49例心内直视术后出血的临床研究

目的　探讨体外循环心内直视术后出血的发生原因及其诊断、治疗和预防。方法　复习本院 16a 15 12例心内直视术后出血抢救病人的临床资料 ,总结引起出血的原因 ,诊断和治疗方法以及治疗效果。结果　 15 12例心内直视手术病人中 ,4 9例发生术后出血 ,2 9例二次剖胸手术止血 ,成功 2 5例 ,死亡 4例 ,死亡率为 13 8% ;2 0例行非手术治疗 ,成功止血 9例 ,死亡 11例 ,死亡率为 5 5 %。结论　术中仔细操作、彻底止血 ,术后早期诊断并采取果断措施尽早再次剖胸手术止血是降低心内直视术后出血死亡率的关键。     

体外循环心内直视术后脑部并发症的急救处理

目的 探讨体外循环心内直视术后中枢神经系统并发症的特点及急救处理。方法 回顾分析３７例患者的临床资料显示,导致心内直视术后脑部并发症的主要因素为急性脑缺血缺氧和脑出血。具体原因有抗凝不当,脑血管畸形破裂,体外循环意外,左室破裂,主动脉破裂,血,气栓,长时间低血压及室性心律紊乱。临床多表现为意识障碍及半侧肢体感觉运动障碍等。紧急处理包括开颅探查,胸内,胸外心脏按压,电击除颤,气管插管人工呼吸及头部降     

体外循环心内直视术后93例的监护体会

1996年 5月至 1 999年 3月我们实施体外循环下心内直视手术 93例 ,4例死亡 ,其中低心排 1例 ,鱼精蛋白过敏 3例 ,治愈 89例 ,治愈率 95 % ,现将监护体会报告如下。1　临床资料本组 93例中男 71例 ,女 2 2例 ,3～ 5 0岁。室间隔缺损 5 4例 ,房间隔缺损 30例 ,心脏瓣膜置换 5例 ,冠状动脉搭桥术 3例 ,法乐四联症 1例 ,手术后监护至出院 ,平均 2 1ｄ。2　神经系统监测患者术毕入ＩＣＵ后即刻观察神志、瞳孔、角膜及四肢有无抽搐等症状。向手术医师、麻醉师了解手术、麻醉、体外循环转机时间及心脏复跳情况 ,查看皮肤有无电灼伤、冻伤等。3　呼…     

体外循环心内直视手术后大出血的观察与护理

体外循环心内直视术后大出血或渗血是术后早期并发症之一 ,如不及早发现 ,及时处理 ,对病人危害极大。术后严密监护 ,及时治疗 ,是抢救病人成功的关键。下面就此谈谈我们的护理体会。1　临床资料我院自 1986年 1月～ 1999年 12月开展体外循环心内直视手术 6 0 0余例 ;其中先天性心脏病 30 0例 ,风湿性心瓣膜病 30 0余例。发生大出血或渗血 ,需再次开胸止血者 17例 ,其中复杂先天性心脏病(法乐氏四联症 ) 3例 ,瓣膜置换术 14例。2　病因及预防2 1　病因出血原因主要有二方面 ,一是术中止血不够彻底 ,二是体外循环病人因肝素化及凝血因子的…     

低温体外循环心内直视术后体温的观察与护理

为探讨该类手术后患者体温变化的特点,作者将68例患者按不同手术类型分为3组,观察术后7d的体温变化情况。结果显示术后61例（89．7％）患者出现39℃以上高热,体温变化与手术类型无关。提示体外循环术后,体温短时间内变化较大,高热的原因除一般的吸收热外,与手术中低温、复温后体温反跳以及体外循环过程中产生的特殊物质有关。因此,针对不同情况采取及时有效的护理措施是极其重要的。     

先心病心内直视手术136例无死亡经验总结

我院 1991～ 2 0 0 0年共收治先心病 177例 ,其中在体外循环下行心内直视手术 136例 ,现介绍如下。1　临床资料1 1　一般资料　全组男性 75例 ,女性 6 1例 ,年龄 1 3～ 42岁。入院后根据病史、体征 ,结合心电图、胸片、心脏彩超及心导管 造影等检查 ,136例中房缺 5 4例、室缺 5 3例、ＰＳ 8例、瓦氏窦瘤破裂 4例、法三 4例、法四 6例、法五 2例、不完全性心内膜垫缺损 3例、Ｅｂｓｔｅｉｎ畸形 2例。1 2　手术方法　全组均在气静复合麻、体外循环下行手术。其中常温、不停跳行房缺修补、室缺修补、ＰＳ肺动脉瓣交界切开共 37例 ,其余均在低…     

