心脏手术中鱼精蛋白重度不良反应致严重循环抑制临床对策.docVIP

心脏手术中鱼精蛋白重度不良反应致严重循环抑制临床对策 　作者：王晓伟，梁永年，陈宇，吴延虎，陈亦江，张石江，秦建伟，陈亮 【摘要】 目的 探讨心脏手术中鱼精蛋白中和肝素时重度不良反应致严重循环抑制的临床治疗对策。方法 回顾性分析我科心脏手术中鱼精蛋白重度不良反应致严重循环抑制的病例资料，总结临床特征和救治重点。11例(8例给药后3～5 min，3例给药后30 min左右)出现严重循环抑制，其中3例为罕见的综合型(非心源性肺水肿型和灾难性肺血管收缩型综合作用)。结果 4例经药物治疗和心脏按摩好转。7例二次转机，6例患者顺利停机，1例不能停机行ECMO支持。表现为综合型(即非心源性肺水肿型和灾难性肺血管收缩型综合作用)的3例患者，2例继发多器官功能衰竭分别死于术后5天和7天，1例ECMO支持320 h后成功脱机，痊愈出院，死亡率66%。其他患者均痊愈。结论 鱼精蛋白重度不良反应至严重循环抑制是心脏手术中的严重并发症，难以预测。必要的预防措施和果断的二次转机是成功救治的关键。非心源性肺水肿型和灾难性肺血管收缩型综合作用的患者死亡率极高，ECMO支持是有效的治疗手段。 【关键词】 心脏手术;鱼精蛋白;循环抑制;临床对策 　　Abstract: OBJECTIVE To explore the clinical treatment of circulatory collapse deriving from the severe adverse reaction to protamine after cardiopulmonary bypass. METHODS We retrospectively analyzed data of patients with circulatory collapse from the severe adverse reaction to protamine(11 patients),and summarized the clinical characteristics and acute management. Among them, 3 patients diagnosed with rare combination type of noncardiac pulmonary edema with catastrophic pulmonary vasoconstriction.RESULTS Circulation status became stable in 4 patients after drug therapies and heart massage, and the other 7 patients received re-cardiopulmonary bypass. Of them, 6 patients weaned off bypass successfully and 1 patient needed ECMO support. Among 3 patients with combination type of noncardiac pulmonary edema with catastrophic pulmonary vasoconstriction, two of them died of MODS and one of them survived after 320 hours ECMO support. The mortality was 66%. CONCLUSION Circulatory collapse deriving from severe adverse reaction to protamine after cardiopulmonary bypass is a severe complication and can not be predicted. Preventive treatment and immediate re-cardiopulmonary bypass are the key point to rescue. The mortality of patients with combination type of noncardiac pulmonary edema with catastrophic pulmonary vasoconstriction is higher and ECMO support is the effective treament. 　　Key words： Open heart operation; Protamine; Circulatory collapse; Clinical treatment 　　CP