: There has been a body of evidence showing that off-pump coronary artery bypass (OPCAB) may reduce morbidity and mortality in the elderly patients. We reviewed our experience, retrospectively, on elderly patients aged 75 years and older who were operated on using the OPCAB technique. We compared their outcome to a similar group of elderly patients who were operated on using conventional coronary artery bypass grafting (CABG) with cardiopulmonary bypass (CPB) during the same period of time. Methods: Registry data and patients' notes and charts were reviewed for 56 consecutive elderly OPCAB patients (age 78.5±3.5 years) and 87 consecutive CPB patients (age 77.2±2.4 years, P=0.01). Both groups had similar risk factor profiles: Parsonnet score 17.4±4.4 (OPCAB) versus 16.6±5.2 (CPB), P=0.19. We studied in detail their preoperative and postoperative data in order to compare the outcomes of both techniques. Results: The length of stay in the intensive therapy unit (ITU) was 35.4±52.9 h for OPCAB patients and 77.6±144.9 h for CPB patients (P=0.0008). No patient died within 30 days in the OPCAB group, whilst ten (11%) CPB patients (P=0.0066) died within 30 days. The incidence of serious complications (including pulmonary oedema, septicaemia, permanent stroke and renal dysfunction requiring haemofiltration or haemodialysis) was one (2%) in the OPCAB group and 11 (13%) in the CPB group (P=0.028). CPB patients required a significantly higher number ten (12%) of intra-aortic balloon pumps (IABP) inserted compared to only one patient (2%) in the OPCAB group who required IABP insertion (P=0.05). Nine (11%) CPB patients were re-operated on for bleeding compared to no OPCAB patient (0%) needing re-operation, P=0.011. Conclusions: Although the mean age of the OPCAB group was significantly higher than the CPB group, the OPCAB group showed a significant reduction in postoperative serious morbidity, ITU stay and mortality. We believe that such a conclusion may have some effect on the decision-making and cost-effectiveness when performing coronary bypass surgery on the elderly population.     

全麻诱导期急性超容量液体填充对非体外循环冠状动脉旁路移植术患者血液动力学的影响

目的 研究全麻诱导期急性超容量液体填充(acute hypervolemic fluid infusion,AHFI)对冠状动脉粥样硬化性心脏病患者行非体外循环冠脉旁路移植术(off-pump coronary artery bypass grafting,OPCABG)血液动力学的影响.方法 40例患者按随机数字表法随机分为6％羟乙基淀粉130/0.4 (6％ hydroxyethyl starch 130/0.4,HES 130/0.4)组和乳酸林格液(lactated ringer's solution,RL)组,每组20例.全麻诱导前5 min开始,30 min内分别输注HES 130/0.4或RL10 ml/kg.在麻醉诱导前5min(T0),诱导后即刻(T1),插管后即刻(T2),插管后5 min(T3)及AHFI结束后(T4)分别记录心率(HR),血压(BP),中心静脉压(central venous pressure,CVP),心脏指数(cardiac index,CI),每搏输出量(stroke volume,SV)及每搏变异指数(stroke volume variation,SVV). 结果 与T0时HR[(66.2±9.5)次/min、平均动脉压(mean arterial pressure,MAP)[(98.6±12.5) mm Hg(1 mm Hg=0.133 kPa)]、CI[(2.7±0.4)L·min-1·m-2]、SV [(82.5±17.4) ml]及SVV[(8.6±4.3)％]比较,HES130/0.4组患者T1时MAP[(82.3±10.8) mm Hg]、CI[(2.3±0.3)L·min-1·m-2]及SV [(73.4±15.5) nl]均下降;在T3和T4时HR[(57.8±6.2)次/min和(56.4±6.9)次/min ]下降;T4时CI[(3.2±0.4)L·min-1· m-2]升高,但是SVV[(6.3±3.2)％]降低(P＜0.05);而RL对照组在T1、T3及T4时MAP[ (78.8±12.1) 、(82.7±12.9)、(79.2±10.1) mm Hg]和SV[(71.3±16.2)、(73.6±15.9)、(74.4±16.3)ml]均降低(P＜0.05或P＜0.01).在T3时与RL对照组CI[(2.5±0.4)L·min-1·m-2]和SV[( 73.6± 15.9) ml]比较,HES 130/0.4组CI[(3.0±0.5)L·min-1·m-2]和SV [(91.2±18.6) ml]均升高(P＜0.05).在T4时与RL对照组MAP[ (79.2±10.1) mm Hg] 、CI[(2.6±0.4)L·min-1· m-2] 、SV[ (74.4±16.3) ml]和SVV[(10.6±4.5)％)]比较,HES130/0.4组MAP[(88.2±9.4)mm Hg]、CI[(3.2±0.4)L·min-1·m-2]和SV[(91.2±18.6)％]均升高,但SVV[(6.3±3.2)％]明显降低(P＜0.05).结论 OPCABG全麻诱导期行AHFI安全有效,使用HES130/0.4比RL能更好地维持全麻诱导期间的血液动力学稳定.     

