心内直视术后出血再次开胸手术常见原因及临床防治
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摘要
目的:总结体外循环心内直视术后出血和心包填塞的临床特点,探讨其发生原因及防治。
方法:回顾性分析湘雅二医院心胸外科于2007年6月至2008年4月因心脏直视术后出血和心包填塞再次开胸手术87例病例,采集相关数据,进行统计学分析。
结果:术后活动性出血21例,急性心包填塞63例,延迟性心包填塞3例。术后76例患者痊愈出院,死亡11例(活动性出血组3例,急性心包填塞8例)。活动性出血组术后动脉收缩压、舒张压、中心静脉压、尿量进行性下降,心率增快(P＜0.05),引流管水柱波动良好,引流量显著增多(P＜0.05)。急性心包填塞组术后pH值、动脉收缩压和舒张压突然快速降低及尿量显著减少,中心静脉压及心率很快增高(P＜0.05)。引流管水柱波动消失,引流量突然减少。延迟性心包填塞组术后PaO_2下降,中心静脉压及心率升高(P＜0.05)。术后活动性出血以心脏切口、胸腺、骨膜及骨髓腔、剑突血管、心包切缘、钢丝穿孔点等多见。66例为手术创面弥漫性渗血。
结论:术前心功能不全及继发多脏器功能失调,体外循环凝血机制紊乱,术中止血不彻底,肝素与鱼精蛋白中和不完全,术后处理不及时是心内直视术后出血或心包填塞的主要原因。调整术前脏器功能,术中操作仔细,止血彻底,加强血液保护,术后严密监护,妥善处理,必要时及时开胸止血是防治术后出血的关键。
[Objective]
To sum up clinical features of postoperative bleeding and cardiac tamponade after cardiac surgery and to explore its causes, prevention, treatment and the indications for reoperation.
[Methods]
The retrospective analysis on 87 reoperative cases of the Second Xiangya Hospital Cardiothoracic Surgery from June 2007 to April 2008 for postoperative bleeding and cardiac tamponade, gathering the related data and performing statistic analysis.
[Results]
We retrospectively analyzed and identified 21 cases of active bleeding, 63 cases of acute cardiac tamponade, 3 cases of delayed cardiac tamponade. 76 postoperative cases were discharged and 11 cases were death (3 cases of active bleeding , 8 cases of acute cardiac tamponade). In the postoperative bleeding group, Artery Systolic Blood Pressure (SABP), Artery Diastolic Blood Pressure (ADBP), Central Venous Pressure (CVP), Urine Volume (UV) all decreased significantly, both Heart Rate (HR) and drainage increased significantly (P <0.05), with the obvious fluctuations of water-column in drainage tube. In the postoperative acute cardiac tamponade group, pH, SABP, DABP decreased suddenly and quickly, UV reduced obviously, and CVP, HR increased rapidly (P <0.05). The water-column fluctuations in drainage tube disappeared and the drainage suddenly reduced. In the postoperative delayed cardiac tamponade group, PaO2 decreased, HR and CVP increased (P <0.05). The postoperative active bleeding chiefly presented in the incision of the heart and great vessels, thymus, periosteum and bone marrow cavity, Xiphoid vessels, pericardial margin, perforation of steel wires. And blood oozed diffusely from wound surface in 66 cases.
[Conclusion]
The chief causes of postoperative bleeding and cardiac tamponade after cardiac surgery include preoperative heart failure, secondary multiple organ dysfunction, disarrangement of clotting mechanism after cardiopulmonary bypass, incomplete stanching during the operation, incomplete neutralization of heparin and protamine, untimely postoperative care. And the key points of the prevention and treatment for postoperative bleeding include the preoperative adjustment of organ function, careful operation, complete stanch , reinforcement of the blood protection and postoperative care, proper handle, and if necessary, performing thoracotomy for hemostasis timely.
方法:回顾性分析湘雅二医院心胸外科于2007年6月至2008年4月因心脏直视术后出血和心包填塞再次开胸手术87例病例,采集相关数据,进行统计学分析。
结果:术后活动性出血21例,急性心包填塞63例,延迟性心包填塞3例。术后76例患者痊愈出院,死亡11例(活动性出血组3例,急性心包填塞8例)。活动性出血组术后动脉收缩压、舒张压、中心静脉压、尿量进行性下降,心率增快(P＜0.05),引流管水柱波动良好,引流量显著增多(P＜0.05)。急性心包填塞组术后pH值、动脉收缩压和舒张压突然快速降低及尿量显著减少,中心静脉压及心率很快增高(P＜0.05)。引流管水柱波动消失,引流量突然减少。延迟性心包填塞组术后PaO_2下降,中心静脉压及心率升高(P＜0.05)。术后活动性出血以心脏切口、胸腺、骨膜及骨髓腔、剑突血管、心包切缘、钢丝穿孔点等多见。66例为手术创面弥漫性渗血。
结论:术前心功能不全及继发多脏器功能失调,体外循环凝血机制紊乱,术中止血不彻底,肝素与鱼精蛋白中和不完全,术后处理不及时是心内直视术后出血或心包填塞的主要原因。调整术前脏器功能,术中操作仔细,止血彻底,加强血液保护,术后严密监护,妥善处理,必要时及时开胸止血是防治术后出血的关键。
[Objective]
To sum up clinical features of postoperative bleeding and cardiac tamponade after cardiac surgery and to explore its causes, prevention, treatment and the indications for reoperation.
