持续血液净化结合控制性心脏减负荷治疗心血管术后严重急性左心衰  

Continuous Renal Replacement Therapy Combines with Reducing the Heart Preload to Treat the Severe Acute Left Heart Failure after Cardiovascular Operations

作　　者：张海涛[1] 刘楠[1] 杨戎[1] 于存涛[1] 朱俊明[1] 常谦[1] 孙立忠[1] 

机构地区：[1]中国医学科学院北京协和医学院阜外心血管病医院血管中心,北京100037

出　　处：《中国体外循环杂志》2008年第4期213-216,共4页Chinese Journal of Extracorporeal Circulation

摘　　要：目的本前瞻性研究旨在应用持续血液净化技术（CRRT）控制机体处于浅低温，迅速减少心脏前负荷，减少心脏做功治疗心血管术后严重左心衰。方法6例心血管术后急性左心衰（左室射血分数LVEF〈30％，肺动脉楔压（PAWP）〉20mmHg），4种正性肌力药物难以维持循环。CRRT控制中心血温34℃；4h内滤出水分使PAWP从23mmHg降至11mmHg；减少血管活性药维持平均动脉压（MAP）60～70mmHg，心排出量（CO）〉2．0L／min；镇静、呼吸机控制呼吸、静脉营养。结果CRRT平均支持6天后心功能显著改善，恢复中心血温36．5℃，增加血管活性药使MAP回升〉80mmHg，恢复容量负荷，维持PAWP10—12mmHg，给予速尿20mg／h，24h尿量大于2000ml停速尿。5例患者顺利出院，1例于心肾功能完全恢复后20天死于残余动脉夹层破裂。结论应用CRRT减低心脏前负荷、减少心脏做功，辅以浅低温减低机体代谢使机体在浅低温下达到新的供需平衡，提高对缺血缺氧的耐受，心脏得以休息而康复，效果显著，为严重左心衰治疗提供了一个新思路。OBJECTIVE The purpose of this prospective study is to reduce the preload of the heart and the heart acting to promote the heart function restoration after cardiovascular operations by using continuous renal replacement therapy （CRRT） and mild hypothermia （34℃）. METHODS Six patients with severe acute left heart failure after cardiovascular surgery were enrolled （LVEF 〈 30%, pulmonary artery wedge pressure （PAWP） 〉 20 mmHg）. Four kinds of positive inotropic drugs can＇not maintain circulation stability. CRRT and mild hypothermia （34℃） were applied to reduce the preload of the heart. The PAWP was reduced from 23 to 11 mmHg, and the mean arterial pressure（MAP） was 60 -70 mmHg. Sedation, controlled ventilation were applied to reduce the body oxygen consumption rate and the PAWP were maintained to 10 - 12 mmHg. RESULTS After 6 - day of CRRT application, the left heart function of the patients was improved. Then the core temperature was rewarmed to 36.5℃, and the MAP were increased to 〉 80 mmHg. Five of the patients discharged from hospital after completely cured and one died of the rupture of residual aortic dissection. CONCLUSION The application of CRRT accompanied the therapeutic mild hypothermia can reduce the preload of the heart and improve the left heart function after cardiovascular operations. It is a new method for treatment the sereve left heart failure.

关 键 词：严重左心衰 浅低温 心脏减负荷 持续血液净化技术 

分 类 号：R654.2[医药卫生—外科学] R541.6[医药卫生—临床医学]