非体外循环冠状动脉搭桥手术的麻醉方法及血液动力学和氧代谢的变化

目的 观察非体外循环冠状动脉搭桥手术的麻醉方法、术中病人血液动力学和氧代谢的变化以及术后病人的早期.非体外循环冠状动脉搭桥手术闰人20例，麻醉用咪唑安定0.1-0.2mg/kg、芬太尼15－30μg/kg及0.5%-2%的吸入麻醉药等，在切皮前、开心包后、心脏操作中、操作完成后10min及术毕观察血液动力学指标及脑氧饱和度，同时采集桡动脉和肺动脉血，测定血气及动脉血乳酸（ABL），计算氧供DO2）、氧耗（VO2）和氧摄取率（ERO2）。术后早期观察术后拔除气管插管、ICU停留及术后住院时间、并发症及死亡等情况。结果 心脏操作中MAP、SV、SI下降，HR、CVP升高，MAP下降以搭回旋支时最明显（P＜0.01），HR升高以搭右冠时最明显（P＜0.01）；心脏操作中DO2降低（P＜0.05），VO2无变化，ERO2升高（P＜0.01）；操作后DO2、ERO2恢复至操作前水平；操作后ABL升高（P＜0.01）。结论 本组麻醉方法使病人完全度过非体外循环搭桥术，在心脏操作期易出现血压、每搏量、心指数下降，伴心率、静脉压升高，但时间短暂无严重后果，氧代谢紊乱及缺氧程度较轻。     

Vacuum-assisted apical suction devices induce passive electrical changes consistent with myocardial ischemia during off-pump coronary artery bypass graft surgery

Objective: Off-pump coronary artery bypass graft surgery is common therapy to completely revascularize diseased hearts. In order to graft posterior arteries in this procedure, the heart must be lifted from the chest cavity and manipulated to expose the surgical field using an apical suction device. This suction device may cause unwanted myocardial ischemia. Methods: In this observational study, we measured myocardial electrical impedance, a parameter that responds to myocardial ischemia, as well as ST-segment changes during off-pump coronary artery bypass graft surgery in 12 patients with two-vessel coronary artery disease undergoing revascularisation of the left anterior descending and the posterior descending coronary arteries. During the posterior descending artery revascularisation phase of the procedure the apical suction device was oriented over the electrodes used to measure myocardial electrical impedance, thus allowing us the opportunity to assess myocardial ischemia in this region of the heart. Results: In these 12 patients, myocardial electrical impedance progressively increased under the suction device during posterior coronary artery revascularisation, suggesting that myocardial ischemia developed in this region of the myocardium. ST-segment changes were negligible while the heart was vertically displaced (and the suction device attached), but increased immediately when the heart was returned to the neutral anatomical position. Conclusion: Our data suggest that the apical suction device may cause ischemia while the heart is vertically displaced and electrically disconnected from the body. Under these conditions, ST-segment changes may not detect myocardial ischemia. Myocardial electrical impedance has the potential to reliably detect intraoperative myocardial ischemia under these circumstances.