不同超滤法在小儿体外循环中的应用比较

目的 比较不同超滤法在小儿体外循环中的效果。方法 80例先天性心脏病病儿，随机分成4组，分别为对照（CUF）组，平衡超滤（BUF）组，改良超滤（MUF）组和平衡超滤＋改良超滤（B＋M）组。在围术期检测肿瘤坏死因子（TNF）、白细胞介素－8（IL－8）和E-selectin的浓度。结果 CUF组各类炎症因子的浓度随转流时间的延长不断上升，BUF和B＋M组停转流时炎症因子的浓度明显低于对照组和MUF组（P＜0．05）。MUF组进行超滤时，炎症因子浓度上升，红细胞压积不断升高，B＋M组在停体外循环时炎症介质浓度较低，但在改良超滤时上升，上升幅度较MUF组低。结论 平衡超滤法能降低体内炎症介质，改良超滤法可以在术后迅速浓缩血液，但不能降低炎症介质的浓度。平衡超滤和改良超滤结合起来应用，可兼有二者的作用，但仍不能在转流后将炎症介质的浓度保持在相当低的水平。     

常规超滤与改良超滤在婴幼儿体外循环心脏手术中的应用分析

目的总结分析婴幼儿先天性心脏病体外循环心脏手术中超滤的临床经验。方法总结分析2004-02～2008-10进行的13kg以下先天性心脏病手术患儿80例的临床资料并随机分组:常规超滤组(CUF组)30例,改良超滤组(MUF)30例,对照组(无超滤组)20例。分析各组各时期K+、HCT、Hb数据及呼吸机辅助时间,术后应用血管活性药物时间、术后引流量、术后胶体应用量等临床资料。结果改良超滤组超滤停止时,其HCT、Hb均高于停机时,高于常规超滤停止时,差异具有统计学意义(P0.01)。常规超滤组停机时,其HCT、Hb均高于改良超滤组停机时,差异具有统计学意义(P0.01)。在呼吸机辅助时间、血管活性药物应用时间及术后胶体用量等方面,改良超滤组优于常规超滤组及对照组,常规超滤组优于对照组,差异具有统计学意义(P0.01)。3组术后引流量未见明显差异。结论常规超滤及改良超滤能较好的改善婴幼儿体外循环手术后的心肺功能,利于术后恢复。     

婴幼儿心脏手术后两种改良超滤方法对血流动力学的影响

目的 评估先天性心脏患儿体外循环术后静脉-动脉改良超滤(V-A MUF)和动脉-静脉改良超滤(A-V MUF)两种方法对血流动力学的影响.方法 40例患儿随机均分为两组,分别在体外循环术后行10 min改良超滤.分别在体外循环前、体外循环后、体外循环后10、30 min,记录心率、血压和中心静脉压血流动力学参数和血细胞压积.经食管超声心动图测定左心室后壁收缩期(LVPWs)和舒张期厚度(LVPWd)、舒张末期容积(EDV)、收缩术期容积(ESV)和射血分数(EF)并进行两组比较.结果 V-A MUF患儿在体外循环术后10 min和30 min比术后即刻能维持更好的动脉收缩压.体外循环术后两组患儿EF均显著下降(P<0.05).V-A MUF组EF值在CPB术后10 min(60%)和30 min(46%)较CPB术后即刻显著升高(P<0.001).A-V MUF组EF值无上升.V-A MUF组左心室后壁厚度较A-VMUF有显著改善(P<0.05).两组在围术期血细胞压积差异无统计学意义.结论 静脉-动脉改良超滤是一种安全有效改善患儿心脏术后血流动力学的方法.

