心内直视术后心包填塞和出血的早期诊治及原因分析

Retrospective clinical study on 26 cases with pericardial tamponade and bleeding after cardiac surgery

目的 分析 2 6例心内直视术后心包填塞和出血的临床特点 ,探讨其发生原因、预防、救治及其二次开胸的早期指征。方法 本研究就 2 0 0 0 - 0 1～ 2 0 0 2 - 0 7心内直视术 (共 170 3例 )后 2 6例二次开胸 (发生率 1 2 7% )病例进行总结分析。结果 据二次开胸手术证实结果 ,分为心包填塞组 (其中急性心包填塞 11例 ,延迟性心包填塞 2例 )和活动性出血组 (13例 )。患者经再次开胸解除心包填塞或手术止血后 2 3例痊愈出院 ,3例死亡 (其中急性心包填塞 2例 ,活动性出血组 1例 )。急性心包填塞组其pH、BE、SP、DP、尿量显著下降 (P <0 0 5 ) ,CVP、HR显著升高 (P <0 0 5 )。延迟性心包填塞发生于术后 4d ,其PaO2 进行性下降 ,CVP进行性升高 (P <0 0 5 )。活动性出血组术后其SP、DP、尿量显著下降 (P <0 0 5 ) ,HR升高 (P <0 0 5 ) ,pH、PaCO2 、PaO2 、HCO-3 、BE无显著差异 (P >0 0 5 )。与急性心包填塞组比较 ,活动性出血组心包和纵隔引流管水柱波动良好 ,引流量显著增多 (P <0 0 5 ) ,术前PT和INR明显延长 (P <0 0 5 )。结论 急性心包填塞和活动性出血是心内直视术后严重并发症 ,主要表现为循环系统不稳定 ,延迟性心包填塞主要表现为PaO2 下降 ,CVP显著升高 ;术前PT和INR明显延长 ,可能参与其?

Objective The main purpose of this study was to evaluate the prophylaxis and management and criteria for early re-exploration by analysis of the clinical characteristics of cases with pericardial tamponde and bleeding after cardiac surgery.Method In a retrospective procedure-matched study,26 of 1 703 patients of cardiac surgery during 31-month period from 01/2000 to 07/2002 underwent re-exploration (1 27%) Results Of 26 patients suffering with tamponade (11 cases with acute tamponade,2 cases with delayed cardiac tamponade)and bleeding(13 cases) after operation,23 patients were fully recovered from re-exploration and 3 patients died.Acute cardiac tamponade patients appeared significant decrease of pH,BE,SP,DP,urine( P <0 05),and increase of CVP,HR( P <0 05).Patients whose delayed pericardial tamponade occurred about the 4th day after operation and who appeared processing descent of PaO 2 and augment of CVP( P <0 05).Bleeding group appeared the significant decrease of SP,DP,urine( P <0 05),increase of HR ( P <0 05),and insignificant changes in pH,PaCO 2,PaO 2,HCO - 3,BE( P >0 05) Compared with acute cardiac tamponade group,the water column of pericardium and mediastina drain tube fluctuated well,and the flow of drainage-tube significantly increased ( P <0 05),and the pre-operative prothrombin time(PT) and INR were significantly elevated in delayed pericardial tamponade patients and bleeding group( P <0 05) Conclusion Hemodynamic lability was the common character of re-exploration cases.The diagnosis of cardiac tamponade was made by metabolic acidosis and hypoxia and high CVP.Weakened or disappeared fluctuation of water column of pericardium and mediastina drain tube might be the positive predictors of acute tamponade.Prothrombin time and INR elongation might be the preoperative risk factors of hemorrhage after operation.The appropriate strategies for management of this entity might be performed re-exploration early. [