体外循环心脏不停跳心内直视术

本文旨在介绍可简化心内直视术操作，缩短心肺转流时间的心脏不停跳法。对不停跳法心内直视术的应用机制，优缺点和适应证进行了探讨。     

体外循环心脏直视术中鱼精蛋白毒性反应的临床防治

目的：探讨体外循环心脏直视术中鱼精蛋白毒性反应的临床特点及防治对策，方法：回顾性分析连续1727体外循环心脏直视术病例，参照Oe及Weiler标准将其分为有反应组（鱼精蛋白毒性反应组）和无反应组，并将有反应组分为轻度和中重度反应组，分析其临床特点，结果：发生鱼精蛋白毒性反应者43例，发生率2．48％，其中轻度反应者35例（81．39％，35／43），中重度反应者8例（18．61％，8／43），有反应组与反应组临床一般情况无明显差别，中重度反应组转流时间及反应持续时间明显较轻度反应组长（P＜0．05）。中重度反应组死亡2例。结论：体外循环心脏直视术中鱼精蛋白毒性反应的发生难以预料；中重度反应者后果严重；临床上应充分认识鱼精蛋白毒性反应的特点，对转流时间较长的患者的应高度警惕鱼精蛋白毒性反应的发生；低浓度缓慢静脉给药可减少毒性反应的发生，发生严重毒性反应者应立即停药，迅速肝素化并再转机辅助循环，有利于对中重度毒性反应的救治。     

浅低温不停跳心内直视手术的体外循环管理探讨

目的探讨浅低温不停跳下心内直视手术的体外循环管理。方法回顾性分析我院78例不停跳心内直视手术的体外循环资料,观察患者的一般情况,体外循环时间,转机中血压、尿量、血气分析、停机时患者的心率、心律、血压、术后并发症等。结果78例患者均平稳完成体外循环,术后无严重并发症,均痊愈出院。结论浅低温不停跳心内直视手术安全可靠,心肌保护良好,可有效减轻低温和缺血再灌注对心肺等脏器的损伤,术后并发症少,患者恢复快。     

体外循环心内直视下先天性心脏病手术疗效分析

目的 探讨心内直视下先天性心脏病手术体外循环管理经验.方法 回顾性总结2005年1月至2009年1月80例4岁以下体外循环心内直视下先天性心脏病手术患儿的临床资料.结果 80例患儿手术经过基本顺利,未发生与体外循环相关的严重并发症,主动脉开放后自动复跳75例,电击复跳5例,无死亡病例.结论 体外循环心内直视下先心病矫治手术技术安全、可行,随着各种诊断技术的提高,以往被视为无法生存的许多复杂重症先心病患儿,可得到有效治疗.     

自体输血对心脏直视手术围术早期的影响

目的通过对23例心脏直视瓣膜手术成年患采用自体输血的临床观察,并与输异体血患组进行对比．探讨术前血色素正常患进行不输血心脏直视手术对围水早期产生的影响和相应处理方法。方法自体输血组的23例患术中采用综合节血措施．包括术毕回输体外循环前经腔静脉营入的肝素血(15～20ml／kg),术毕回输洗血球机清洗的手术刨口血血球和全部机血应用抑肽酶等：(1)自身对照比较患术前、术后返ICU及次晨的血红蛋白(Hb)、血小板(PLT)、白蛋白(ALB)、凝血酶原时间(PT)、纤维蛋白原(FIB）及动脉血氧分压(PaO2)的变化。(2)同时选择27例接受输异体血的瓣膜替换术患作为对照,比较两组间中心静脉压、血红蛋白、血小板及术后引流量等差异。结果自体输血组患术后Hb、PLT、AI．B、FIB均较术前降低(P<005),PT显延长(P<0．05);但Hh、PLT、FIB、PT仍在正常范围,ALB经补充后也能达到正常下限,Pa02水后较术前显升高。与对照组相比．实验组患术后Hb、PLT、引流量、术后晶体和蛋白输用量并无统计学显差异,而术中失血量、用库血量积术后代血浆用量却有明显差异。结论采用自体输血的心脏直视手术。围术期虽有轻度贫血但不影响血液的携氧功能,术后出凝血状况也不受影响。自体输血的影响主要集中在洗血球机回收刨VA失血同时也造成血浆丢失．加上不可控失血．造成术后围术早期血容量与血中白蛋白的变化,术后需补充适量代血装或人血白蛋白。     