Abstract：

Objective Evaluate the effects of venous-arterial modified ultrafiltration on hemodynamics compared to arterial-venous in children undergoing cardiopulmonary bypass (CPB) for repair of congenital heart defects. Methods Forty patients underwent MUF randomly divided into two groups,group V-A MUF (n =20) and group A-V MUF (n =20) for 10 min after CPB. They were studied before CPB, after CPB, 10 min after CPB, and 30 min after CPB. Haemodynamic data including heart rate, blood pressure, central venous pressure and hematocrit were recorded. Transoesophaegeal echocardiography determined left ventricular posterior wall thickness in end-systole ( LVPWs) and end-diastole (LVPWd) , end diastolic volume (EDV) , end systolic volume (ESV) and ejection fraction (EF) were measured and compared in two groups. Results Patients in V-A MUF maintained better systolic arterial blood pressure at 10 min and 30 min compared with 0 min values after CPB. A significant decrease in EF were observed in both groups immediately after CPB ( P < 0.05 ). Significant increase in EF was observed at 10 min (60% ) and 30 min (46% ) after CPB compared with 0 min value after bypass in V-A MUF (P <0.001 ). In A-V MUF, no such increase in EF was observed. EF were significantly higher at 10 min and 30 min in V-A MUF as compared with A-V MUF (P < 0. 001). There was also significant improvement in posterior wall thickness in V-A MUF (P <0.05). Haematocrit values were not different in duration of postoperative between two groups. Conclusion Veno-arterial modified ultrafiltration is a safe and effective method of improving hemodynamics in children following cardiac surgery.     

血液超滤策略对低体重婴幼儿心肺转流期乳酸和血糖的影响

目的 比较三种不同血液超滤(UF)方法对低体重(＜8 kg)婴幼儿心肺转流(CPB)期乳酸(LAC)和血糖(GLU)的影响.方法 196例心内直视术手术患儿分成三组.DM组,合并应用改良超滤(MUF)和稀释性超滤(DUF),117例;M组,CPB结束后应用单纯MUF,22例;C组,在CPB中应用常规超滤(CUF),57例.记录术前、升主动脉阻断后、停CPB前和术后LAC和GLU.结果 C组升主动脉阻断后、停CPB前血细胞比容(Hct)明显高于其他两组,但术后明显低于其他两组(P＜0.05);术后M组和DM组的LAC明显低于C组(P＜0.05);DM组的GLU明显低于C组(P＜0.05),术后用血量、24 h胸腔引流量明显少于M组和C组,术后拔管时间明显短于C组(P＜0.05).结论 应用复合血液UF不仅能有效地降低库血的用量、减少CPB后患儿的LAC和GLU水平,而且能改善机体的氧代谢,有效地促进CPB后患儿心肺功能的恢复.     

改良超滤联合常规超滤用于重症心脏瓣膜病患者瓣膜置换术的效果

目的 评价改良超滤联合常规超滤用于重症心脏瓣膜病患者瓣膜置换术的效果.方法 择期行瓣膜置换术的重症心脏瓣膜病患者108例,性别不限,年龄≥18岁,体重50～80kg,采用随机数字表法,将患者随机分为常规超滤绀(CUF组,n=56)和改良超滤联合常规超滤组(CMUF组,n=52).CMUF组于 CPB结束后行改良超滤,流世400 ml/min,超滤时间15～20 min.分别于诱导后(T1)、常规超滤开始(T2)、常规超滤结束(T3)、改良超滤开始(T4)、改良超滤结束(T5)、CPB结束后2 h(T6)、8h(T7)及24 h(T8)时采集动脉血样行血气分析,并测定血浆IL-6和IL-8浓度.计算T5-8时的氧合指数,并记录气道压.记录术中尿量、术后24 h尿量、胸腔引流量、术后呼吸机支持时间、术后血制品使用情况及ICU停留时间.结果 与CUF组比较,CMUF组T5,6时Hct升高,T7,8时氧合指数升高,术后呼吸机支持时间、术后24 h尿量、胸腔引流量和浓缩红细胞用量减少(P＜0.05)、血浆IL-6和IL-8浓度、气道压、术中尿量和ICU停留时间比较差异无统计学意义(P＞0.05).结论 改良超滤联合常规超滤可于重症心脏瓣膜病瓣膜置换术患者,改善术后脏器功能,减少异体输血.     