[Methods]
The retrospective analysis on 87 reoperative cases of the Second Xiangya Hospital Cardiothoracic Surgery from June 2007 to April 2008 for postoperative bleeding and cardiac tamponade, gathering the related data and performing statistic analysis.
[Results]
We retrospectively analyzed and identified 21 cases of active bleeding, 63 cases of acute cardiac tamponade, 3 cases of delayed cardiac tamponade. 76 postoperative cases were discharged and 11 cases were death (3 cases of active bleeding , 8 cases of acute cardiac tamponade). In the postoperative bleeding group, Artery Systolic Blood Pressure (SABP), Artery Diastolic Blood Pressure (ADBP), Central Venous Pressure (CVP), Urine Volume (UV) all decreased significantly, both Heart Rate (HR) and drainage increased significantly (P <0.05), with the obvious fluctuations of water-column in drainage tube. In the postoperative acute cardiac tamponade group, pH, SABP, DABP decreased suddenly and quickly, UV reduced obviously, and CVP, HR increased rapidly (P <0.05). The water-column fluctuations in drainage tube disappeared and the drainage suddenly reduced. In the postoperative delayed cardiac tamponade group, PaO2 decreased, HR and CVP increased (P <0.05). The postoperative active bleeding chiefly presented in the incision of the heart and great vessels, thymus, periosteum and bone marrow cavity, Xiphoid vessels, pericardial margin, perforation of steel wires. And blood oozed diffusely from wound surface in 66 cases.
[Conclusion]
The chief causes of postoperative bleeding and cardiac tamponade after cardiac surgery include preoperative heart failure, secondary multiple organ dysfunction, disarrangement of clotting mechanism after cardiopulmonary bypass, incomplete stanching during the operation, incomplete neutralization of heparin and protamine, untimely postoperative care. And the key points of the prevention and treatment for postoperative bleeding include the preoperative adjustment of organ function, careful operation, complete stanch , reinforcement of the blood protection and postoperative care, proper handle, and if necessary, performing thoracotomy for hemostasis timely.
引文
1、汪曾炜、刘维永、张宝仁,等,心脏外科学[M]北京:人民军医出版社,2003:395
2、罗国华,吴清玉,陶田富,等,体外循环心内直视术后再次开胸止血[J]中国胸心血管外科杂志,2000,2(7):59
3、Miller BE Spitzer KK.Anesthetic and perfusion issues in contemporany pediatric cardiac surgery[J].Crit Care Nurs Q,2002,25(3):48-62,QUIE 110-111
4、陈林,肖颖彬,闵家新,等,心内直视术后畸形心包填塞与动脉血气分析[J]中国危重病急救医学,1999,11(7):436
5、Pierli c,Ladanza A,Pasqua AD,et al.Acute superior vena,cara and right atrial tamponade in an infant after open heart surgery[J].International Journal of Cardiology,2002,83(2):195-197
6、刘林,曹振飞,曾伟生.9例心脏直视手术后晚期心包填塞[J].中华胸心血管外科杂志,1997,(3):167-169
7、李峰、周汝元、林敏,等,体外循环术后异常失血原因分析与防治[M]安徽医科大学学报,2005,40(2):182
8、龙村,刘晋萍,等,体外循环[M]北京:人民军医出版社,2004:287
9、纪宏文、邓硕增,体外循环术后异常失血原因分析与防治[J]中国循环杂志,2001,13(1):59
10、Despotis GJ,Filos ks,20ys TN,et al.Factors associated with excessive postoperative blood loss and hem ostatics transfusion riquirments:A multivariate analysis in cardiac surgical patients[J],Anisth Anal,1996,82:13-21
11、金惠民主编 病理生理学[M]第五版,北京,人民卫生出版社,2001:144
12、阮长耿,血栓与止血[M]第11版,南京:江苏科技出版社,1994.327-331
13、龙村,刘晋萍,体外循环[M]北京:人民军医出版社,2004:370
14、王晴威,邓硕曾,体外循环心脏手术中纤溶系统的改变[J]中国循环杂志,1997.12(2);84
15、田伟枕,金维,心脏外科主治医师1000问[M]北京:中国协和医科大学出版社,2005:191
16、龙村,胡小琴,肝素、鱼精蛋白和丹参在心内直视手术中对促血栓素B2和血小板的作用中华胸心血管外科杂志,2005,8(4):242-243
17、周瑞海,张彦恩,苏润毅,等,硝普钠对心脏换瓣病人血小板聚集功能的影响[J],中华胸心血管外科杂志,2008,14:10-11
18、陈晓,心脏外科术后二次开胸止血63例分析[J],中国误诊学杂志,2006,6(21),4236
19、季远平,刘俊成,龙永贵,等,泸州医学院学报,体外循环术后再次开胸止血27例[J],2007,30(2):123
1.Karski JM,Teasdal SJ,Peter N,et al.Preveation of bleeding after cardiopulmonary bypass with high-dose tranexamic acid.J thorac Cardiovasc Surg,2005.110.835-842.