Tubular proteinuria and enzymuria following open heart surgery

Objective We investigated the effect of cardiac surgery on a marker of tubular damage, an enzyme called neutral endopeptidase (NEP), and on a marker of tubular function, retinol binding protein (RBP). Markers of tubular damage or function are useful in the early detection of acute renal failure and help identify the risk factors for this disease. We also examined if colloid interfered with NEP measurement.Design A controlled prospective cohort study.Setting A teaching cardio-thoracic unit in London, England.Patients and participants Thirty-four patients underwent cardiac surgery. Eight patients waiting for cardiac surgery acted as controls.Interventions Twenty-five patients had coronary artery bypass graft, four patients had valve replacements, one patient had a coronary artery bypass graft with a valve replacement and one patient had a left ventricular aneurysm repair.Measurements and Results Neutral endopeptidase was measured in all the patients and controls. In separate subgroups RBP (n=5) and Gelofusine use (n=12) were recorded. Urine samples were collected pre-operatively, 3 h, 1 and 4 days post-operatively. NEP rose significantly (p<0.05) after cardiac surgery compared with the control population. RBP also rose significantly (p<0.05) after cardiac surgery. NEP correlated with RBP 3 h post-operatively (p<0.05, r²=0.97). There was no correlation between the amount of Gelofusine given and NEP excretion.Conclusion Excretion of NEP and RBP were both increased after cardiac surgery. Colloid did not affect the excretion of NEP, although in other studies it has affected the excretion of RBP. This may make NEP excretion a better index of acute and impending renal damage following cardiac surgery.Partial funding was obtained via a research vacation scholarship from the Wellcome Trust. (JB)Work was carried out at The Middlesex Hospital, London.     

自制弹力绷带用于PICC置管后的止血效果观察

目的 探讨PICC置管后穿刺点止血的有效方法.方法 将63例行PICC置管的血液病患者,在3M透明贴膜加纱布固定的基础上,加用自制弹力绷带加压包扎.观察病人穿刺点出血的情况.结果 58例患者PICC置管后局部无出血迹象,24 h出血停止率为92％.结论 PICC置管后穿刺点采用自制弹力绷带局部加压包扎,止血效果好,是预防血液病患者PICC置管后穿刺点出血的有效方法.     

Value of C-reactive protein in reflecting the magnitude of complement activation in children undergoing open heart surgery

The kinetics of C-reactive protein (CRP) were studied prospectively in 30 children (aged 21 days – 16 years) undergoing open heart surgery. CRP was related to the kinetics of total haemolytic complement, complement C3a and postoperative complications. Two (7%) patients died and ten (33%) had postoperative complications. The patients with complications were younger (p<0.035), underwent longer perfusions (p<0.001) and had longer aortic cross-clamping times (p<0.003). The mean peak CRP level after surgery (108 mg/l) was reached, on the average, in 43 h. No statistical difference in CRP concentrations was found between the complication and non-complication groups. Extensive complement activation was seen in every patient. CRP did not reflect the magnitude of complement activation induced by cardiopulmonary bypass. The patient sample was too small to draw reliable conclusions about the value of CRP in detecting postoperative complications after open heart surgery in children.     

大隐静脉曲张手术止血方法的研究及护理

目的 :研究大隐静脉曲张止血的方法。方法 :对单纯性下肢静脉曲张 10 8例施行大隐静脉高位结扎加剥脱术。实验组 (A组 ) 5 4例 ,用PVC管残腔止血法 ,对照组 (B组 ) 5 4例 ,用棉纱垫压迫止血法。结果 :手术时间A组平均 (85± 2 5 )min ,B组 (10 5± 2 3)min ;术中出血量A组 (75± 18)mL ,B组 (115± 2 1)mL ;术后并发腹股沟切口下血肿 ,A组无 ,B组 3例。结论 :大隐静脉高位结扎加剥脱术治疗下肢静脉曲张简便易行 ,止血效果好 ,缩短了手术时间 ,术后并发症少     