平衡超滤法与改良超滤法的应用比较

目的　比较平衡超滤法和改良超滤法在小儿心肺转流术 (CPB)中使用的效果。　方法　 40例先天性心脏病患者 ,随机分成两组 :平衡超滤组 (BU F组 )和改良超滤组 (MU F组 ) ,分别在整个 CPB期间和停 CPB后进行超滤。结果　 BUF组在 CPB中滤出液体 815 .0± 30 0 .9ml,MU F组滤出液体 394.4± 81.4ml;BUF组在 CPB过程中炎症因子的浓度无明显变化 ,而 MUF组则有上升趋势 ,CPB结束时 BUF组炎症因子浓度明显低于 MUF组 (P<0 .0 5 ) ;MUF组进行超滤时 ,红细胞压积明显提高 ,炎症因子浓度有所上升。　结论　平衡超滤法能在 CPB中维持较低的体内炎症介质浓度 ,改良超滤法可以在术后迅速浓缩血液 ,但对降低炎症介质的浓度影响较小。     

肺血少型小体质量婴儿心脏直视手术体外循环管理

目的探讨肺血少型小体质量婴儿先天性心脏病心内直视手术的体外循环(CPB)管理策略,以促进患儿恢复,减少术后并发症。方法对38例体质量5 kg的先心病心内直视手术婴儿,实施浅、中低温CPB,术中零平衡超滤结合术后改良超滤。回顾性分析患儿CPB资料。结果开放主动脉后心脏自动复跳34例,无严重心律紊乱。术后所有患儿均顺利脱离体外循环,无严重CPB并发症。结论肺血少型小体质量婴儿,CPB小剂量预充,术中较高的血球压积和胶体渗透压,与温度良好匹配的流量,完善的心肺等器官保护,以及超滤是减少CPB术后并发症,促进患儿术后顺利恢复的有效措施。     

血液稀释在小儿心内直视手术中的应用

目的：３０例小儿心内直视手术以海脉素为心肺机预充液，搪塞血液稀释对小儿血球压积、血浆总蛋白、血小板及血浆电解质的影响。方法：３０例分为三组，血液稀释组（ＨＥＤ），稀释式自身输血ＨＡＴ），输库血组（ＳＢＴ），每组１０例，观察三组麻醉前、心肺转流１５ｍｉｎ，回输机器余血１５ｍｉｎ、术后２４ｈ和７２ｈ血球压积，血浆总蛋白 、血小板及血浆电解质变化。结果：心肺转流１５ｍｉｎＨＥＤ组和ＳＢＴ组呈中度、ＨＡＴ     

围手术期全程血液管理在老年腰椎退行性疾病治疗中的应用

目的观察围手术期全程血液管理对老年腰椎退行性疾病患者术中出血量、术后引流量以及输血量的影响,探讨减少围手术期出血的有效方法。方法回顾性分析2014年1月—2016年12月收治的90例老年退行性腰椎疾病患者,早期45例患者采用围手术期常规血液管理模式(常规组),后期45例患者采用围手术期全程血管理模式(全程组)。记录并比较2组患者手术时间、术中出血量、术后引流量、输血例数及输血量、血红蛋白浓度和红细胞压积。结果全程组手术时间、术中出血量、术后引流量、输血例数、输血量均低于常规组,术后3 d及1周血红蛋白浓度、红细胞压积均高于常规组,差异均具有统计学意义(P0.05)。结论老年腰椎退行性疾病患者采用围手术期全程血液管理可有效降低术中出血量和术后引流量,降低输血量和输血率,有利于患者术后恢复。     

成分库血在婴幼儿体外循环预充中的应用

目的探讨婴幼儿体外循环中减少库血用量的方法。方法将小于3岁的先天性心脏病患者160例分成实验组（n＝80）和对照组（n＝80）,实验组在体外循环预充时加入浓缩红细胞,对照组加入全血。结果实验组患者在体外循环中应用浓缩红细胞量240±80ml,胶体（血定安）400±101ml;对照组患者在体外循环预充中应用库血量400±96ml,血浆190±57ml;实验组用血量明显减少,而两组患者术后的恢复情况无明显差别。结论成分库血在体外循环预充中可明显提高红细胞压积,不影响患者术后恢复,并可以明显减少库血用量。     

Influence of modified ultrafiltration on coagulation, fibrinolysis and blood loss in adult cardiac surgery.

