心脏直视手术的体外循环意外事件探讨

Analysis of cardiopulmonary bypass accidents and failure in cardiac surgery

目的探讨心脏直视手术中发生体外循环(CPB)意外的原因及对策。方法回顾性分析近2年内4 792例心脏直视手术病历资料,其中CPB意外14例,发生率0.29%。结果 14例意外事件中,设备故障6例,药物反应1例,人为因素7例,经及时对症处理,12例治愈,2例死亡。结论人为因素成为心脏直视手术中CPB意外事件发生的主要原因。因此加强医务人员培训及责任心教育对降低CPB意外的发生率具有重要的帮助。

Objective To explore the causes and countermeasures of cardiopulmonary bypass accidents in open heart surgery.Methods A retrospective analysis of 4792 cases of open heart surgery in recent 2 years was performed,including 14 cases of cardiopulmonary bypass accidents. Results The incidence rate was 0.29%. These accidents reported 6 episodes of equipment failure,1 episode of severe protamine allergy and 7 episodes caused by human factors. Two episodes resulted in death with causes of cerebral infarction and MODS. Conclusion Human factors were the main cause of cardiopulmonary bypass accidents in open heart surgery. Therefore it is of great help to strengthen the training of staff and the education in responsibility to reduce the incidence of cardiopulmonary bypass accidents.