2.Katsaros D,Petricevic m,Snow NJ,et al.Tranexamic acid reduces post bypass blood use:A double-blineded,prospective,randomized study of 210 patient.Ann Thorac Surg.2006,61.1131-1135.
3.阮长耿主编.学栓与止血[M].第11版.南京:江苏科技出版社,2004,327-331.
4.Hardy JF,Desroches J.Natural and synthetic antifibrinolytics in cardiac surgery.Can Anaesch.2005.39:353.
5.Sorti S,Vittorini S,LuBi VS,et al.No Variation in Hsp70mRNA level during cardiac surgery in pediatric patients evaluated by semiquantitative RT-PCR.Clin chem.Lab Med,[J]2005,39:1240-1243.
6.Nelson DP,Wechsler SB,miura T,et al.myocardial immediate early gene activation after cardiopulmonary bypass with cardiac ischemia-reperfusion.Aun ThoracSurg,[J].2006,73:156.
7.De Vroege R,Van Oecveren W,van Klavenbosch J,et al.The impact of heparin-coated cardiopulmonary bypass circuits on pulmonary fauction and the release of inflammatory mediators,[J].Auesth.Analg,2004,98(6):1586-1594.
8.Mossinger H,Dietrich W,Braun SL,et al.High-dose aprotinin reduces activation of hemostasis.Allogeneic blood requirement,and duration of postoperative ventilation in pediatric cardiac surgery[J].Ann Thotac Surg,2003,75(2):430-437.
9.Sugita T,Watarida S,Katsugama K,et al.Effect of a human urinary protease inhibitor Ulinastain on respiratory fanction in pediatric undergoing cardiopulmonay bypass[J].J Cardiorasc Surg,2002,43(4):437.
10.Schleusak C,Doendst T,Preusser s et al.Cardiopulmonary bypass reduction of bronchial blood flow:a potential mechanism for cung injury in a neonartal pig model[J].J Thorac cardiovasc Surg,2006,123(6).1199-1200.
11.Mcmullan DM,BekkerJM,parry AJ,et al.Alterations in endogenous nitric oxide production after cardiopulmonary bypass in cambs with normal and increased pulmonary blood flow circulation[J], 2005,102(9): 172.
12.Lis, Price R, phiroz D, et al. Systemic imflamn atory response during cardiopulmonary bypass and strategies [J]. Extra Carpur Technol, 2005,13 7(2): 180.
13. Laffgy JG, Boycan JF, Cheng DC. The systemic inflammatory response to cardiac surgery . implications for the aneschesiofogist [J]. Aneschesiology,2007,97(1):215.
14. Kotaui N, Hashimoto H, Sessler DI, et al, Cardiopulmonary bypass produces greater pulmonary than systemic proinflammatory cyto kines [J]. Anesth Analy,2004,90(5):1039.
15. Wan S, Yim Ap, Wong CK,et al. Expession of FHLI and cytokine messeuger RNAs in human myocardium after cardiopulmonary bypass Int J Cardiol , 2002,86:256-272.
16.Chiang CH, Wu CP ,Perng WC, et al. Use of anti-tumour necrosis factor-alpha antibody or 3-desza-adenosine as additives to promote protection by Universiey of Wisconsin solutton in ischeamia/refusion injury [J]. Clin Sci,2006,99(3):215.
17.Qing M, Vazquez-Jimenez JE ,Schumacher K. Moderate hypothermia during cardiopulmonary by-pass increases intramyocaridial syuchesis of heat shock protein 72.[J] Thorac Cardiovasc Surg,2002,oct:124(4),724.
18.Wang G, cheu TT, Gao CQ. Protective effects of ulinastation ischemic reperfusion injury in the rabbit lung in traumatic hemorrhagic shock [J]Zhong guo Wei Zhong Bing Ji Jin Yi Xue ,2005,17(1):36.
