The Application Effect of Predictive Nursing on Cardiopulmonary Rehabilitation of Patients Undergoing Heart Valve Surgery with Extracorporeal Circulation

Objective:To evaluate the application effect of predictive nursing on patients undergoing heart valve surgery with extracorporeal circulation(ECC).Methods:92 ECC patients admitted to the hospital between July 2021 and July 2023 were selected and grouped by random number table method;the observation group practiced predictive nursing,while the reference group practiced conventional nursing.The cardiopulmonary rehabilitation and other indexes were compared between the groups.Results:The postoperative rehabilitation time of the observation group was shorter than that of the reference group,the treatment compliance was higher than that of the reference group,the cardiopulmonary function indexes were all better than that of the reference group,and the complication rate was lower than that of the reference group(P<0.05).Conclusion:The implementation of predictive nursing for ECC patients can promote postoperative rehabilitation,improve patients’treatment compliance,and enhance the cardiopulmonary rehabilitation effect,and nursing safety is high.

Impact and Management under Extracorporeal Circulation of a Patient with Renal Insufficiency on Dialysis with a High-Flow Arteriovenous Fistula in the Cardiac Surgery Department of the Angers Teaching Hospital about a Case and Review of the Literature

Arteriovenous fistulas have a substantial impact on systemic hemodynamics, however their effect on extracorporeal circulation is not well understood. We report our clinical observation on the management under extracorporeal circulation of a patient with renal insufficiency with a high-flow arteriovenous fistula. This is a 59-year-old man who was referred to us for surgical treatment of ischemic coronary artery disease in a context of anuric chronic renal failure. Hypothermia at 32°C is started from the start in CEC due to hyperflow at the level of the arteriovenous fistula. We performed two coronary artery bypasses of the marginal and IVA via the two internal thoracic arteries. The patient is hemofiltered in order to avoid hyperkalaemia and possibly avoid fluid overload related to filling per CEC. The clamping time was 71 minutes and the SCC lasted 141 minutes. There was no homologous transfusion in the operating room. It turns out that the input/output balance is zero at the end of the CEC. The postoperative course was simple.

Extracorporeal membrane oxygenation states basilar artery thrombectomy and left posterior cerebral artery stent thrombectomy:A case report

BACKGROUND Extracorporeal membrane oxygenation(ECMO)is a new type of extracorporeal respiratory and circulatory assistance device.It can drain venous blood out of the body and inject it into veins or arteries after being oxygenated by an oxygenator(membrane lung)to replace lung and heart functions in a short time.ECMO can provide tissue blood perfusion and gas exchange almost equivalent to cardiac output and extend the effective treatment time window for patients with acute circulatory failure to restore cardiopulmonary function.CASE SUMMARY We report a case of an 81-year-old woman who underwent whole cerebral angiography,basilar artery thrombectomy and stent thrombectomy in the posterior artery of the left brain after implantation of ECMO.The patient was admitted to the hospital due to myocardial infarction.Considering that the cause of the patient’s disturbance of consciousness was unknown and cerebrovascular accident could not be ruled out after the implantation of ECMO,the department of Radioactive Intervention performed cerebral angiography.And the result of the angiography indicated vascular occlusion.After the basilar artery thrombectomy and stent thrombectomy in the posterior artery of the left brain,the patency of the occlusive vessel was achieved.CONCLUSION Although the patient eventually died of circulatory failure,the result of this case verifies the feasibility of cerebral angiography and thrombectomy in patients with implanted ECMO in the intubated state.

Application Effect of External Diaphragm Pacemaker Combined with Active Respiratory Circulation Technology in Pulmonary Rehabilitation of Perioperative Lung Cancer Patients