经升主动脉注射鱼精蛋白的肺保护作用

目的 探讨经升主动脉注射鱼精蛋白对婴幼儿体外循环心脏直视手术的肺保护作用.方法 60例(年龄≤1岁,体重≤10 kg)行体外循环心脏直视手术患儿,随机分为升主动脉组和中心静脉组各30例,比较2组注射鱼精蛋白前和注射鱼精蛋白后10 min、1 h、3 h气道峰压(Ppeak)、气道平台压(Pplate)及肺顺应性(CL)、氧合指数(OI)、肺隔离白细胞、中性粒细胞计数和术后呼吸机辅助通气时间的差异.结果 在注射鱼精蛋白1、3 h后,升主动脉组肺隔离白细胞、中性粒细胞计数、Ppeak、Pplate较中心静脉组明显减低(t值分别为2.743、3.512,3.218、3.469,3.716、5.243,3.853、4.783,P均＜0.05),升主动脉组CL及OI较中心静脉组明显增高(t值分别为3.976、4.267,4.557、4.265,P均＜0.05);升主动脉组较中心静脉组呼吸机辅助通气时间明显缩短[(8.03±5.14)、(10.56±6.95)h,t=2.599,P＜0.05].结论 经升主动脉注射鱼精蛋白能够减轻体婴幼儿体外循环心脏直视手术肺损伤,是一种良好的肺保护措施.

Abstract：

Objective To study the protective effect of intraaortic protamine injection on lung in infants undergwent opening heart operation by cardiopulmonary bypass surgery. Methods Sixty infants (age ≤ 1 year,weight ≤ 10 kg)who accepted opening heart operation by cardiopulmonary bypass surgery were randomly assigned into 2 groups ( n = 30 in each group) reciving intra-aortic and intra-venous protamine injection respectively. P-peak, P-plate, CL, Oxygenation Index, the number of WBC and neutrophil segregated in lungs were compared between two groups before injecting protamine and 10 minutes, 1 hour, 3 hours after injecting protamine. The time of mechanical ventilation were compared as well. Results P-peak, P-plate, the number of WBC and neutrophil segregated in lungs of intra-aortic injection group significantly decreased than intra-venous injection group at 1 hour, 3 hours after injecting protamine (t =2.743, 3.512; 3.218, 3.469; 3.716, 5.243; 3.853,4. 783 respectively, Ps ＜ 0. 05 ), while the CL and Oxygenation Index increased significantly ( t = 3. 976,4. 267; 4. 557,4. 265 respectively, P ＜ 0. 05 ). The duration of mechanical ventilation follow operation in intraaortic injection group ( [8. 03 ± 5. 14] h ) was shorter compared with intra-venous injection group ( [10. 56 ±6.95]h) (t =2.599,P＜0.05). Conclusion By intra-aortic protamine injection the lung injury decreased significantly. It shows good protective effect on lung in infants underwent opening heart operation by cardiopulmonary bypass surgery.     

Initial postoperative serum lactate levels predict survival in children after open heart surgery

Objective To evaluate the relationship between postoperative serum lactate levels and outcome in children undergoing open heart surgery.Design Prospective, noninterventional study.Setting Pediatric intensive care unit (PICU) of a university hospital.Patients 41 nonconsecutive children who had had cardiopulmonary bypass for repair of congenital heart disease.Interventions None.Measurements and results Serum lactate levels were measured on admission to the PICU immediately after open heart surgery. Lactate levels were correlated with bypass and cross clamp times, estimated intraoperative blood loss, lowest temperature on bypass, admission Pediatric Risk of Mortality score, anion gap, and measures of postoperative morbidity. Mean lactate levels on admission to the PICU were 6.86±0.79 mmol/l for nonsurvivors (n=7) and 2.38±0.13 mmol/l for survivors (n=34) (p<0.0001), and 4.87±0.7 mmol/l and 2.35±0.19 mmol/l, for patients with (n=11) and without (n=30) multiple organ system failure, respectively (p<0.0001). Admission lactate levels correlated with all measurements of postoperative morbidity. A serum lactate level of greater than 4.2 mmol/l had a positive predictive value of 100% and a negative predictive value of 97% for postoperative death.Conclusions Initial postoperative serum lactate levels after pediatric open heart surgery may be predictive of outcome. Lactate levels are also higher in patients who go on to develop multiple organ system failure. Elevated postoperative lactate levels may reflect intraoperative tissue hypoperfusion, and measures aimed at increasing oxygen delivery, with normalization of lactate, may improve patient outcome.