高龄患者瓣膜手术的体外循环管理.DOCVIP

临床医学论文-高龄患者瓣膜手术的体外循环管理 【摘要】? 目的回顾性总结高龄患者瓣膜置换术的体外循环（CPB）经验。方法28例65～73岁老年患者在全麻低温CPB下行瓣膜置换术，CPB采用中度低温，心肌保护应用4∶1（血：晶体）高钾（20 mmol/L）含镁（20 mmol/L）停搏液正灌或与逆灌联合，开升主动脉前温血灌注；CPB中维持灌注流量2.4L～2.8L/（m2·min）和平均动脉压（MAP）60～90 mm Hg；预充白蛋白20 g。CPB中应用超滤、悬浮红细胞、抑肽酶、速尿。结果 CPB时间45 min～305 min，升主动脉阻断时间25 min～168 min，围术期死亡1人，其余顺利康复出院。结论 4∶1高钾含镁冷血停搏液正灌或与逆灌联合、开升主动脉前温血灌注为有效的心肌保护方法，CPB中维持较高的平均动脉压及充足的流量，应用白蛋白、抑肽酶、速尿等有助于脑、肺、肾等重要脏器的保护。 【关键词】? 体外循环;高龄; 瓣膜置换 　　Management of Cardiopulmonary Bypass on Aged Patients?with Valve Replacement Operations 　　Abstract: OBJECTIVE To summarize the clinical experience of cardiopulmonary bypass(CPB) in valve replacement operations on aged patients. METHODS28 patients，range from 65 to 73 years old.They were received valve replacement surgery under hypothermic CPB after systemic anesthesia. Myocardial protection performed used blood cardioplegia .High perfusion flow 2.4L～2.8L/(m2·min)and high mean arteria pressure 60～90mmHg during CPB. All patients were given albumin 20g in CPB prime. Ultrafiltration technique,suspend red blood cell, aprotinin and furosemide were used during CPB. RESULTS CPB time was 45～305min, aortic cross-clamp time was 25～168min. One of the patients died during surgery, the others recovered ．CONCLUSIONIt was effective that myocardial protection performed by anterograde or by combination with anterograde and retrograde cardioplegia perfusion using 4∶1 hyperkalaemic, hypermagnesemic cold blood cardioplegia, or by warm blood anterograde cardioplegia before releasing the aortic cross-clamp. It helped to protect brain, lung and kidney that using albumin, aprotinin and furosemide during CPB.?　　Key words：CPB；Aged；Valve replacement 　　瓣膜病患者由于长期容量负荷及压力负荷加重，心脏扩大，心肌受损，心功能差。高龄老年患者除了心脏疾患还常有各脏器功能的减退及其它合并症，如高血压、脑血管疾病、糖尿病、肾功能不全等，手术并发症较多，死亡率较高。因此对高龄瓣膜患者心脏手术CPB管理提出更高的要求 　　1资料与方法? 　　1.1临床资料 　　本组28例，男13例，女15例，年龄65～73（68.8±3.6）岁，体重43～75（56±11.4）kg。术前心功能Ⅲ～Ⅳ级，其中Ⅲ级17例，Ⅳ级11例。心胸比例0.47～0.79（0.67±0.11）。28例中行主动脉瓣置换术7例，二尖瓣置换术8例，主动脉瓣置换合并二尖瓣置换术3例，二尖瓣置换术合并三尖瓣成形术6例，二尖瓣置换术合并冠状动脉旁