本文選題：冠脈搭橋術(shù) + 局部腦氧飽和度��； 參考：《河北醫(yī)科大學(xué)》2017年碩士論文

【摘要】：目的:通過研究非體外循環(huán)下冠狀動脈旁路移植術(shù)(off-pump coronary artery bypass,OPCABG)患者術(shù)中局部腦氧飽和度(regional cerebral oxygen saturation,rSO_2)的變化,評價rSO_2的變化對術(shù)后認(rèn)知功能及預(yù)后的影響,為臨床正確合理應(yīng)用rSO_2提供臨床依據(jù)。方法:選擇2016年1月至2016年12月?lián)衿谛蠴PCABG的患者50例,ASAⅢ或Ⅳ級,男性44例,女性6例。術(shù)前合并糖尿病的13例,合并高血壓的31例,心功能分級2級的30例、3級的20例。入組患者術(shù)前血紅蛋白均在正常范圍,肝腎功能未見明顯異常。設(shè)定術(shù)中r SO_2絕對值低于50%或降低幅度大于術(shù)前20%為腦缺氧。若rSO_2絕對值低于50%或降低幅度大于術(shù)前30%為處理標(biāo)準(zhǔn),通過提高血壓來提高rSO_2。根據(jù)有無發(fā)生腦缺氧將患者分為兩組,發(fā)生腦缺氧組設(shè)為H組,未發(fā)生腦缺氧組設(shè)為N組。術(shù)前用蒙特利爾認(rèn)知功能(MoCA)量表評估患者認(rèn)知功能。如果患者受教育年限≤12年則MoCA評分加1分,如測試評分26分或與術(shù)前相比降低2分則認(rèn)為存在認(rèn)知功能障礙。入室后常規(guī)監(jiān)測血壓(BP)、心率(HR)、脈搏氧飽和度(SpO2)、腦電雙頻指數(shù)(BIS)、呼吸末二氧化碳(PETCO2)、體溫(Temp)、中心靜脈壓(CVP)、rSO_2。術(shù)中若出現(xiàn)嚴(yán)重低血壓或心律失常經(jīng)積極糾正后仍不能滿足全身灌注改行體外循環(huán)下冠狀動脈旁路移植術(shù)(on-pump coronary artery bypass,ONCABG)。術(shù)中應(yīng)用自體血液回收技術(shù),將患者血紅蛋白維持在10g/L,體溫維持在36.0-37.5℃。手術(shù)結(jié)束后有效鎮(zhèn)靜鎮(zhèn)痛,控制呼吸送回心臟外科ICU。分別記錄術(shù)前、插管后即刻、離斷左乳內(nèi)動脈前、搭橋操作結(jié)束即刻(前降支、右冠、回旋支/第一分支、側(cè)壁鉗)、關(guān)胸、術(shù)畢即刻的BP、HR、SpO2、rSO_2、BIS、PETCO2、Temp、CVP;記錄患者術(shù)后1周、術(shù)后1月的MoCA評分及預(yù)后—選擇嚴(yán)重神經(jīng)系統(tǒng)并發(fā)癥、拔管時間、ICU停留時間及術(shù)后住院時間作為預(yù)后指標(biāo)。嚴(yán)重神經(jīng)系統(tǒng)并發(fā)癥包括:腦梗塞、腦出血、昏迷、新發(fā)癲癇。若術(shù)中發(fā)生腦缺氧,記錄其當(dāng)時的情況及持續(xù)時間。若術(shù)中發(fā)生特殊情況(如:室顫)亦記錄當(dāng)時情況及持續(xù)時間結(jié)果:入組(n=50)患者均在非體外循環(huán)下完成冠脈搭橋手術(shù),術(shù)后均恢復(fù)順利。其中9例患者術(shù)中rso2下降幅度基礎(chǔ)值20%,發(fā)生了腦缺氧(h組,n=9);41例患者術(shù)中rso2下降幅度≤基礎(chǔ)值20%且絕對值50%,無腦缺氧發(fā)生(n組,n=41)。所有患者術(shù)中未發(fā)現(xiàn)rso2絕對值低于50%或降低幅度大于術(shù)前30%。兩組患者均完成了術(shù)后1周moca的測試,術(shù)后1月有45例病人完成moca測試(n組4例失訪,h組1例失訪)。兩組患者術(shù)后1周及1月moca評分未發(fā)現(xiàn)26分者或與術(shù)前相比降低2分者。對兩組患者術(shù)前一般情況可能影響術(shù)中腦缺氧發(fā)生與否的因素進(jìn)行l(wèi)ogistics回歸分析,未發(fā)現(xiàn)年齡、性別、bmi、高血壓、糖尿病、心功能、冠脈病變支數(shù)對術(shù)中腦缺氧的發(fā)生與否有影響。對map與rso2進(jìn)行分析發(fā)現(xiàn)rso2值與map呈正相關(guān),相關(guān)系數(shù)為0.601,p0.05。對h組患者術(shù)中發(fā)生腦缺氧時的情況進(jìn)行分析發(fā)現(xiàn),腦缺氧發(fā)生在吻合右冠(4例)、后室間支(4例)及出現(xiàn)室顫(3例)時(2例為吻合第一分支時,1例為吻合后室間支時),平均持續(xù)時間為7.64±0.81min,其中2例患者在吻合右冠及后室間支時均出現(xiàn)腦缺氧,持續(xù)時間為15.50±0.71min。術(shù)中發(fā)生室顫的3例患者,行胸腔內(nèi)心臟按壓時rso2最小值的分別是58、60、60,與術(shù)前相比下降百分比分別是21%、22%、22%,均在1min內(nèi)將室顫糾正,但rso2恢復(fù)延遲,缺氧時間為7.67±0.58min。兩組患者均無pocd發(fā)生,無嚴(yán)重神經(jīng)系統(tǒng)并發(fā)癥的發(fā)生。術(shù)中rso2下降幅度基礎(chǔ)值20%,持續(xù)時間7-8min內(nèi)對術(shù)后認(rèn)知功能及嚴(yán)重神經(jīng)系統(tǒng)并發(fā)癥的發(fā)生無明顯影響。對兩組患者預(yù)后進(jìn)行統(tǒng)計學(xué)分析發(fā)現(xiàn),發(fā)現(xiàn)h組患者拔管時間和icu停留時間延長于n組,差異有統(tǒng)計學(xué)意義(p0.05);術(shù)后住院時間差異無統(tǒng)計學(xué)意義(p0.05)。結(jié)論:1 OPCABG術(shù)中rSO_2不能有效預(yù)測術(shù)后認(rèn)知功能障礙及嚴(yán)重神經(jīng)系統(tǒng)并發(fā)癥的發(fā)生。2 OPCABG術(shù)中rSO_2降低幅度基礎(chǔ)值20%,拔管時間和ICU停留時間延長。3 OPCABG術(shù)中rSO_2下降幅度維持在基線的20%以內(nèi),可縮短拔管時間及ICU停留時間。