Aim: To explore the application effect of external diaphragm pacemaker combined with active respiratory circulation technology in pulmonary rehabilitation of perioperative lung cancer patients. Methods: A total of 98 lung cancer patients admitted to our hospital from April 2020 to November 2021 were selected as the observation objects, and then divided into a control group and an observation group using the random number table method, with 49 cases in each group. The control group received routine admission guidance and active respiratory circulation training, while the observation group was supplemented with external diaphragm pacemaker on the basis of the control group. The intervention effect was evaluated by blood gas indicators, pulmonary function indicators, diaphragm function indicators, sputum comfort degree, and activity tolerance indicators before and after intervention. Results: Before intervention, there were no significant differences in blood gas analysis indicators, pulmonary function indicators, diaphragm function indicators, sputum comfort degree, and activity tolerance indicators between the two groups (P > 0.05). After intervention, the improvement degree of the above indicators in the observation group was higher than that in the control group (P < 0.05). Conclusions: The application of external diaphragm pacemaker combined with active respiratory circulation technology in pulmonary rehabilitation of perioperative lung cancer patients is significant, which can effectively improve the pulmonary function, blood gas function, and diaphragm function of lung cancer patients after surgery, and improve the activities of daily living and quality of life of patients.

Hyperbilirubinemia after extracorporeal circulation surgery:A recent and prospective study

AIM： To clarify the incidence and nature of postoperative hyperbilirubinemia in patients after modern extracorporeal circulation, to analyze possible perioperative risk factors, and to elucidate the clinical significance of postoperative hyperbilirubinemia associated mortality and morbidity. METHODS： Between March 2005 and May 2006, three hundred and eighty six consecutive patients undergoing extracorporeal circulation surgery due to a variety of cardiac lesions were investigated prospectively. The incidence of postoperative hyperbilirubinemia was defined as a serum total bilirubin concentration of more than 51 μmol/L. Several perioperative parameters were compared by logistic regression between hyperbilirubinemia and non-hyperbilirubinemia patients to determine possible risk factors contributing to postoperative hyperbilirubinemia and mortality. RESULTS： Overall incidence of postoperative hyperbilirubinemia was 25.3% （98/386）. In patients with postoperative hyperbilirubinemia, 56.2% reached peak total bilirubin concentration on the first postoperative day, 33.5% on the second day, and 10.3% on the seventh day. Eighty percent of the increase of total bilirubin resulted from an increase of both conjugated and unconjugated bilirubin. Development of postoperative hyperbilirubinemia was associated with a higher mortality （P 〈 0.01）, longer duration of mechanical ventilation （P 〈 0.05） and longer ICU stay time （P 〈 0.05）. Preoperative total bilirubin concentration, preoperative right atrium pressure, numbers of valves replaced and of blood transfusion requirement were identified as important predictors for postoperative hyperbUirubinemia. CONCLUSION： Early postoperative hyperbilirubinemia after modern extracorporeal circulation is mainly caused by an increase in both conjugated and unconjugated bilirubin, and is associated with a high mortality. Important contributing factors are the preoperative total bilirubin concentration, preoperative severity of right atrial pressure, numbers of valve replacement procedures, and the amount of blood transfusion requirement during and shortly after surgery. We suggest that postoperative hyperbilirubinemia is a multifactorial process, which is caused by,both the impaired liver function of bilirubin transport and the increased production of bilirubin from haemolysis.

Is it possible to block the cancer cells in circulating blood by extracorporeal circulation? Implications of the immune system and other factors (review)

The presence of cancer cells in circulating blood and the possibility of colonization in the tissues of the body worsen in a determinant way the prognosis of the disease. Nevertheless, there are factors in the body that can lead to a prognostic improvement, even in such conditions. In addition to the immune system, other favorable factors can act at the level of the microenvironment of the tumor so much that cases of spontaneous total regression, not only of primary tumors but also metastases, have been reported in the literature. Since it was recently reported that patients with renal tumors and in permanent hemodialysis present at post mortem examination, a metastatic spread much less extensive than observed in patients deceased for renal tumors but not on hemodialysis. The authors maintain it likely that the dialytic membrane concurs to block at least in part the cancer cells circulating in the blood. The possibility to block cancer cells can be extended in addition to the dialytic membrane also to other types of filters inserted in the extracorporeal circulation. The block of the cancer cells thus is obtained and that occurs in regional lymph nodes and in the microenvironment of the tumor causing a relative increase in the elements of the immune system compared to the number of cancer cells, which could determine clearly positive therapeutic results also in cases with advanced metastatic spread.

