改良超滤法在成人微创心脏手术体外循环中的应用

Application of modified ultrafiltration in cardiopulmonary bypass during minimally invasive cardiac surgery in adults

目的探讨改良超滤法在成人微创心脏手术体外循环中的应用价值。方法行右前外侧小切口微创心脏手术成人患者30例,随机分为改良组17例和常规组13例,常规组采用常规超滤,改良组采用改良超滤;检测2组术前麻醉诱导后、停跳液灌注后5min、超滤开始、停体外循环机后20min、体外循环后4h时血红蛋白、乳酸、血糖和血浆胶体渗透压,记录主动脉阻断时间、体外循环转流时间、预充量、术中库血用量、超滤总量、术中尿量、术后库血用量、术后24h尿量、术后24h引流量、术后呼吸机辅助时间、ICU停留时间,比较术中超滤相关并发症发生情况。结果 2组均成功实施超滤,无超滤相关并发症发生;改良组术中库血用量[(96±80)mL]、术后库血用量[(96±32)mL]、术后24h引流量[(522.2±233.4)mL]较常规组[(224±96)、(176±48)、(740.3±198.4)mL]少(P<0.05),超滤总量[(1 280±79)mL]较常规组[(708±85)mL]多(P<0.05),主动脉阻断时间[(61.8±13.5)min]、体外循环转流时间[(98.5±25.5)min]、预充量[(1 635±190)mL]、术中尿量[(305±101)mL]、术后24h尿量[(3 147±1 168)mL]、呼吸机辅助时间[(8.9±4.1)h]、ICU停留时间[(2.1±0.2)d]与常规组[(63.8±18.1)min、(101.5±18.5)min、(1 651±183)mL、(321±98)mL、(2 708±1 176)mL、(9.5±4.7)h、(2.3±1.3)d]比较差异均无统计学意义(P>0.05);改良组停体外循环机后20min时血红蛋白水平[(94.7±5.8)g/L]高于常规组[(79.3±4.5)g/L](P<0.05),乳酸[(2.1±1.1)mmol/L]、血糖[(7.4±5.1)mmol/L]、血浆胶体渗透压值[(20.8±0.6)mm Hg]与常规组[(2.0±1.3)mmol/L、(6.9±4.5)mmol/L、(21.0±0.4)mm Hg]比较差异无统计学意义(P>0.05);余时间点2组血红蛋白、乳酸、血糖、血浆胶体渗透压值比较差异均无统计学意义(P>0.05)。结论微创心脏手术体外循环中应用改良超滤法可减少围术期库血用量,减轻组织水肿,有利于减少术后创面渗出。

Objective To explore the clinical value of modified ultrafiltration to cardiopulmonary bypass （CPB） during minimally invasive cardiac surgery in adults. Methods Thirty adult patients undergoing right anterolateral minimally invasive cardiac surgery were randomly divided into modified group （n= 17） receiving modified ultrafiltration and conventional group （n=13） receiving conventional ultrafiltration. The levels of hemoglobin, lactic acid, plasma glucose and plasma colloid osmotic pressure were detected at time points of preoperative anesthesia induction, 5 rain after injection of cardioplegia, at the begin of ultrafiltration, 20 minutes after the stop of CPB, and after CPB for 4 h, respectively. The aortic clamping time, CPB time, priming volume, intraoperative banked blood used volume, total ultrafiltration volume, intraoperative urine volume, postoperative banked blood used volume, postoperative 24 h urine volume, postoperative 24 h drainage volume, postoperative ventilator support time, ICU stay and intraoperative ultrafiltration related complications were recorded. Results Ultrafiltration was successfully accomplished in two groups, with no uttrafiltration related complications. The intraoperative banked blood used volume （（96 ± 80） mL）, postoperative banked blood used volume （（96±32） mL） and postoperative 24 h drainage volume （（522.2±233.4） rnL） were significantly less, and total ultrafiltration volume （（1 280 ± 79） mL） was significantly larger in modified group than those in conventional group clamping time （（61.8±13.5） min）, CPB time （（98.5±25.5） min）, priming volume （（1 635±190） miD, intraoperative urine volume （（305±01） mL）, postoperative 24 h urine volume （（3 147±1 168） mL）, ventilator support time （（8.9± 4.1） b） and ICU stay （（2.1±.2） d） in modified group in comparison with those in conventional group （（63.8±18.1） rain, （101.5±18.5） rain, （1 651±183） mL, （321±98） mL, （2 708±1 176） mL, （9.5±4.7） h, （2.3±1.3） d） （P〈0.05）. The hemoglobin level （（94. 7 ± 5.8）g/L） in modified group was significantly higher than that in conventional group （（79.3±4.5） g/L） in 20 rain after stop of CPB （P〈.05）, and there were no significant differences in the levels of lactic acid, plasma glucose and colloid osmotic pressure between modified group （（2. 1 _±l. 1） mmol/L, （7.4 ± 5. 1） mmol/L, （20.8±0.6） mm Hg） and conventional group （（2.0± 1.3） mmol/L, （6. 9±4. 5） mmol/L, （21. 0± 0.4） mm Hg） （P〈0.05）. There were no significant differences in the levels of hemoglobin, lactic acid, plasma glucose and colloid osmotic pressure at the other time points between two groups （P〈 0.05 ）. Conclusion The modified ultrafiltration method can reduce the perioperative banked blood used volume, reduce tissue edema, and contribute to the reducing of postoperative wound exudation in minimally invasive cardiac surgery.