19.Nakanishk, Takedas, sakamoto A, et al .Effects of ulinastaotin treatmeut on the cardiopulmonary bypass-indcued hemodynamic instability and pulmonary dysfuntion Crit Care Med,2006,34(5):1351.
20. Sievers H, Freundzkaas C, Eleftherradis S, et al. Lung protection during total cardiopulmonary bypass by isolated lung perfasion preliminary results of anovel perfusion strategy[J]. Ann Thorac Surg 2002,74(4): 1167.
21.Larson DF, Bow ersm, Schechner HW, et al. Neautrophil activation during cardiopulmonary bypass in padiatric and adulft patieuts.[J]. perfusion, 2006,11(1):21.
22.Gando S, Tedo I Lucreased neutrophil elastase release in patieuts with cardiopulmonary arrest role of elastase inhibitor patieuts with cardiopulmonary arrest role of elastase inhibitor [J].Lnteusive Care Med, 2005,21(8):636.
23.Kotani N Hashimoto H,Sessler D,et al.Cardiopulmonary bypass produce greater pulmonary than systemic proinflammatory cytokines Auesth Auesth Anakg 2007.90:1039.
24.季远平,刘俊成,龙永贵,等,泸州医学院学报,体外循环术后再次开胸止血27例[J],2007,30(2):123.
25.Schurr UP,Zund G,Hoerstup SP,et al.Preperative administration of steroids Infuleuce on adhesion molecules and cytokines after cardiopulmonary bypass[J].Ann Thorac Surg,2003,72(4):1316.
26.Sievers HH,Freund-Kaas C,E leftheriadis S,et al.Lang protection during total cardiopulmonary bypass by Bolated Lung perfusion Preliminary results of a novel perfusion strategy[J].Ann Thorac Surg.2002,74(4).1167-1172.
27.李峰,周汝元,林敏,等,体外循环术后异常失血原因分析和防止[m]安徽医科大学学报,2005,40(2):182.
28.龙村,孙晋萍,等,体外循环[m],北京:人民军医出版社,2004:287.
29.Pierli C,Ladanza A,Pasqua AD,et al.Acute superior vena,cara and right atrial tamponade in an infant after open heart surgery[J].International Journal of Cardiology,2002,83(2):195-197.
30.罗国华,吴清山,陶田富,等,体外循环心内直视术后再次开胸止血[J],中国胸心血管外科杂志,2000,2(7):59.
31.Pierli C,Ladanza A,Pasqua AD,et al.Acute superior vena,care and right atrial tampunade in an infant after open heart surgery[J].International Journal Cardiology,2002,83(2):195-197.
32.刘林,曹振飞,曾伟生。9例心脏直视手术后晚期心包填塞[J]。中华胸心血管外科杂志,2006,(3):167-169.
33.Miller BE,Spitzer KK.Anesthetic and perfusion issues in contemporany pediatric cardiac surgery[J].Crit Care Nurs Q,2002,25(3):48-62;QUIE 110-111.
34.Parolari A,Guarnieri D,Alamanni F et al.Platelet function and anesthetics in cardiac surgery:an in vitro and ex vivo study.Anesth Analg.2007,89:26.
35.Slaughter TF,Lebleu TH,Douglas JM,et al.Characterization of prothrombin action during cardiac surgery by hemonstatic molecular markers.Anesthesiology,2004,80:520-526.
36.Hardy JF,Belisle S.Natural and synthetic antifibrinolyticy in adult cardiac surgery: efficacy, effectiveness and efficiency. Can J Anaesth, 2005,41:1104-1112.
37.Bonkon AM, Schaff HV, Cardwer TJ, et al. Diagnosis and management of postoperative pericardial effusions and late cardiac tamponade following open-heart surgery. Ann Thorac Surg, 2001,31:512.
38.Jones JW, Izzat NN, Rashad MN, et al. Usefulness of right ventricular indices in early diagnosis of cardiac tamponade. Ann Thorac Surg, 2002,54:44.
39.Czer LS. Mediastinal bleeding after cardiac surgery:etiologies, diagnostic considerations, and blood conservation methods. J Cardiothorac Anesth, 2007,3:760.
40.Nelson RM, Jenson CB, Smoot WM 3~(rd). Pericardial tamponade following open-heart surgery. J Thorac Cardiovase Surg.2004.5 8:510.
41.Tyberg TI. Care cardiac tamponade after open heart surgery:incidence,role of anticoagulants in its pathogenesis and its relationship to the postpericardiotomy syndrome. Circulation, 2001,63:1223.
42.Wippem ann J,A Ibes JM, Hartrumpfm, et al. Comparison of minimally invasive closed circuit extracorporeal circulation with conventional cardiopulmonary bypass and with off-pump technique in CABG patient selected parameters of coagulation and inflammatory system. Eur J Cardiothorac Surg. 2005;28(1):127-132.