Successful extracorporeal life support in sudden cardiac arrest due to coronary anomaly

Extracorporeal life support(ECLS) has recently been reported to have a survival benefit in patients with cardiac arrest. It is now used widely as a lifesaving modality. Here, we describe a case of sudden cardiac arrest(SCA) in a young athlete with an anomalous origin of the right coronary artery from the left coronary sinus. Resuscitation was successful using ECLS before curative bypass surgery. We highlight the efficacy of ECLS for a patient with SCA caused by a rare, unexpected aetiology. In conclusion, ECLS was a lifesaving modality for SCA due to an anomalous coronary artery in this young patient.

Extracorporeal cardiopulmonary resuscitation for adult cardiac arrest patients

Cardiac arrest is a major cause of unexpected death in developed countries, and patients with cardiac arrest generally have a poor prognosis. Despite the use of conventional cardiopulmonary resuscitation(CPR), few patients could achieve return of spontaneous circulation(ROSC). Even if ROSC was achieved, some patients showed re-arrest and many survivors were unable to fully resume their former lifestyles because of severe neurological deficits. Safar et al reported the effectiveness of emergency cardiopulmonary bypass in an animal model and discussed the possibility of employing cardiopulmonary bypass as a CPR method. Because of progress in medical engineering, the system of venoarterial extracorporeal membrane oxygenation(ECMO) became small and portable, and it became easy to perform circulatory support in cardiac arrest or shock patients. Extracorporeal cardiopulmonary resuscitation(ECPR) has been reported to be superior to conventional CPR in in-hospital cardiac arrest patients. Venoarterial ECMO is generally performed in emergency settings and it can be used to perform ECPR in patients with out-of-hospital cardiac arrest. Although there is no sufficient evidence to support the efficacy of ECPR in patients with out-of-hospital cardiac arrest, encouraging results have been obtained in small case series.

Veno-Venous Extra-Corporeal Membrane Oxygenation (ECMO) in a Child with Hemoptysis and Fontan Circulation

Background: Extracorporeal membrane oxygenation is a rescue life support technique used in life threatening conditions of refractory respiratory and/or cardiac distress. Indication for extracorporeal life support in children depends on age and varies from pulmonary to cardiac pathologies. In some cases, it may be used as a bridge to a therapeutic procedure. We described here the management of respiratory failure due to hemoptysis in a child with a Fontan circulation and veno-venous extracorporeal membrane oxygenation which served as a bridge to angio-embolization. Hemoptysis can be a life threatening condition which can lead to hypovolemic shock and impaired alveolar gas exchange. The latter can result in respiratory failure and consequent asphyxia. When hemoptysis occurs in a patient with a univentricular heart and a Fontan circulation, management of this clinical situation can be challenging due to the particular physiology of the latter. Total cavopulmonary connection is a palliative surgical repair which constitutes Fontan circulation as a definitive treatment in patients with a univentricular heart. Methods: Case report description of a 16 year-old boy with a univentricular heart and a Fontan circulation who presented hemoptysis managed with a veno-venous extracorporeal membrane oxygenation (ECMO) as a bridge to angio-embolization. Results: Hemoptysis due to diffuse intra-alveolar hemorrhage from collateral circulation was successfully treated in this young patient with pulmonary vascular embolization. This allowed to wean the patient from extra-corporeal membrane oxygenation. Conclusion: Veno-venous ECMO can be life-saving as a bridge to angio-embolization for severe hemoptysis in patients with Fontan circulation. The reported case allows to underline that our multidisciplinary approach in this complex pediatric patient surely participated to improve outcome.

