一例复杂先天性心脏病早产儿术后应用体外膜肺氧合的护理

总结1例复杂先天性心脏病早产儿术后应用体外膜肺氧合（ECMO）辅助的观察与护理。对抗出血始终是应用ECMO的重要内容,转流期间使用血小板伴肝素输注方式和监测ACT手段有效控制出血的同时不发生栓塞。精确的计算出入量、合理使用抗生素、营养的支持和皮肤护理。在有效循环血量的支持下,患儿成功脱离ECMO且存活。     

A型主动脉夹层术后脑部并发症危险因素分析

Ohjective Retrospectively analyze the risk factors of neurological complications of 160 patients with type A aortic dissection who underwent surgical repalr using cerebral peffusion under deep hypothemia circulatory arrest and to sum the experience of cerebral protection. Methods From January 2004 to January 2006,160 patients with type A dissection underwent surgical repair with cerebral perfusion and DHCA. There were 106 male petients ond 54 female with age from 17 to 76 years old [mean, (56±13) years old]. Antegrade selective cerebral perfusion (SCP) through axillary artery was performad for 131 patients and retrograde cerebra l perfusion (RCP) from superior caval vein for 29 patients. Emergency surgery was perfomed in 83(51.8%) patients who were suf- fered from acute type A dissection, and the others were chronic elective surgery. All the factors underwent univariaare and multivariate analysis. Results Mean cardionpulmonary bypass (CPB) duration was (188± 57) minutes and mean cerebral perfusion time was (36±16) minuties. Sixteen patieats died in hospital and the in-hospital mortality was 10.0%. Deaths were due to multiple argan fail- ure in 9 patients, respiratory failure in 2, low cardiac output syndrome in 2, bloeding in 2, aeptic shock in 1. Postoperative respirato- ry dysfunction were observed in 22 (13.7%) parley. Postoperative renal failure happened in 20(12.5%) patients. Postoperative low cardiac output appeared in 8(5.0%) patients. Penmanent neurological deficits occurred in 8(5.0%) petients. The preopertive renal dysfunction (OR= 11.71, P=0.005), coronary artery disease (OR= 7.35, P =0.035), eet～ml vasenlar disease (OR= 13.39, P=0.021) and postoperative low cardinc ontput (OR=22.21, P=0.008) were found robe the relative risk factor. Tran- sient neurological deficts(TND) were noted in 32 patients. Over seventy years old (OR=1.17, P=0.042) was the independent risk predictors. Surgery procedures, CPB time, cross-clamp time, cerebral perfusion time, methods for cerebral perfusion, filtration used or not, the esophageal temperature and the bladder temperature and the hematocrit (HCT) during CA did not significantly influence the cerebral outcomes.Conclusion In our experience, cerebral perfusion duration within the limits of safe time and the methods of cerebral perfusion did not influence the neurological outcomes which depended on the severity of the underlying disease and on the function of end-organs. Protection of all the end-organs would be helpful to the cerebral protection.     

体外膜肺氧合在成人心脏手术术后心力衰竭治疗中的应用

目的:观察体外膜肺氧合(extracorporeal membrane oxygenation,ECMO)对成人心脏手术术后心力衰竭患者的治疗效果,探讨在此类患者应用ECMO的适应证。方法:自2006年11月—2007年1月,对3例成人心脏术后心力衰竭的患者进行ECMO支持治疗,均采用股动-静脉插管。ECMO期间维持血流动力学和呼吸指标稳定。结果:ECMO时间平均102.3h。3例患者心功能改善、均顺利脱机。1例康复出院,1例脱机31d后因严重肺部感染死亡,1例脱机5d后因心律失常死亡。结论:ECMO是治疗成人心脏术后心功能衰竭的有效方法,但需正确掌握适应证,合理选择患者。     

金黄凝胶对大鼠急性软组织损伤的治疗作用研究

目的探讨金黄凝胶对大鼠急性软组织损伤的治疗作用。方法随机选取10只大鼠作为对照组,将其余大鼠随机分为模型组、双氯芬酸钠凝胶(0.010 g)组、青鹏软膏(0.300 g)组、金黄散膏(0.069 g)组以及金黄凝胶0.033、0.069、0.138 g组。采用砝码砸伤法造成大鼠急性软组织损伤。造模后24 h开始给药,各组分别以各受试药物均匀涂抹大鼠左后肢砸伤部位。观察砸伤部位肿胀程度,计算肿胀度;测定造模部位痛阈值;记录损伤指数;测定血清白细胞介素-1β(IL-1β)、白细胞介素-6(IL-6)、前列腺素E_2(PGE_2)、一氧化氮(NO)的含量;观察造模部位的病理变化。结果与模型组比较,给药第3、5天金黄凝胶0.033、0.069、0.138 g组肿胀度均显著降低、痛阈值显著升高(P0.05、0.01);金黄凝胶0.033、0.069、0.138 g组给药5 d后损伤指数显著降低(P0.05、0.01)。与模型组比较,金黄凝胶0.033、0.069、0.138 g组PGE_2显著降低(P0.01),金黄凝胶0.138 g组IL-6、0.069 g组NO显著降低(P0.05)。各给药组大鼠对病变均有不同程度改善,除金黄凝胶0.033 g组外,各给药组大鼠肌肉病变均显著降低(P0.05、0.01)。结论金黄凝胶对急性软组织损伤具有治疗作用。     