43.Koster A, Fischer T, Praus M, et al. Hemostatic activation and inflammatory response during cardiopulmonary bypass impact of heparin management Anesthesiology, 2002;97(4):837-841.
44.Shiiya N ,Matsuzaki K, Kunihara T, et al Heparin reduction use of cardiotomy suction is associated with hyperfibrinolysis during perfusion with a heparin-coated semi-closed cardiopulmonary bypass J Artif Organ,2006,9 (4):214-219.
45.Hertfelder H J,BosM,Weber D,et al.Perioperative monitorting mary and Secondary hemostasis in coronary artery bypass grafting Thromb Hemost 2005,31(4): 426-440.
46.Shore-Lesserson L, Davia L, Reich J, et al.Tranexamic acid reduces trans-fusions and mediastinal drainage in repeat cardiac surgery.Anesth Anal,2006,83:18.
47.Lis,Price R,Phiroz D,et al.Systemic inflammatory response during cardiopulmonary bypass and strategies.J Extra Corpor echnol,2005,T37(2):180.
48.Hattori T,Khan MM,Colman RW,et al.Plasma tissue factor plus associated peripheralm on nuclear cells activate factors Ⅶ and Ⅹ in cardiac surg calwounds.J Am Coll Cardioc J.2005;46(4):707-713.
49.Kunt AS,Darcin OT,Aydin S,et al.Mini-dose pump-prime aprotin inhibited enhanced fibriuolytic activity and reduced blood loss and transfusion requirements after coronary artery bypass surgery.J Thromb Thrombolysis.2005;19(3):197-200.
50.Kestin A,Valeri K,Khuri S et al.The platelet function defect of cardiopulmonary bypass.Blood,2003,82:107.
51.Storck J,Hllger N,Zimmermann R.The influence of heparin and protamine sulfate on platelet ADP and platelet factor 4 release and the expression of glycoprotein Ⅱ b/Ⅲa.Haemostasis.2004,34:358.
52.Ammar T,Fisher C.The effects of heparinase Ⅰ and protamine on platelet reactivity.Anesthesiology.2007,86:1382.
53.Toshiaki M,Peter J,Olson F et al.Protamine reversal of heparin affects platelet aggregation and activated clotting time after cardiopulmonary bypass.Anesth Analg,2004,87:781.
54.龙村,胡小琴,肝素、鱼精蛋白和丹参在心内直视手术中对促血栓素B2和血小板的作用 中华胸心血管外科杂志,2005,8(4):242-243.
55.Despotis GJ,Filos KS,Zoys TN,et al.Factors associateol with excessive postoperative blood loss and hemostatic transfusion requirements:A multivariate analysis in cardiac surgical patients.Anesth Anal,2006,82:13-21.
56.金惠民主编 病理生理学[M]第五版,北京,人民卫生出版社,2001:144
57.Despotis.GJ,Filos ks 20ys TN,et al.Factors associated with excessive postoperative blood loss and hemostatics transfusion riquirments:A multivarite analysis in cardiac surgical patients[J],Anisth Anal,2003,82:13-21.
58.王晴威,邓硕曾,体外循环心脏手术中纤溶系统的改变[J]中国循环杂志,2007.12(2);84.
59.纪宏文、邓硕增,体外循环术后异常失血原因分析与防治[J]中国循环杂志,2001,13(1):59
60.田伟枕,金维,心脏外科主治医师1000问[M]北京:中国协和医科大学出版社,2005:191.
61.周瑞海,张彦恩,苏润毅,等,硝普钠对心脏换瓣病人血小板聚集功能的影响[J],中华胸心血管外科杂志,2008,14:10-11.
