肺动脉血栓内膜剥脱术脑保护策略及效果  

Brain protection strategy and effectivity in pulmonary thromboendarterectomy

作　　者：甄雅南[1] 刘晓鹏 林凡[1] 杨煜光[1] 孙光[1] 张亚军[2] 王莉芳[2] 翟振国[3] 谢万木[3] 万钧[3] 陶新曹[3] 段军[4] 李爱莉[5] 刘鹏[1] Zhen Yanan;Liu Xiaopeng;Lin Fan;Yang Yuguang;Sun Guang;Zhang Yajun;Wang Lifang;Zhai Zhenguo;Xie Wanmu;Wan Jun;Tao Xincao;Duan Jun;Li Aili;Liu Peng(Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing 100029, China;Department of Surgical Anesthesia, China-Japan Friendship Hospital, Beijing 100029, China;Department of Respiratory and Critical Care Medicine, China-Japan Friendship Hospital, Beijing 100029, China;Department of Surgical Intensive Care, China-Japan Friendship Hospital, Beijing 100029, China;Department of Cardiology, China-Japan Friendship Hospital, Beijing 100029, China)

机构地区：[1]中日友好医院心脏血管外科,北京100029 [2]中日友好医院手术麻醉科,北京100029 [3]中日友好医院呼吸与危重医学科,北京100029 [4]中日友好医院外科重症医学科,北京100029 [5]中日友好医院心脏科,北京100029

出　　处：《中华医学杂志》2019年第37期2916-2920,共5页National Medical Journal of China

摘　　要：目的总结慢性血栓栓塞性肺动脉高压(CTEPH)患者行深低温-停循环下肺动脉血栓内膜剥脱术(PTE)术中脑保护经验及效果。方法回顾性分析中日友好医院2016年12月至2018年8月间25例PTE手术资料。全部手术均在深低温停循环下完成,术中采用严格的脑保护标准,包括:体外循环控制性均衡降温、脑氧饱和监测、停循环时间监控、脑表面恒定低温保护等。统计并分析围手术期神经系统不良事件,术前及出院前采用简易智力状态检查(MMSE)量表和蒙特利尔认知评估(MoCA)量表评估患者智力水平及认知功能。结果25例患者均顺利完成手术,1例(4%)患者术后因感染死亡。患者平均肺动脉压(mPAP)由术前(52.9±16.7)mmHg降至术后即刻的(23.6±8.1)mmHg以及术后3个月的(20.7±7.9)mmHg,差异均有统计学意义(t=10.01、10.73,均P<0.01)。患者肺血管阻力(PVR)由术前975.4(788.6~1 292.8)dyn·s·cm^-5降至376.1(283.6~565.5)dyn·s·cm^-5(Z=5.34,P<0.01)。围手术期共3例患者出现神经系统并发症,其中2例表现为缺氧性脑病,1例为脑出血,此3例患者均于出院前完全康复。单因素分析显示局部脑氧饱和度(rSO2)<40%持续时间及rSO2较基线最大下降率与术后出现神经系统损害显著相关。多因素分析显示仅rSO2<40%持续时间与术后神经系统损害显著相关。患者术前及术后MMSE量表和MoCA量表评分差异均无统计学意义(均P>0.05)。结论充分的脑保护措施对于降低PTE手术神经系统并发症至关重要。术中实时监测rSO2并严格控制停循环时间有助于进一步减少神经系统损害的发生。Objective To summarize the experience and effectivity of brain protection in 25 patients who suffered from chronic thromboembolic pulmonary hypertension (CTEPH) and received pulmonary thromboendarterectomy (PTE) under deep hypothermic circulatory arrest. Methods Retrospective analysis of 25 PTE surgeries in our center from December 2016 to August 2018. All cases were completed underdeep hypothermic circulatory arrest. Standard brain protections were strictly executed, including: balanced and controlled extracorporeal circulation cooling, cerebral oxygen saturation (rSO2) monitoring, strictly control of circulatory arrest time, and etc. The neurological adverse events during the perioperative period were recorded and statistically analyzed, and the intelligence level and cognitive function of the patients were evaluated by MMSE scale and MoCA scale before surgery and discharge. Results All the 25 patients successfully completed the surgery, and 1 patient (4%) died of postoperative infection. The mean pulmonary arterial pressure decreased from (52.9±16.7) mmHg before surgery to (23.6±8.1) mmHg immediately after surgery (t=10.01, P<0.01), and(20.7±7.9) mmHg at 3 months follow-up (t=10.73, P<0.01). Pulmonary vascular resistance decreased from 975.4 (788.6-1 292.8) dyn·s·cm^-5 to 376.1 (283.6-565.5) dyn·s·cm^-5 (Z=5.34, P<0.01). Neurological complications occurred in 3 patients during the perioperative period, including 2 patients with hypoxic encephalopathy, and 1 patient with cerebral hemorrhage. All 3 patients fully recovered before discharge. Univariate analysis showed that the duration of rSO2<40% and the maximum decrease rate of rSO2 from baseline were significantly correlated with postoperative neurological damage. Multivariate analysis showed only time of rSO2<40% was significantly correlated with postoperative neurological damage. There was no significant difference in MMSE and MoCA score before and after surgery (P>0.05). Conclusions Adequate brain protection measures are essential to reduce the neuro

关 键 词：血栓栓塞 高血压 肺性 动脉内膜切除术 治疗结果 

分 类 号：R654.3[医药卫生—外科学]