血清中NSE和脑脊液中S100β及JNK蛋白对评估急性CO中毒迟发性脑病的预测价值

目的探讨血清中神经元特异性烯醇化酶(NSE)和脑脊液中神经营养因子(S100β)、c-Jun氨基末端激酶(JNK)蛋白对急性CO中毒迟发性脑病(DEACMP)的预测价值。方法选取CO中毒治疗后病情稳定者200例,其中81例DEACMP患者,119例非DEACMP患者,同期健康检查者100名为对照组。3组均采集外周静脉血测定血清中NSE和脑脊液中S100β及JNK蛋白水平。结果治疗前DEACMP组和非DEACMP组血清中NSE水平及阳性率均明显高于对照组(P0.05);治疗前DEACMP组血清中NSE和脑脊液中S100β、JNK1和JNK2蛋白表达明显高于非DEACMP组(P0.05),治疗后均明显降低,DEACMP组明显高于非DEACMP组(P0.05)。联合检测时任意1个指标为阳性时预测DEACMP的灵敏度、特异度、阳性预测值和阴性预测值依次为91.25%、67.23%、65.18%和89.89%;联合检测均为阳性时依次为52.50%、75.63%、59.15%和70.31%。结论早期检测血清中NSE和脑脊液中S100β及JNK蛋白表达对DEACMP有预测作用,联合检测较单项检测的预测价值更高。     

A型主动脉夹层术后肾功能衰竭危险因素分析

目的 分析深低温停循环(DHCA)结合脑灌注下A型主动脉夹层术后肾功能衰竭(RF)的相关危险因素,并探讨肾脏保护措施.方法 2004年1月至2007年10月157例患者在DHCA结合脑灌注下行A型主动脉夹层手术,男性115例,女性42例;年龄17～76岁.129例采用腋动脉插管选择性脑灌注,28例采用上腔静脉逆行性脑灌注.对所有术前、术中相关因素行单因素及多因素分析.结果 平均心肺转流时间(188.0±10.8)min,脑灌注时间(36.0±3.1)min.住院死亡15例(9.6%),永久性神经功能障碍8例(5.1%),术后RF 20例(12.8%).多因素分析示,术前肾功能不全和年龄>70岁是术后RF发生的相关危险因素.术后RF患者其住院死亡率(45%,P=0.001)和永久性神经功能障碍的发生率(25%,P=0.009)远高于其他患者.结论 高龄及术前肾功能不全是A型主动脉夹层术后RF发生的高危因素.     

A型主动脉夹层术后脑部并发症危险因素分析

Ohjective Retrospectively analyze the risk factors of neurological complications of 160 patients with type A aortic dissection who underwent surgical repalr using cerebral peffusion under deep hypothemia circulatory arrest and to sum the experience of cerebral protection. Methods From January 2004 to January 2006,160 patients with type A dissection underwent surgical repair with cerebral perfusion and DHCA. There were 106 male petients ond 54 female with age from 17 to 76 years old [mean, (56±13) years old]. Antegrade selective cerebral perfusion (SCP) through axillary artery was performad for 131 patients and retrograde cerebra l perfusion (RCP) from superior caval vein for 29 patients. Emergency surgery was perfomed in 83(51.8%) patients who were suf- fered from acute type A dissection, and the others were chronic elective surgery. All the factors underwent univariaare and multivariate analysis. Results Mean cardionpulmonary bypass (CPB) duration was (188± 57) minutes and mean cerebral perfusion time was (36±16) minuties. Sixteen patieats died in hospital and the in-hospital mortality was 10.0%. Deaths were due to multiple argan fail- ure in 9 patients, respiratory failure in 2, low cardiac output syndrome in 2, bloeding in 2, aeptic shock in 1. Postoperative respirato- ry dysfunction were observed in 22 (13.7%) parley. Postoperative renal failure happened in 20(12.5%) patients. Postoperative low cardiac output appeared in 8(5.0%) patients. Penmanent neurological deficits occurred in 8(5.0%) petients. The preopertive renal dysfunction (OR= 11.71, P=0.005), coronary artery disease (OR= 7.35, P =0.035), eet～ml vasenlar disease (OR= 13.39, P=0.021) and postoperative low cardinc ontput (OR=22.21, P=0.008) were found robe the relative risk factor. Tran- sient neurological deficts(TND) were noted in 32 patients. Over seventy years old (OR=1.17, P=0.042) was the independent risk predictors. Surgery procedures, CPB time, cross-clamp time, cerebral perfusion time, methods for cerebral perfusion, filtration used or not, the esophageal temperature and the bladder temperature and the hematocrit (HCT) during CA did not significantly influence the cerebral outcomes.Conclusion In our experience, cerebral perfusion duration within the limits of safe time and the methods of cerebral perfusion did not influence the neurological outcomes which depended on the severity of the underlying disease and on the function of end-organs. Protection of all the end-organs would be helpful to the cerebral protection.     