OBJECTIVES: Modified ultrafiltration (MUF) significantly reduce blood loss and transfusion requirements in pediatric cardiac surgery presumably by a reduction in inflammatory mediators which decrease the inflammatory axes and decrease the cross-activation of fibrinolysis and thrombosis. The influence of MUF on blood loss and homologous blood transfusion in adult cardiac surgery has not yet been determined. Furthermore, data about the influence on routine coagulation tests, platelet activation as well as the coagulation and fibrinolytic systems are limited. METHODS: In a prospective randomized study 48 patients scheduled for elective myocardial revascularization were randomized into a control group (n=16), a conventional ultrafiltration (CUF) group (n=16) and a MUF group (n=16). Perioperatively, serial blood samples were drawn at specific intervals to evaluate coagulation, fibrinolysis, and platelet function. RESULTS: Neither the coagulation nor the fibrinolytic system was positively influenced by MUF or CUF. The routine clotting tests were comparable except for a significantly higher antithrombin III activity after MUF compared to the CUF control group persisting 24 h postoperatively. Platelet factor 4 activity and platelet counts showed no differences among the groups. MUF considerably reduced the postoperative blood loss (MUF, 6.4+/-1.7 ml/kg bw per 24 h vs. CUF, 9.2+/-2.5 ml/kg bw per 24 h (P=0.003) vs. control, 8.9+/-2.2 ml/kg bw per 24 h (P=0.008)) and allogeneic blood transfusion (MUF, 2.0+/-3.4 ml/kg bw per 24 h vs. CUF, 6.9+/-5.1 ml/kg bw per 24 h (P=0.034) vs. control, 7.0+/-6.3 ml/kg bw per 24 h (P=0.029)). CONCLUSIONS: MUF in adult cardiac surgery significantly reduces postoperative blood loss and transfusion requirements. The mechanism for reduced blood loss could not be elucidated in this study.     

Conventional and conventional plus modified ultrafiltration during cardiac surgery in high-risk congenital heart disease.

BACKGROUND: This prospective nonrandomized study is the critical assessment of conventional ultrafiltration (CUF) and modified ultrafiltration (MUF) techniques and their efficiency in congenital heart disease surgeries. Use of cardiopulmonary bypass (CPB) in children is associated with body water retention as a consequence of prime volume and systemic inflammatory reaction. The CUF during CPB has reduced body water excess and the MUF after CPB, removes inflammatory mediators, improves hemodynamic performance, and decreases transfusion requirements. METHODS: Forty-one patients, aged 9 to 36 months, submitted to surgical correction for cardiac defects, using CPB, were divided into 2 similar groups: CUF (21 patients) operated between 1996-1997 were ultrafiltered during CPB, and CUF+MUF, (20 patients) operated between 1997-1998 and ultrafiltered during and after CPB. Postoperative duration of ventilator support, pediatric intensive care unit stay (PICU), hospital stay of the groups with and without preoperative pulmonary hypertension (PH), as well as transfusion requirement, hematocrit and platelet counts were compared. RESULTS: There were no technical complications and a significant ultrafiltrate in the CUF+MUF group was observed as compared to the CUF group. No significant differences were observed between the CUF and CUF+MUF groups regarding ventilatory support, PICU stay and hospital stay. Requirements for red cell transfusion, Ht and platelet counts were not statistically different. CONCLUSIONS: CUF and CUF+MUF were safe and efficient methods for patient stabilization independent of diagnosis and complexity of surgery. Future clinical evaluation should address a larger population of patients to research the different variables.     