[Abstract]:Objective: To study the off-pump coronary artery bypass grafting (off-pump coronary artery bypass, OPCABG) in patients with regional cerebral oxygen saturation (regional cerebral oxygen saturation, rSO_2) changes, changes in evaluation of rSO_2 effect on cognitive function and prognosis after surgery, to provide clinical basis for the clinical reasonable application of rSO_2. Methods: 50 cases from January 2016 to December 2016 in patients undergoing OPCABG, ASA class III or IV, 44 cases were male, 6 were female. 13 cases with diabetes, 31 patients with hypertension, heart function classification of 30 cases of grade 2, grade 3 in 20 cases. The patients of preoperative hemoglobin were in the normal range, liver and kidney function had no obvious abnormalities. Set the intraoperative R SO_2 absolute value less than 50% or greater than 20% to reduce preoperative cerebral hypoxia. If the absolute value of rSO_2 is less than 50% or greater than 30% to reduce the preoperative treatment standards by improving The blood pressure to improve rSO_2. according to whether the occurrence of cerebral ischemia patients were divided into two groups, the occurrence of cerebral hypoxia group as group H, without the occurrence of cerebral hypoxia group as N group. With Montreal cognitive function before operation (MoCA) scale to assess cognitive function in patients. If the patient is less than or equal to 12 years of schooling years MoCA scores add 1 points, such as test scores of 26 or lower compared with the preoperative 2 points that have cognitive dysfunction. After entering the routine monitoring of blood pressure (BP), heart rate (HR), pulse oxygen saturation (SpO2), bispectral index (BIS), end tidal carbon dioxide (PETCO2), temperature (Temp), center venous pressure (CVP), rSO_2. operation in case of serious hypotension or cardiac arrhythmia after active correction still can not meet the whole body perfusion diverted to coronary artery bypass grafting (on-pump coronary artery bypass, ONCABG). The application of intraoperative autotransfusion system, patients with hemoglobin maintained at 10g /L, the temperature maintained at 36.0-37.5 degrees. After the end of surgery is effective for sedation and analgesia, respiratory control back to cardiac surgery ICU. were recorded before surgery, immediately after intubation, transection of left internal mammary artery bypass operation before, immediately after (the anterior descending branch of right coronary artery, circumflex branch / first, side wall clamp), closed chest. At the end of operation of the BP, HR, SpO2, rSO_2, BIS, PETCO2, Temp, CVP; recorded 1 weeks after surgery, the MoCA score and the outcome of the January selection of serious neurological complications after surgery, extubation time, ICU stay time and postoperative hospital stay as a prognostic indicator of serious neurological complications included.: cerebral infarction, cerebral hemorrhage, coma, new onset epilepsy. If brain hypoxia occurred during operation, record the situation at that time and duration. If special circumstances occur during operation (such as ventricular fibrillation) also recorded at the time and duration of the results: in the group (n=50) were performed in the off-pump coronary artery bypass surgery circulation, postoperative 鍧囨仮澶嶉『鍒，

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