Clark护理联合循环管路小组模式在血液透析患者中的应用探索

目的探讨Clark护理联合循环管路小组模式在血液透析患者中应用的临床价值。方法回顾性分析2021年3月至2022年3月我院106例肾功能衰竭患者的临床资料,采用便利抽样方法,遵循自愿原则将接受Clark护理联合循环管路小组护理的患者为研究组(53例),接受常规护理的患者为对照组(53例)。比较两组的医院焦虑抑郁量表(HAD)、纤维蛋白原(FIB)、匹兹堡睡眠质量指数(PSQI)、血清肌酐(Scr)、D二聚体(D-D)、血磷(P)、全段甲状旁腺素(iPTH)、成年人健康自我管理能力测评量表(AHSMARS)、血钙(Ca)、终末期肾病维持性血液透析患者治疗依从性量表(MTAS-ESRD)、血小板(PLT)、透析并发症发生情况及肾脏疾病特异性调查表(KDQ)评分。结果干预前,两组的HAD、FIB、PSQI、P、D-D、AHSMARS、Scr、Ca、iPTH、MTAS-ESRD、PLT、各项KDQ评分差异无统计学意义(P>0.05);干预后,研究组的HAD、FIB、PSQI、P、Scr、Ca、D-D、iPTH、PLT低于对照组(P<0.05),研究组的AHSMARS、MTAS-ESRD、各项KDQ评分(躯体症状、挫折、疲劳、与他人关系)高于对照组(P<0.05)。研究组的透析并发症发生率低于对照组(P<0.05)。结论Clark护理联合循环管路小组护理在血液透析患者中的应用效果良好,能够提高血液代谢产物清除效率与管路安全性,改善患者不良情绪、健康管理能力与依从性,降低体外循环凝血等并发症发生风险,提升生活质量。

导师制短期高级培训在体外循环高难度专项技术提升中的应用探索

目的评估导师制短期高级培训应用于体外循环高难度专项技术教学的效果,探索该培养模式的应用。方法纳入2022年1月至2023年1月于首都医科大学附属北京安贞医院体外循环与机械循环辅助科进修的32名医师作为研究对象,进修时长均为1个月。分不同专业进修方向,包括主动脉内球囊反搏(8名)、微创体外循环(8名)、大血管体外循环(8名)和小儿体外循环(8名),自选导师进行一对一教学。分别于入科前和出科后由科室内不参与导师教学制度的专业医师对学员能力进行评估并打分,出科后3 d内完成对学员的问卷调查,观察学员自评和学员对导师的评价结果。结果经过为期1个月的培训,学员在理论知识、临床操作、危重患者管理、异常情况判定及处理、团队沟通合作意识方面的能力均得到显著提升,各项评分及总分均高于入科前[(4.5±0.5)分比(2.5±0.7)分、(4.4±0.7)分比(2.5±0.5)分、(3.8±0.9)分比(1.8±0.7)分、(4.0±0.7)分比(2.4±0.6)分、(4.4±0.6)分比(2.5±0.6)分、(21.1±1.8)分比(11.8±1.3)分],差异均有统计学意义(均P<0.001)。经学员自评,其理论知识方面提升的平均值为57.2%,临床操作技术方面提升的平均值为61.9%,危重患者管理方面提升的平均值为60.0%,疑难杂症诊疗方面提升的平均值为64.1%,意外情况处理方面提升的平均值为65.3%。学员对导师在理论知识和临床经验、临床操作熟练程度及教学参与程度、反馈工作及时性方面的评价均较高,平均分值不低于4.00分。结论导师制短期高级培训在体外循环高难度专项技术提升中发挥了积极作用,对于体外循环专业进修学员有很好的教学效果,可以在有一定专业基础的体外循环进修医师教学中应用。

体外循环下心血管外科术后谵妄管理审查指标制定及障碍因素分析

目的:评估体外循环下心血管外科病人术后谵妄管理证据在临床的应用现状,构建审查指标,分析循证实践的障碍与促进因素,为临床制定策略提供依据。方法:以知识转化模式(knowledge to action framework,KTA)为指导,系统检索、评价、汇总证据,制定审查指标并明确审查方法,2022年8月20日—9月30日进行基线审查,根据基线审查结果分析循证实践过程中的障碍和促进因素,并制定相应的策略。结果:共纳入35条证据,对证据进行遴选,最终纳入23条适合临床的最佳证据、27条审查指标。其中10条审查指标的准确执行率为0,9条审查指标准确执行率低于30%,4条审查指标准确执行率较高,在80%以上。对审查指标逐条分析后,明确主要障碍因素为制度流程建立不足、术后谵妄护理工具构建不完善、医护间合作欠佳、护理人员认知缺乏、环境支持不足、人力资源不足等。结论:基于最佳证据和专业判断构建的审查指标科学、有效,具有适宜性和可行性,障碍因素及促进因素分析与变革策略的制订可为体外循环下心血管外科术后谵妄管理临床实践提供保障。