The benefits of continuous ultrafiltration in pediatric cardiac surgery

BACKGROUND: Systemic inflammatory response and capillary leak syndrome, caused by extracorporeal circulation, have negative effects on the function of vital organs during the postoperative period. Modified ultrafiltration (MUF) has been developed as an alternative method to reduce the detrimental effects of cardiopulmonary bypass. The aim of this prospective, randomized study is to analyze the effects of MUF in a pediatric population undergoing congenital cardiac surgery. METHODS: Twenty-seven patients who underwent open-heart surgery at our institution were included in this prospective study. They were randomized into two groups as follows: Group I (n=14) of conventional ultrafiltration during bypass and Group II (n=13) receiving both conventional and modified ultrafiltration during and after the cessation of the bypass, respectively. The amount of prime volume, postoperative chest drain loss, transfusion requirements, hemodynamical parameters, duration of mechanical ventilatory support, and length of intensive care unit stay were compared between the two groups. During the postoperative period, the concentrations of hematological, biochemical and inflammatory parameters were also compared by analyzing the blood samples obtained at various time points. RESULTS: MUF resulted in a significant increase in hemoglobin, hematocrit and platelet levels, and significantly reduced the amount of chest tube output and transfused blood and blood products. MUF also shortened the duration of postoperative mechanical ventilatory support, length of the intensive care unit stay and improved postoperative hemodynamical parameters. During the early postoperative hours, IL-8 is significantly reduced in patients undergoing MUF, however, the concentrations of IL-8 were similar in both groups at the end of 24 h. CONCLUSIONS: MUF decreases the duration of mechanical ventilatory support, the length of intensive care unit stay, the need for blood transfusion and improves postoperative hemodynamics. It is associated with increased levels of hemoglobin, hematocrit and platelets. We can conclude that MUF attenuates the inflammatory response by decreasing the levels of inflammatory mediators.     

Efficacy of modified ultrafiltration in coronary artery bypass grafting]

We evaluated the efficacy of modified ultrafiltration (MUF) in coronary artery bypass grafting. Twenty patients were divide into two groups consisting of a control group (n = 11) and a MUF group (n = 9). MUF was carried out for fifteen minutes immediately after the completion of cardiopulmonary bypass. The blood flow through the ultrafilter was 300 ml/min and about 1,200 ml of water was removed. The hematocrit elevated significantly from 25% to 30% in the MUF group (p < 0.01). Postoperative blood loss in the first 24 hours in the MUF group was significantly less than that in the control group (8 +/- 2 ml/kg vs 12 +/- 4 ml/kg, p < 0.01). There was no statistical difference in the percentage of the increase in body weight after the operation, inflammatory reaction and pulmonary function (A-a DO2, PaO2/FIO2 and duration of intubation) between two groups. In conclusion, MUF is useful to hemoconcentrate and reduce postoperative blood loss in coronary artery bypass grafting.     

Effects of combined conventional ultrafiltration and a simplified modified ultrafiltration in adult cardiac surgery

Background Today’s practice of cardiac surgery encounters an increasing number of older and/or sicker patients, who are expected to have higher morbidity and mortality. Ultrafiltration during cardiac surgery is one of the strategies to prevent major vital organ dysfunction associated with cardiopulmonary bypass (CPB) and therefore might reduce the morbidity and mortality in these patients. This study aims to evaluate the effects of combined conventional ultrafiltration (CUF) and a simplified modified ultrafiltration (S-MUF) on clinical outcome in sick adult patients undergoing cardiac surgery. Methods In this prospective, randomized controlled study fifty adult patients with > 3 Euro SCORE who underwent open heart surgery were enrolled. In this study group (n=25), both CUF and S-MUF was performed, using a simplified circuit. The control group of patients (n=25) were treated identically to the study group except no ultrafiltration was performed. Effects of ultrafiltration on hemodynamics, hematocrit, pulmonary function, postoperative blood loss and homologous blood and blood component usage were recorded. Results During the immediate S-MUF period there was a significant increase in MAP (mean arterial pressure) and haematocrit (54.3 ± 11.6 to 74.3 ± 9.1 mmHg; p < 0.001) and (28.6 ± 5.4% to 36.6 ± 4%; p < 0.001 respectively) in the study group, where as no such phenomenon was observed in the control group. This fact remains true for both the groups during the post operative period. In contrary to the control group, the oxygenation parameters were improved significantly (p < 0.05), immediately after S-MUF and remained at a higher level (p < 0.05) during the postoperative period in the study. The total postoperative blood loss was significantly less in the study group than the control group (402 ± 249 ml vs 603 ± 377 ml, p < 0.05) and (1.8 ± 1.3 U/patient vs 3.1 ± 1.1 U/patient, p < 0.001 respectively). The total duration of mechanical ventilation, ICU stay, inotropic/vasodilator support and hospital stay were similar in both the groups. Conclusion The use of combined CUF and S-MUF can effectively concentrate the blood, transiently improve pulmonary function and decrease postoperative blood loss as well as postoperative requirement of allogenic blood transfusion in sick adult patients. It did not have any major impact on clinical outcome.     