62.陈晓,心脏外科术后二次开胸止血63例分析[J],中国误诊学杂志,2006
2、罗国华,吴清玉,陶田富,等,体外循环心内直视术后再次开胸止血[J]中国胸心血管外科杂志,2000,2(7):59
3、Miller BE Spitzer KK.Anesthetic and perfusion issues in contemporany pediatric cardiac surgery[J].Crit Care Nurs Q,2002,25(3):48-62,QUIE 110-111
4、陈林,肖颖彬,闵家新,等,心内直视术后畸形心包填塞与动脉血气分析[J]中国危重病急救医学,1999,11(7):436
5、Pierli c,Ladanza A,Pasqua AD,et al.Acute superior vena,cara and right atrial tamponade in an infant after open heart surgery[J].International Journal of Cardiology,2002,83(2):195-197
6、刘林,曹振飞,曾伟生.9例心脏直视手术后晚期心包填塞[J].中华胸心血管外科杂志,1997,(3):167-169
7、李峰、周汝元、林敏,等,体外循环术后异常失血原因分析与防治[M]安徽医科大学学报,2005,40(2):182
8、龙村,刘晋萍,等,体外循环[M]北京:人民军医出版社,2004:287
9、纪宏文、邓硕增,体外循环术后异常失血原因分析与防治[J]中国循环杂志,2001,13(1):59
10、Despotis GJ,Filos ks,20ys TN,et al.Factors associated with excessive postoperative blood loss and hem ostatics transfusion riquirments:A multivariate analysis in cardiac surgical patients[J],Anisth Anal,1996,82:13-21
11、金惠民主编 病理生理学[M]第五版,北京,人民卫生出版社,2001:144
12、阮长耿,血栓与止血[M]第11版,南京:江苏科技出版社,1994.327-331
13、龙村,刘晋萍,体外循环[M]北京:人民军医出版社,2004:370
14、王晴威,邓硕曾,体外循环心脏手术中纤溶系统的改变[J]中国循环杂志,1997.12(2);84
15、田伟枕,金维,心脏外科主治医师1000问[M]北京:中国协和医科大学出版社,2005:191
16、龙村,胡小琴,肝素、鱼精蛋白和丹参在心内直视手术中对促血栓素B2和血小板的作用中华胸心血管外科杂志,2005,8(4):242-243
17、周瑞海,张彦恩,苏润毅,等,硝普钠对心脏换瓣病人血小板聚集功能的影响[J],中华胸心血管外科杂志,2008,14:10-11
18、陈晓,心脏外科术后二次开胸止血63例分析[J],中国误诊学杂志,2006,6(21),4236
19、季远平,刘俊成,龙永贵,等,泸州医学院学报,体外循环术后再次开胸止血27例[J],2007,30(2):123
1.Karski JM,Teasdal SJ,Peter N,et al.Preveation of bleeding after cardiopulmonary bypass with high-dose tranexamic acid.J thorac Cardiovasc Surg,2005.110.835-842.
2.Katsaros D,Petricevic m,Snow NJ,et al.Tranexamic acid reduces post bypass blood use:A double-blineded,prospective,randomized study of 210 patient.Ann Thorac Surg.2006,61.1131-1135.
3.阮长耿主编.学栓与止血[M].第11版.南京:江苏科技出版社,2004,327-331.
4.Hardy JF,Desroches J.Natural and synthetic antifibrinolytics in cardiac surgery.Can Anaesch.2005.39:353.
5.Sorti S,Vittorini S,LuBi VS,et al.No Variation in Hsp70mRNA level during cardiac surgery in pediatric patients evaluated by semiquantitative RT-PCR.Clin chem.Lab Med,[J]2005,39:1240-1243.
6.Nelson DP,Wechsler SB,miura T,et al.myocardial immediate early gene activation after cardiopulmonary bypass with cardiac ischemia-reperfusion.Aun ThoracSurg,[J].2006,73:156.
7.De Vroege R,Van Oecveren W,van Klavenbosch J,et al.The impact of heparin-coated cardiopulmonary bypass circuits on pulmonary fauction and the release of inflammatory mediators,[J].Auesth.Analg,2004,98(6):1586-1594.
8.Mossinger H,Dietrich W,Braun SL,et al.High-dose aprotinin reduces activation of hemostasis.Allogeneic blood requirement,and duration of postoperative ventilation in pediatric cardiac surgery[J].Ann Thotac Surg,2003,75(2):430-437.
9.Sugita T,Watarida S,Katsugama K,et al.Effect of a human urinary protease inhibitor Ulinastain on respiratory fanction in pediatric undergoing cardiopulmonay bypass[J].J Cardiorasc Surg,2002,43(4):437.
10.Schleusak C,Doendst T,Preusser s et al.Cardiopulmonary bypass reduction of bronchial blood flow:a potential mechanism for cung injury in a neonartal pig model[J].J Thorac cardiovasc Surg,2006,123(6).1199-1200.
11.Mcmullan DM,BekkerJM,parry AJ,et al.Alterations in endogenous nitric oxide production after cardiopulmonary bypass in cambs with normal and increased pulmonary blood flow circulation[J], 2005,102(9): 172.
12.Lis, Price R, phiroz D, et al. Systemic imflamn atory response during cardiopulmonary bypass and strategies [J]. Extra Carpur Technol, 2005,13 7(2): 180.
13. Laffgy JG, Boycan JF, Cheng DC. The systemic inflammatory response to cardiac surgery . implications for the aneschesiofogist [J]. Aneschesiology,2007,97(1):215.
14. Kotaui N, Hashimoto H, Sessler DI, et al, Cardiopulmonary bypass produces greater pulmonary than systemic proinflammatory cyto kines [J]. Anesth Analy,2004,90(5):1039.