中-浅低温停循环行主动脉弓部手术后神经系统并发症发生危险因素及与术中最低膀胱温的关系

目的探讨中-浅低温停循环行主动脉弓部手术后神经系统并发症发生危险因素及与术中降温至最低膀胱温的关系,旨在为术中停循环下温度控制及预后改善提供更多参考。方法回顾性纳入2016年1月至2023年1月于本院行中-浅低温停循环主动脉弓部手术患者共123例,根据术后有无神经系统并发症分为并发症组(35例)和无并发症组(88例);采用单因素和Logistic回归模型多因素分析确定患者神经系统并发症发生独立危险因素,并进一步通过多元线性回归模型评估术中最低膀胱温与患者神经系统并发症发生风险间的关系。结果单因素分析结果显示,术前脑灌注情况、术中最低膀胱温、手术时间、体外循环时间及升主动脉阻断时间均可能与主动脉弓部手术患者神经系统并发症发生有关(P<0.05);Logistic回归模型多因素分析结果显示,术前脑灌注不良和术中最低膀胱温均是中-浅低温停循环行主动脉弓部手术患者神经系统并发症发生独立危险因素(OR=1.26,1.85,95%CI:1.12~4.48,1.37~6.83,P<0.05);多元线性回归模型分析结果显示,术中最低膀胱温与患者术后神经系统并发症发生风险独立相关(OR=0.54,95%CI:0.30~0.91,P=0.02);其中术中最低膀胱温30~34℃是患者神经系统并发症发生独立保护因素(OR=0.07,95%CI:0.01~0.92,P=0.04)。结论中-浅低温停循环行主动脉弓部手术患者神经系统并发症发生与术前脑灌注情况和术中最低膀胱温有关,术中维持膀胱温在浅低温有助于降低神经系统并发症发生风险。

双胎妊娠11周突发主动脉窦瘤破入右心房患者的围手术期护理

总结1例双胎妊娠11周突发主动脉窦瘤破入右心房患者的围术期护理体会。护理要点:术前孕妇心脏功能监测,包括瘤体及破裂状况监测、预警右心衰竭及猝死,术中并发症监测及预防,术后精准容量管理及肾功能监测,围术期胎儿监测,健康教育及出院指导。经过9d的精心治疗和护理,患者康复出院,随访36周后经剖宫产分娩双胎,母儿状况良好。

体外循环手术同期改良迷宫射频消融治疗心脏疾病合并持续性心房颤动的临床研究

目的:探究体外循环手术同期改良迷宫心房颤动射频消融术(COX-Maze IV,CMIV)治疗心脏疾病合并持续性心房颤动的有效性和对左心房功能的影响。方法:回顾性分析2016年1月至2023年8月,我科治疗的235例持续性心房颤动合并其他需体外循环手术患者的临床资料,患者均接受同期改良CMIV手术。男性68例、女性167例,评均年龄(51.5±6.7)岁,心房颤动病程中位数4年。术后随访12个月,观察患者窦性心律恢复及左心房功能恢复情况。结果:235例患者均顺利完成手术,出院前心房颤动转为窦性心律或交界性心律占206例(90.0%),194例(84.7%)恢复左心房功能,平均A波速度(37.6±11.4)cm/s。术后12个月随访,维持窦性心律及左心房功能恢复患者分别占82.7%和80.1%。结论:体外循环手术同期改良CMIV治疗心脏疾病合并持续性心房颤动是有效的,且有助于左心房功能恢复。

关于体外循环专业质量控制指标遴选的一些思考

质控指标体系是医疗质量管理与控制体系的重要组成部分。构建科学、规范的医疗质控指标体系对加强科学化、精细化医疗质量管理,促进医疗质量持续改进具有重要意义[1-2]。近年来,为进一步加强医疗质量与医疗技术管理,规范临床诊疗行为,促进医疗服务的标准化、同质化,国家卫生健康委办公厅陆续发布了部分临床专业质控指标、单病种质量控制指标、国家限制类技术质控指标。截止到2023年11月国家卫健委共制定了43个专业(含限制性技术等)质量质控指标,同期国家卫生健康委医院管理研究所汇总了2015年至2023年11月间由国家卫健委发布的各专业的医疗质量控制指标,并编制发布了《医疗质量管理与控制指标汇编》5.0版本供临床参阅。

