体外循环下心脏直视手术肝素抗凝管理的研究进展

Anticoagulation with heparin in open heart surgery under extracorporeal circulation

背景 CPB下心脏直视手术抗凝的合理实施必不可少,尤其是抗凝过程中适当的药物及剂量, 精准的抗凝监测及维持，对于预防CPB 过程中致命性血栓形成、动脉栓塞，降低凝血系统活性，改善患者预后等极为重要。 目的 综述CPB下心脏手术抗凝药物肝素的临床问题。 内容 包括CPB下抗凝药物肝素的应用、个体化管理、临床改进等,为CPB下抗凝药物合理实施提供依据。 趋向 近年来研究表明，抗凝药物肝素应用于CPB的药物剂量，监测方法仍需改善。肝素替代药物的发展也为CPB抗凝提供新方向。

Background Anticoagulation is required for successful implementation of CPB. Particularly, appropriate dosing, monitoring, and maintenance of anticoagulation are essential to prevent devastating thrombosis of the CPB circulation or occlusion of the aorta, to minimize the stimulation of the coagulation system, and to improve the prognosis of the patients. Objective To review issues regarding heparin as an anticoagulant drug in extracorporeal circulation. Content Heparin is the most commonly used anti-coagulation drug because its action has many favoring features, including rapid onset, high capacitance, and readily reversibility. It activates fibrinolytic system to prevent thrombosis in CPB. But the variability of responses to heparin among individual patients pose demands for personalized regimens for its usage. To formulate a regimen, real-time monitoring of patients＇ coagulation system should be performed by measuring several critical parameters, including activated clotting time, levels of heparin, thromboelastography, etc. Protamine can be used to counteract with heparin. The risks of heparin-induced thrombocytopenia （HIT） should be taken into consideration before the operation. If patients have propensity to HIT or are resistant to heparin, heparin must be replaced with its substitutes. Trend Further investigations are demanded to improve the monitoring of the coagulation system in CPB and to develop better substitutes for heparin.