15. Wan S, Yim Ap, Wong CK,et al. Expession of FHLI and cytokine messeuger RNAs in human myocardium after cardiopulmonary bypass Int J Cardiol , 2002,86:256-272.
16.Chiang CH, Wu CP ,Perng WC, et al. Use of anti-tumour necrosis factor-alpha antibody or 3-desza-adenosine as additives to promote protection by Universiey of Wisconsin solutton in ischeamia/refusion injury [J]. Clin Sci,2006,99(3):215.
17.Qing M, Vazquez-Jimenez JE ,Schumacher K. Moderate hypothermia during cardiopulmonary by-pass increases intramyocaridial syuchesis of heat shock protein 72.[J] Thorac Cardiovasc Surg,2002,oct:124(4),724.
18.Wang G, cheu TT, Gao CQ. Protective effects of ulinastation ischemic reperfusion injury in the rabbit lung in traumatic hemorrhagic shock [J]Zhong guo Wei Zhong Bing Ji Jin Yi Xue ,2005,17(1):36.
19.Nakanishk, Takedas, sakamoto A, et al .Effects of ulinastaotin treatmeut on the cardiopulmonary bypass-indcued hemodynamic instability and pulmonary dysfuntion Crit Care Med,2006,34(5):1351.
20. Sievers H, Freundzkaas C, Eleftherradis S, et al. Lung protection during total cardiopulmonary bypass by isolated lung perfasion preliminary results of anovel perfusion strategy[J]. Ann Thorac Surg 2002,74(4): 1167.
21.Larson DF, Bow ersm, Schechner HW, et al. Neautrophil activation during cardiopulmonary bypass in padiatric and adulft patieuts.[J]. perfusion, 2006,11(1):21.
22.Gando S, Tedo I Lucreased neutrophil elastase release in patieuts with cardiopulmonary arrest role of elastase inhibitor patieuts with cardiopulmonary arrest role of elastase inhibitor [J].Lnteusive Care Med, 2005,21(8):636.
23.Kotani N Hashimoto H,Sessler D,et al.Cardiopulmonary bypass produce greater pulmonary than systemic proinflammatory cytokines Auesth Auesth Anakg 2007.90:1039.
24.季远平,刘俊成,龙永贵,等,泸州医学院学报,体外循环术后再次开胸止血27例[J],2007,30(2):123.
25.Schurr UP,Zund G,Hoerstup SP,et al.Preperative administration of steroids Infuleuce on adhesion molecules and cytokines after cardiopulmonary bypass[J].Ann Thorac Surg,2003,72(4):1316.
26.Sievers HH,Freund-Kaas C,E leftheriadis S,et al.Lang protection during total cardiopulmonary bypass by Bolated Lung perfusion Preliminary results of a novel perfusion strategy[J].Ann Thorac Surg.2002,74(4).1167-1172.
27.李峰,周汝元,林敏,等,体外循环术后异常失血原因分析和防止[m]安徽医科大学学报,2005,40(2):182.
28.龙村,孙晋萍,等,体外循环[m],北京:人民军医出版社,2004:287.
29.Pierli C,Ladanza A,Pasqua AD,et al.Acute superior vena,cara and right atrial tamponade in an infant after open heart surgery[J].International Journal of Cardiology,2002,83(2):195-197.
30.罗国华,吴清山,陶田富,等,体外循环心内直视术后再次开胸止血[J],中国胸心血管外科杂志,2000,2(7):59.
31.Pierli C,Ladanza A,Pasqua AD,et al.Acute superior vena,care and right atrial tampunade in an infant after open heart surgery[J].International Journal Cardiology,2002,83(2):195-197.
32.刘林,曹振飞,曾伟生。9例心脏直视手术后晚期心包填塞[J]。中华胸心血管外科杂志,2006,(3):167-169.
33.Miller BE,Spitzer KK.Anesthetic and perfusion issues in contemporany pediatric cardiac surgery[J].Crit Care Nurs Q,2002,25(3):48-62;QUIE 110-111.
34.Parolari A,Guarnieri D,Alamanni F et al.Platelet function and anesthetics in cardiac surgery:an in vitro and ex vivo study.Anesth Analg.2007,89:26.
35.Slaughter TF,Lebleu TH,Douglas JM,et al.Characterization of prothrombin action during cardiac surgery by hemonstatic molecular markers.Anesthesiology,2004,80:520-526.
36.Hardy JF,Belisle S.Natural and synthetic antifibrinolyticy in adult cardiac surgery: efficacy, effectiveness and efficiency. Can J Anaesth, 2005,41:1104-1112.
37.Bonkon AM, Schaff HV, Cardwer TJ, et al. Diagnosis and management of postoperative pericardial effusions and late cardiac tamponade following open-heart surgery. Ann Thorac Surg, 2001,31:512.
