深低温停循环上腔静脉逆行灌注在主动脉瘤手术中应用

Use of Deep Hypothermic Circulatory Arrest with Retrograde Cerebral Perfusion in Patients Who Underwent Aortic Aneurysm Operations

目的结合深低温停循环(DHCA)上腔静脉逆行脑灌注(RCP)脑保护技术在主动脉瘤手术中应用,探讨脑保护的方式。方法选取我院2006年1月～2008年12月在体外循环下应用DHCA结合RCP的主动脉瘤患者13例,标准全身麻醉,头部置冰帽,全身血流降温,鼻咽温降至16～18℃,肛温18～20℃时,应用DHCA结合RCP,RCP期间控制右颈内静脉压力20～25mmHg,根据压力调整灌注流量;采用控制降、复温速率和冷复灌技术管理温度;PH+α稳态法管理血气;合理的脑保护药物应用;适度的血液稀释和浓缩技术。结果体外循环时间190～689(305.23±129.09)min,主动脉阻断时间123～326(179.12±63.22)min,RCP时间25～96(45.77±20.58)min。心脏自动复跳11例,除颤复跳2例。本组患者均顺利脱离体外循环。术后4h内清醒4例,6h内清醒2例,12h内清醒4例,96h清醒1例,无神经系统并发症。术后早期死亡2例,1例死于肺部感染,1例死于多器官功能衰竭,死亡原因与体外循环无关。结论RCP是一种简单有效的脑保护技术,能明显延长DHCA时间,结合综合脑保护措施的应用,取得较为满意的临床效果。

Objective The aim of our study was to evaluate the efficacy and safety of deep hypothermic circulatory arrest （DHCA） with retrograde cerebral perfusion （RCP） as a method of cerebral protection during aortic aneurysm operations. Methods From January 2006 to December 2008, 13 consecutive patients with aortic aneurysms underwent operations performed with DHCA ＋RCP in our hospital, after induction of general anaesthesia, ice packs were placed around the patient＇s head to cover the entire head, then the patient was placed on full extracorporeal blood circulation（ECC） and systemic core cooling was started, when the nasopharyngeal temperature had reached 16℃ to 18℃, rectal temperature had reached 18℃ to 20℃, DHCA combined with RCP were used. Cerebral perfusion was adjusted to maintain the right internal jugular vein pressure between 20 and 25 mmHg. We controlled cooling and rewarming rates and cold reperfusion to manage the temperature; Either pH-stat or α -stat were used to assess blood gas; We also used rational drug therapy and adequate blood dilution and concentration technology. Results The mean bypass time was 305.23±129.09 minutes （range, 190 to 689 minutes）, the mean cross-clamp time was 179.12± 63.22 minutes （range, 123 to 326 minutes）, and the mean RCP time was 45.77±20.58 minutes （range, 25 to 96 minutes）. 11 patients＇ hearts were observed beating spontaneously and 2 electrically paced. All patients were successfully weaned off ECC. 4 patients were awake within 4 hours after operation, 2 patients were awake within 6 hours, 4 patients were awake within 12 hours and 1 patient was awake within 96 hours respectively. No neural complications had been observed. 2 patients died in the early postoperative period, of which 1 was related to pulmonary infection and 1 died from multi-organ failure, the causes of death were not related to ECC. Conclusion RCP is an simple and effective method of cerebral protection with a longer DHCA time, combined with a comprehensive method of cerebral protection, may encourage results in terms of clinical outcome.