含血预充液超滤技术在婴儿心脏手术中的应用

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目的探讨体外循环(CPB)手术中含血预充液进行超滤洗涤后是否能使预充液达到生理状态,以及该方法对患者围术期电解质、酸碱平衡和心肺功能的影响。方法选取2009年2月至2009年6月在复旦大学附属儿科医院施行先天性心脏病手术治疗的40例患者,随机分为两组,实验组(n=20):男12例,女8例;年龄131.00±103.00 d,体重4.14±0.96 kg;术前利用CPB管道中血液超滤器对含血预充液进行超滤洗涤20 min。对照组(n=20):男11例,女9例;年龄127.00±88.00 d,体重4.38±1.05 kg;预充液在CPB管道中循环20 min。测定含血预充液洗涤前、后和患者围术期血气分析和电解质等指标;用超声心动图检测心功能指标包括短轴缩短率(FS),射血分数(EF)和心排血量(CO);观察肺功能变化。结果两组患者无死亡,均顺利出院。实验组呼吸机辅助呼吸时间显著短于对照组(2.7±0.3 d vs.4.1±0.4 d,P<0.05)。实验组含血预充液经洗涤超滤后的各项指标均达到正常值范围,pH值升高(从6.89±0.22升至7.40±0.57,P=0.001),BE值升高(从-16.12±0.98 mmol/L上升至+0.31±2.40 mmol/L,P=0.000),钾离子浓度降低(从10.33±2.13 mmol/L降至4.27±0.93 mmol/L,P=0.000);白细胞介素-8浓度降低(从78.40±6.10 pg/ml下降至64.30±48.10 pg/ml,P=0.036);缓激肽浓度降低(从5 982±1 353pg/ml下降至531.00±35.00 pg/ml,P=0.031)。实验组FS、EF和CO术后下降幅度均小于对照组,术后4 h实验组CO显著高于对照组(2.77±0.95 L/min vs.1.66±0.75 L/min,P=0.001);术后24 h实验组EF高于对照组(67.44%±6.89%vs.61.17%±9.02%,P=0.003)。术后6 h两组肺泡-动脉血氧分压差(A-aDO2)和呼吸指数(RI)显著上升(P<0.05),然后开始逐渐下降恢复至术前水平。实验组趋向于更早开始恢复肺功能。术后48 h,实验组A-aDO2和RI明显低于对照组(P<0.05)。结论对含血预充液进行洗涤超滤可使CPB预充液更符合生理状态,减少炎性介质,改善婴幼儿术后心肺功能,这对新生儿和小婴儿进行复杂先天性心脏病手术时显得尤其重要。 Objective To investigate whether the preconditioning solution can reach the physiological state after ultrafiltration with blood preconditioning in CPB surgery and the effects of this method on electrolyte, acid-base balance and cardiopulmonary function during perioperative period. Methods Forty patients with congenital heart disease undergoing pediatric hospital affiliated to Fudan University from February 2009 to June 2009 were randomly divided into two groups: experimental group (n = 20): 12 males and 8 females ; Age 131.00 ± 103.00 d, body weight 4.14 ± 0.96 kg; preoperative use of CPB pipeline blood ultrafilter for blood prefilled with ultrafiltration washing 20 min. The control group (n = 20): 11 males and 9 females; the age was 127.00 ± 88.00 days and the body weight was 4.38 ± 1.05 kg. The priming solution was circulated for 20 minutes in the CPB tube. The blood gas analysis and electrolytes and other indexes before and after the preconditioning with blood and the perioperative period were measured. The cardiac function indexes including short axis shortening (FS), ejection fraction (EF) and cardiac output (CO); observed changes in lung function. Results There were no deaths in both groups and all were discharged smoothly. The ventilator-assisted breathing time in the experimental group was significantly shorter than that in the control group (2.7 ± 0.3 d vs.4.1 ± 0.4 d, P <0.05). In the experimental group, the indexes of the blood prefilled liquid after washing and ultrafiltration all reached the normal range, the pH value increased (from 6.89 ± 0.22 to 7.40 ± 0.57, P = 0.001) and the BE value increased (from -16.12 (P <0.0002), ± 0.98 mmol / L increased to +0.31 ± 2.40 mmol / L, P = 0.000) and the concentration of potassium decreased (from 10.33 ± 2.13 mmol / L to 4.27 ± 0.93 mmol / L, 8 decreased from 78.40 ± 6.10 pg / ml to 64.30 ± 48.10 pg / ml, P = 0.036; decreased bradykinin concentrations from 5 982 ± 1 353 pg / ml to 531.00 ± 35.00 pg / ml, P = 0.031). The decrease of FS, EF and CO in the experimental group were less than those in the control group, and the CO in the experimental group 4 h after operation was significantly higher than that in the control group (2.77 ± 0.95 L / min vs 1.66 ± 0.75 L / min, P = 0.001) After 24 h, the experimental group EF was higher than the control group (67.44% ± 6.89% vs.61.17% ± 9.02%, P = 0.003). The alveolar-arterial partial pressure of oxygen (A-aDO2) and respiratory index (RI) of the two groups increased significantly (P <0.05) 6 h after operation, and then gradually decreased to the preoperative level. The experimental group tended to begin earlier to restore lung function. After 48 h, the A-aDO2 and RI in the experimental group were significantly lower than those in the control group (P <0.05). Conclusion The ultrafiltration of blood priming solution can make CPB prefill more physiological, reduce the inflammatory mediators and improve the cardiopulmonary function after infants and young children, which is very complicated for neonates and small infants during complicated congenital heart surgery It is especially important.
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