肝素涂层膜肺对体外循环炎症反应的影响

目的　本研究旨在观察心脏瓣膜置换术患者在体外循环 (CPB)各时段炎症因子和血流动力学的变化 ,并探讨肝素涂层膜肺对其的影响。方法　选择择期行双瓣置换术的患者 2 0例 ,随机分成两组 :A组为肝素化膜肺组 ,B组为对照组。全部患者分别在麻醉诱导前、主动脉阻断开放前、开放主动脉后 30min和术后 2h时取血测定细胞因子IL - 1β、IL - 6、IL - 8、TNF的浓度。并且分别在麻醉诱导前和术后 2h测定血流动力学指标。 结果　两组患者血液中的细胞因子 (IL - 1β、IL - 6、IL - 8、TNF)浓度 ,于CPB开始后即迅速上升。在CPB过程中IL - 1β、IL - 6、IL - 8和TNF的浓度均处于较高水平 ,且与麻醉诱导前相比部分有显著性差异 (p<0 .0 5 )。其中IL - 1β和IL - 6的浓度在术后 2h时仍有缓慢上升 ,IL - 8和TNF的浓度则在术后稍有下降。A组 (肝素化膜肺组 )和B组 (对照组 )相比较 ,细胞因子 (IL - 1β、IL - 6、IL - 8、TNF)浓度上升的程度均较小。开放 30min时IL - 1β和IL- 8的浓度在两组间有显著性差异 (p <0 .0 5 ) ,术后 2h时IL - 6的浓度在两组间的差异也有显著性 (p <0 .0 5 ) ,但TNF的浓度在两组间无显著性差异。结论　肝素化膜肺能改善CPB管路与血液的生物相容性 ,减少血液与异物表面接触引起的炎症反应     

心内直视手术中应用康斯特保护液的心肌保护研究

目的研究心内直视手术中应用康斯特保护液(HTK液)的心肌保护作用。方法瓣膜置换术患者34例,随机分为两组,HTK液组和4∶1冷含血停搏液组,各17例。主动脉阻断后分别注入5℃~8℃HTK液和4∶1冷含血心肌保护液。在术中和术后抽动脉血测定心肌肌钙蛋白T(cTnT)、肌酸激酶(CK)、肌酸激酶同工酶(CK-MB、CKMM)和丙二醛(MDA)、超氧化物歧化酶(SOD)和黄嘌呤氧化酶(XOD)浓度,并在电镜下观察心肌超微结构的变化。结果两组中的cTnT、CK、CKMB和CKMM浓度,在开放后均逐步升高,与阻断前比较有统计学差异(P<0.05),HTK液组上升的幅度小于4∶1冷含血停搏液组,在开放后120m in时有统计学意义(P<0.05)。两组中的MDA浓度,在阻断后均逐步升高,于开放后120m in达到高峰,术后24 h稍有下降;两组间在术后24 h的差异有统计学意义(P<0.05)。两组中SOD的浓度均逐渐下降,XOD的浓度则均逐渐上升,变化幅度在开放后120m in和术后24 h有统计学差异(P<0.05)。电镜显示HTK液组中心肌超微结构变化明显优于4∶1冷含血停搏液组。结论心内直视手术中应用HTK溶液进行心肌保护,不仅比我们现在常用的4∶1冷含血心脏停搏液效果好,而且只需要灌注一次,方法简便,特别适用于心肌缺血时间较长的患者,值得在临床上推广应用。     

31例心脏移植的体外循环转流及供心保护经验

目的:报道连续31例心脏移植的体外循环转流经验及供心保护经验.其中扩张性心肌病29例,缺血性心肌病1例,复杂性先天性心脏病1例.方法:体外循环采用中度低温、轻度血液稀释法.供心保护方法为10例采用晶体保存液,21例采用UW液.结果:31例手术脱离体外循环顺利,无手术死亡.结论:良好的供心保护,监测各重要生理指标,使灌注充分合理是成功顺利脱离体外循环的关键.