Efficacy of modified ultrafiltration in reoperation for valvular disease

We evaluated the efficacy of modified ultrafiltration (MUF) in reoperation for valvular disease. Fourteen patients were divide into two groups consisting of a control group (n = 6) and a MUF group (n = 8). MUF was carried out for fifteen minutes immediately after the completion of cardiopulmonary bypass. The blood flow through the ultrafilter was 300 ml/min and about 1,200 ml of water was removed. The hematocrit elevated significantly from 25% to 31% in the MUF group (p < 0.05). The percentage of the increase in body weight after the operation in the MUF group was significantly less than that in the control group (3.3 +/- 3.1% vs 8.3 +/- 4.3%, p < 0.05). The PaO2/FIO2 after the operation in the MUF group was significantly higher than that in the control group (376 +/- 125 mmHg vs 242 +/- 79 mmHg, p < 0.05). The duration of mechanical ventilation in the MUF group was significantly less than that in the control group (1.1 +/- 1.1 days vs 5.3 +/- 3.3 days, p < 0.05). In conclusion, MUF is useful to hemoconcentrate, reduce postoperative body weight gain and promote early recovery of pulmonary function in reoperation for valvular disease.     

The effect of modified ultrafiltration in pediatric open heart surgery.

Since 1997 we have performed modified ultrafiltration (MUF) in pediatric open heart operations. To elucidate the clinical effects of MUF, patients under 20 kg in weight who underwent corrective open heart operation since 1997 are divided into 2 cohorts according to the enforcement of MUF (control group versus MUF group) retrospectively. Procedures, age, bodyweight, cardiopulmonary bypass (CPB) time, operation time, amount of donor blood use, postoperative inotrope dose, postoperative intubation time, and postoperative gas exchange capacity of lung expressed with respiratory index (RI) were compared between groups. Furthermore, a multiple linear regression analysis was performed to find independent correlates with postoperative RI. Finally scattergrams of intubation time and RI were drawn against several factors. In univariate analyses, the MUF group had significantly shorter intubation time and better RI. Multivariate analysis revealed that the enforcement of MUF was an independent correlate of postoperative RI. Analyses on the scattergrams revealed that the above mentioned favorable effects of MUF were prominent in the patients younger than 3 years or weighing less than 10 kg. We concluded that MUF had significant effects on pulmonary function preservation in pediatric open heart operations, especially for smaller children.     

Balanced ultrafiltration, modified ultrafiltration, and balanced ultrafiltration with modified ultrafiltration in pediatric cardiopulmonary bypass.

This study evaluates the effect of balanced ultrafiltration, modified ultrafiltration, and balanced ultrafiltration with modified ultrafiltration on inflammatory mediators in children's open-heart surgery. Eighty children with congenital heart disease were randomly divided into four groups: control group (C group); balanced ultrafiltration group (BUF group); modified ultrafiltration group (MUF group); and balanced ultrafiltration with modified ultrafiltration group (B+M group). Clinical data of these groups were similar. Tumor necrosis factor (TNF), interleukin-8(IL-8), and E-selectin were measured at the beginning of cardiopulmonary bypass (CPB), 30 min later, at the cessation of CPB, at the cessation of MUF (MUF group and B+M group), and 2 hours postoperatively. During CPB, the concentrations of TNF, IL-8, and E-selectin increased significantly in C and MUF groups and did not change significantly in BUF and B+M groups. In the period of MUF, TNF and IL-8 increased; whereas, E-selectin did not change. The study shows that ultrafiltration can filter out the inflammatory mediators, but only BUF can decrease the concentrations of them. Moreover, MUF only can concentrate blood. Combining both techniques has both effects, but the effect of BUF was offset by MUF.