体外循环相关全身炎症反应与器官损伤

心肺转流(cardiopulmonary bypass,CPB)后器官损伤高发生率依然是横亘在心血管外科发展道路上的难题,其中急性肾功能衰竭7.7%~28.1%[1],呼吸衰竭11.8%[2],神经损伤6%[2],围术期死亡率0.90%~3.91%[3],均远高于其他手术。目前大量证据显示,全身炎性反应是导致器官损伤的主要原因之一。临床上,约28.3%的CPB患者发展为全身炎症反应综合征(systemic inflammatory response syndrome,SIRS),且其严重程度与不良预后密切相关[4]。

一种用于CRRT/ECMO血路管的多功能可视固定装置的设计与应用

目的探讨一种用于连续性肾脏替代治疗/体外膜肺氧合(CRRT/ECMO)血路管的多功能可视固定装置在治疗过程中的应用效果。方法将2024年1月至5月进行连续性肾脏替代(CRRT)治疗和(或)体外膜肺氧合(ECMO)治疗的156例患者随机分为对照组和观察组,每组78例。对照组采用弹力绷带和胶布固定体外循环管路,观察组使用多功能可视固定装置对血路管进行固定,比较两组患者留置导管发生移位的例次、患者舒适度和医患满意度。结果观察组留置导管发生扭曲或移位、置管处有渗出、辅料污染需要更换发生率均低于对照组(P<0.05),观察组满意度及护士满意度均高于对照组。结论用于CRRT/ECMO血路管的多功能可视固定装置能提高管路固定效果,有效降低患者治疗过程中意外事件的发生率,提高患者舒适度和护患满意度,值得在临床推广应用。

体外循环技术在A型主动脉夹层产妇救治中的应用

产妇并发A型主动脉夹层(TAAD)是一种罕见且极度危重的临床紧急情况,亟需紧急手术治疗。由于产后特殊的生理状态、夹层对凝血因子及血小板的显著消耗,以及体外循环过程中不可避免的凝血因子大量破坏,这些因素共同构成了子宫内大出血的高危风险。因此,在体外循环辅助下实施夹层手术,无疑是一项技术性与挑战性并存的医学任务。体外循环灌注师不仅需要精准掌控体外循环系统的运行,更要对手术过程中的出血与止血情况保持高度警觉。本文深入探讨了TAAD产妇行体外循环技术的操作要点,旨在为临床实践中体外循环技术的应用提供宝贵的参考,以期提高手术成功率,降低患者的风险。

血栓弹力图指导的输血应用于体外循环心脏手术围手术期的效果观察

目的探析血栓弹力图指导的输血在体外循环心脏手术围手术期中的应用效果。方法选取行体外循环心脏手术的65例患者为研究对象,以随机对照的方式分为对照组(33例)及研究组(32例)。对照组参照凝血指标行输血指导,研究组参照血栓弹力图行输血指导。比较两组输血情况(血小板、自体血液、新鲜冰冻血浆、红细胞输入量)、输血效果[手术完成时、重症加强护理病房(ICU)转出时的血红蛋白水平及血小板计数增高指数]、临床结局(气管插管时间、住院时间、ICU停留时间和死亡情况)。结果两组红细胞、自体血液输入量比较无明显差异(P>0.05);研究组血小板、新鲜冰冻血浆输入量分别为(523.32±152.39)、(321.41±65.33)ml,比对照组的(655.11±187.48)、(375.52±71.74)ml少(P<0.05)。两组手术完成时的血红蛋白、血小板计数增高指数比较无明显差异(P>0.05);研究组ICU转出时的血红蛋白(118.41±10.41)g/L、血小板计数增高指数(13.90±2.01)%比对照组的(105.41±9.19)g/L、(10.41±2.33)%高(P<0.05)。研究组无死亡病例,对照组死亡1例,死亡率为3.03%,组间比较无差异(P>0.05);研究组气管插管时间(19.12±5.49)h、ICU停留时间(21.06±4.55)h、住院时间(16.42±4.35)d比对照组的(21.81±5.11)h、(23.96±5.02)h、(19.33±5.06)d短(P<0.05)。结论在体外循环心脏手术围手术期输血中实行血栓弹力图指导,可减少输血量,提高输血效果;同时也能缩短气管插管时间,改善临床预后,值得应用和推广。