38.Jones JW, Izzat NN, Rashad MN, et al. Usefulness of right ventricular indices in early diagnosis of cardiac tamponade. Ann Thorac Surg, 2002,54:44.
39.Czer LS. Mediastinal bleeding after cardiac surgery:etiologies, diagnostic considerations, and blood conservation methods. J Cardiothorac Anesth, 2007,3:760.
40.Nelson RM, Jenson CB, Smoot WM 3~(rd). Pericardial tamponade following open-heart surgery. J Thorac Cardiovase Surg.2004.5 8:510.
41.Tyberg TI. Care cardiac tamponade after open heart surgery:incidence,role of anticoagulants in its pathogenesis and its relationship to the postpericardiotomy syndrome. Circulation, 2001,63:1223.
42.Wippem ann J,A Ibes JM, Hartrumpfm, et al. Comparison of minimally invasive closed circuit extracorporeal circulation with conventional cardiopulmonary bypass and with off-pump technique in CABG patient selected parameters of coagulation and inflammatory system. Eur J Cardiothorac Surg. 2005;28(1):127-132.
43.Koster A, Fischer T, Praus M, et al. Hemostatic activation and inflammatory response during cardiopulmonary bypass impact of heparin management Anesthesiology, 2002;97(4):837-841.
44.Shiiya N ,Matsuzaki K, Kunihara T, et al Heparin reduction use of cardiotomy suction is associated with hyperfibrinolysis during perfusion with a heparin-coated semi-closed cardiopulmonary bypass J Artif Organ,2006,9 (4):214-219.
45.Hertfelder H J,BosM,Weber D,et al.Perioperative monitorting mary and Secondary hemostasis in coronary artery bypass grafting Thromb Hemost 2005,31(4): 426-440.
46.Shore-Lesserson L, Davia L, Reich J, et al.Tranexamic acid reduces trans-fusions and mediastinal drainage in repeat cardiac surgery.Anesth Anal,2006,83:18.
47.Lis,Price R,Phiroz D,et al.Systemic inflammatory response during cardiopulmonary bypass and strategies.J Extra Corpor echnol,2005,T37(2):180.
48.Hattori T,Khan MM,Colman RW,et al.Plasma tissue factor plus associated peripheralm on nuclear cells activate factors Ⅶ and Ⅹ in cardiac surg calwounds.J Am Coll Cardioc J.2005;46(4):707-713.
49.Kunt AS,Darcin OT,Aydin S,et al.Mini-dose pump-prime aprotin inhibited enhanced fibriuolytic activity and reduced blood loss and transfusion requirements after coronary artery bypass surgery.J Thromb Thrombolysis.2005;19(3):197-200.
50.Kestin A,Valeri K,Khuri S et al.The platelet function defect of cardiopulmonary bypass.Blood,2003,82:107.
51.Storck J,Hllger N,Zimmermann R.The influence of heparin and protamine sulfate on platelet ADP and platelet factor 4 release and the expression of glycoprotein Ⅱ b/Ⅲa.Haemostasis.2004,34:358.
52.Ammar T,Fisher C.The effects of heparinase Ⅰ and protamine on platelet reactivity.Anesthesiology.2007,86:1382.
53.Toshiaki M,Peter J,Olson F et al.Protamine reversal of heparin affects platelet aggregation and activated clotting time after cardiopulmonary bypass.Anesth Analg,2004,87:781.
54.龙村,胡小琴,肝素、鱼精蛋白和丹参在心内直视手术中对促血栓素B2和血小板的作用 中华胸心血管外科杂志,2005,8(4):242-243.
55.Despotis GJ,Filos KS,Zoys TN,et al.Factors associateol with excessive postoperative blood loss and hemostatic transfusion requirements:A multivariate analysis in cardiac surgical patients.Anesth Anal,2006,82:13-21.
56.金惠民主编 病理生理学[M]第五版,北京,人民卫生出版社,2001:144
57.Despotis.GJ,Filos ks 20ys TN,et al.Factors associated with excessive postoperative blood loss and hemostatics transfusion riquirments:A multivarite analysis in cardiac surgical patients[J],Anisth Anal,2003,82:13-21.
58.王晴威,邓硕曾,体外循环心脏手术中纤溶系统的改变[J]中国循环杂志,2007.12(2);84.
59.纪宏文、邓硕增,体外循环术后异常失血原因分析与防治[J]中国循环杂志,2001,13(1):59
60.田伟枕,金维,心脏外科主治医师1000问[M]北京:中国协和医科大学出版社,2005:191.
61.周瑞海,张彦恩,苏润毅,等,硝普钠对心脏换瓣病人血小板聚集功能的影响[J],中华胸心血管外科杂志,2008,14:10-11.
62.陈晓,心脏外科术后二次开胸止血63例分析[J],中国误诊学杂志,2006