搏动体外循环增加小儿脑氧供及改善组织微循环的临床研究  

Clinical study of pulsatile cardiopulmonary bypass on increasing cerebral oxygenation and ameliorating tissue microcirculation in pediatric heart surgery

作　　者：赵举[1] 杨九光[1] 刘晋萍[1] 李守军[2] 闫军[2] 孟颖[3] 王旭[3] 龙村[1] 

机构地区：[1]阜外心血管病医院体外循环科,北京100037 [2]阜外心血管病医院心外科,北京100037 [3]阜外心血管病医院小儿ICU,北京100037

出　　处：《中国体外循环杂志》2011年第3期145-148,162,共5页Chinese Journal of Extracorporeal Circulation

基　　金：中央级公益性科研院所青年基金(2008F020)

摘　　要：目的通过观察大脑局部脑氧饱和度(ScO2)及血浆中内皮素-1(ET-1)的改变,判定小儿体外循环(ECC)期间搏动灌注与非搏动灌注对脑氧供和组织微循环灌注的影响。方法 40例行一期根治手术的典型法洛四联症患儿随机分为搏动灌注组(PP组,n=20)和非搏动灌注组(NP组,n=20)。PP组患儿在心脏阻断期间用Jostra HL20型人工心肺机行改良滚压泵搏动灌注,NP组ECC全程均采用传统滚压泵平流灌注。每位患儿的ScO2从麻醉诱导后一直持续监测到返回ICU 6 h。采集不同时点的血液标本测定血浆内皮素-1(ET-1)浓度及血浆游离血红蛋白(PFH)水平,通过血流动力学的持续观察对比搏动ECC的效果。结果在PP组通过有创血压监测即可观察到有效的搏动灌注效果,PP组在心脏阻断期间的脉压差(ΔP)明显高于NP组(P<0.01)。PP组ScO2在心脏停跳阶段高于NP组,且这种优势一直持续到患儿返回ICU 2 h。ET-1水平在ECC结束时PP组低于NP组(P<0.01),且持续到ICU 8 h。PFH浓度在心肌阻断开放时、ECC结束时及ICU 2 h PP组均高于NP组(P<0.05)。结论大脑局部ScO2对ECC期间脑氧的变化非常敏感。搏动ECC可以通过提高脑氧供并改善组织微循环来实现其趋于正常生理的灌注特性,但是在紫绀型患儿中搏动灌注有增加血液破坏的风险。OBJECTIVE To evaluate the effects of pulsatile perfusion（PP） and nonpulsatile perfusion（NP） on cerebral oxygen saturation（ScO2） and endothelin-1（ET-1） in pediatric Tetralogy of Fallot（TOF） patients underwent open heart surgery with cardiopulmonary bypass（CPB）.METHODS 40 pediatric patients were randomly divided into pulsatile perfusion group（PP,n=20） and nonpulsatile perfusion group（NP,n=20）.In the PP group,modified roller pump was used to perform pulsatile perfusion during cross-clamping period in CPB,while in the NP group,roller pump was used to perform continuous flow perfusion during CPB.ScO2 was monitored from the operation beginning until 6 h after patients back to ICU.Hemodynamic status,ET-1 concentration and plasma free hemoglobin（PFH） in blood samples were also monitored over times in all patients.RESULTS Effective PP could be monitored in PP group and pulse pressure（ΔP） was significantly higher in PP group than that in NP group（P〈0.01）.ScO2 of PP group was higher than that of NP group（P〈0.01） during cross-clamping period and this advantage maintained until 2 h after patients back to ICU（P〈0.05）.ET-1 level in blood was lower when CPB weaned off in PP group than NP group（P〈0.01） and this tendency persisted until 8 h after patients back to ICU.PFH concentration in PP group at preclamp off and CPB weaned off and ICU 2 h were higher than that of NP group（P〈0.05）.CONCLUSION ScO2 can sensitively indicate the variety of patients cerebral oxygenation during CPB.Pulsatile perfusion can increase ScO2 and improve microcirculation during cross-clamping period in TOF pediatric patients＇,but PP would cause severe hemolysis in these cyanotic patients than NP.

关 键 词：搏动灌注 体外循环 法洛四联症 脑氧饱和度 内皮素-1 血浆游离血红蛋白 

分 类 号：R726.5[医药卫生—儿科]