体外循环不良事件的单中心回顾性分析

Retrospective analysis of adverse events related to cardiopulmonary bypass dur⁃ing open heart surgery

目的探讨心肺转流(CPB)下心外手术不良事件的原因和应对方法,提升医生处理突发情况的能力。方法收集2016年9月至2021年9月间,在本院心外科行CPB的病例资料3114例,回顾性分析手术中不良事件的发生情况。结果共发生不良事件36例,发生率为1.16%,其中人为因素11例,非人为因素25例,除严重意外导致死亡1例,其余患者均治愈出院,无并发症。结论CPB不良事件发生率低,但其出现迅速,若发现不及时可能会导致严重后果。对不良事件反馈学习,提高危机意识,加强人员培训,对降低CPB不良事件发生率有重要意义。

Objective To investigate the causes and countermeasures of adverse events related to cardiopulmonary bypass(CPB)during open heart surgery in order to improve the ability of dealing with CPB emergencies.Methods The data of 3114 cases underwent cardiac surgery with CPB in our hospital from September 2016 to September 2021 were collected,and the incidence of ad⁃verse events during surgery was analyzed retrospectively.Results A total of 36 cases of adverse events occurred with the incidence of 1.16%,including 11 cases of human factors and 25 cases of non-human factors.Except for 1 case of death caused by serious accident,the other patients were cured and discharged from hospital without complications.Conclusion CPB has a low incidence of adverse e⁃vents,but it happens rapidly.If it is not found in time,it may lead to serious consequences.Feedback learning of adverse events,im⁃proving crisis awareness and strengthening personnel training might reduce the incidence of adverse events in CPB procedure.