Objective:To investigate the current situation of cardiopulmonary bypass(CPB) in China and analyze the causes, to guide the formulation and implementation of technology standard.Methods:The survey task force sent out a nationwide survey to obtain up-to-date information on perfusion practice by ChSECC(Chinese Society of Extracorporeal Circulation). The unit of analysis for the survey was the medical center performs CPB. The survey consisted 48 questions covering four topics of qualifications, including certification and education, policies and practices, device and equipment, techniques used.Results:There were 540 of the 714 centers for an overall response rate of 76%. According to the annual number of CPB, they were divided into 4 groups: group A(≤50 cases/year), group B(50-100 cases/year), group C(100-500 cases/year) and group D(≥500 cases/year). The response rate of center with more than group D last year was 100%. Most of the perfusionists had certification issued by ChSECC. Although there were more than 80% of group D performed regular training and assessment of perfusionist, the result was still not ideal enough. Low utilization of safety equipment was not depend on the annual operation volume in most of responding centers. Ultrafiltration and blood protection technology had high application rate in group D compared with group A and B.Conclusion:The certification rate of perfusionists are high. Lower the number of annual CPB cases, lower the proportion of regular evaluation and training, and lower rate of standards performance. No matter the amount of CPB, the application rate of safety equipment is not ideal. Higher the number of CPB cases, higher the utilization rate of CPB related technologies.

1引言 自2019年年末以来,新型冠状病毒(COVID-19,也称2019-nCoV)在武汉感染流行并迅速蔓延全国各地,根据国家整体防控方案各地进行隔离等措施,全国各医疗部门共抗疫情[1].然而部分感染患者进行相关手术仍需体外循环支持.为规范管理、准化流程,现制定疑似及确诊COVID-19感染患者的体外循环工作原则及流程,供广大同道参考.同时也会根据疫情的变化适时更新该规范.

1 临床资料 患者 男,60岁.主因"突发持续剧烈胸痛2 h"于2013年2月27日18:25就诊于中国医学科学院阜外医院.入院查体:病危面容,意识淡漠,平卧位,大汗,全身湿冷,血压70/50 mmHg (1 mmHg=0.133 kPa),窦性心律,心率109次/分,律齐,未闻及明显杂音,双肺呼吸音粗,双下肺可闻及湿啰音,双下肢不肿.既往高血压病史5年;吸烟史30年,10支/d.入院心电图示:窦性心律,右束支传导阻滞,aVR导联ST段抬高0.2 mV,Ⅰ、aVL、V2～V4导联ST段抬高0.1～0.8 mV,Ⅱ、Ⅲ、aVF、V5～V6导联ST段压低0.3～0.6 mV(图1).超声心动图示:节段性室壁运动异常,左心室前壁、前间壁及心尖段运动幅度明显减低,左心室舒张末期内径46 mm,左心室射血分数45%.实验室检查示:肌钙蛋白I 0.013 ng/ml(参考值＜0.02 ng/ml),D-二聚体阴性.初步诊断:急性广泛前壁心肌梗死,Killip心功能分级Ⅳ级,高血压病1级(极高危).

1 麻醉与体外循环的关系概述 在职责层面,麻醉科医生的职责是保障手术患者安全、为外科提供手术条件; 而体外循环科医生的职责主要是保障心脏手术患者安全、为外科提供手术条件,因此,对于需要使用体外循环技术进行支持的手术,尤其是心脏外科手术,麻醉与体外循环的职责和目的高度相似.

Objective In order to provide the basic theory for reasonable management of cerebral perfusion and avoid cerebral ischemia,this study was designed to establish one unique piglet extracorporeal circulation model and explore real-time monitoring of the dynamic changes in cerebral perfusion and regional cerebral oxygen saturation(rSO2)during different stages of cardiopulmonary bypass(CPB).Methods Twelve piglets were divided into 3 groups randomly(n=4):control group,high blood flow group(H group)and low blood flow group(L group).A unique double arterial line with single pump was established in this piglet's model.Cerebral flow rates were monitored using TS410 transit-time tubing flowmeters(Transonic Systems Inc.,Ithaca,NY).Regional cerebral oxygen saturation (rSO2)was monitored simultaneously as one of parameters of cerebral autoregulation.Arterial samples were drawn to measure the concentrations of S100 protein.Hematoxylin-eosin(HE)and Nissl staining were performed to detect morphologic characteristics of hippocampus.Results During cross-clamping of CPB,cerebral blood flow in L group[(19.0 ± 7.4)mL/(kg·min)]was lower than that in H group[(30.8 ± 9.9)mL/(kg·min)] (P=0.072),and the rSO2in L group(47.3% ±3.3%)was lower than that in H group(52.6% ± 3.1%) (P<0.05).There were no significant difference in HE and Nissl staining in hippocampus neuron among the three groups.Conclusions The current study demonstrated that the impairment of cerebral autoregulation and cerebral perfusion was determined by the whole blood flow of extracorporeal circulation.High blood flow in extracorporeal circulation had better cerebral perfusion during cross-clamping than low blood flow.

目的 通过使用SimMan模拟系统进行体外膜肺氧合(ECMO)模拟培训,旨在提高ECMO团队及成员管理ECMO患者和应对突发事件的综合能力.方法 230名学员参与本模拟训练,3～4名学员一组,使用SimMan模拟系统设计6种不同的ECMO场景.模拟导师带领每组学员分析讨论不同场景所产生的各种原因及应对措施并提出预防方案,对学员的专业知识、临床评估、技术能力及团队协作等各方面的表现进行综合评分.结果 学员们在模拟前表现为认识评估不确切,团队协作交流不充分,综合评分低,经过理论培训和模拟导师指导下的场景模拟教学后各方面均表现出明显改善,评分具有非常显著地提升(P＜0.01).结论 ECMO模拟培训可以有效提升ECMO团队临床思维能力以及应对突发事件的综合处置能力.

目的 成人心外科术后不同体外膜氧合(extracorporeal membrane oxygenation,ECMO)建立时机是否影响预后的相关研究尚无报道.该研究拟通过单中心回顾研究探讨ECMO建立时机和预后的关系.方法 回顾性收集了84例因心源性疾病接受静脉-动脉(venous-arterial,VA) ECMO支持的成年患者(≥18周岁).患者分为术后l天内(early,E组)和术后1天以后(late,L组)两组.结果 65例(77.4％)患者于术后l天内建立ECMO,,建立时间中位数为l d(0～ld),最长为17d.E组患者术前NYHA评分3～4级(73.9％ vs47.4％,P＜0.01)、EuroSCORE评分中～高危组患者(69.2％vs 42.2％,P=0.039)显著高于L组,E组转机时间显著长于L组([314±125]min vs [176±88] min,P＜0.01)、建立ECMO的原因不同(P＜0.01),E组主要为不能脱机(39/65),L组患者为低心排和或低氧血症(19/19).ECMO辅助第一天的最高血浆乳酸水平(P=0.02)、平均动脉压最小值(P=0.019)、血小板最小值(P=0.033)E高于L组,最大多巴胺剂量(P=0.019)E组低于L组.ECMO辅助期间,感染(P=0.044),急性肾衰竭(P=0.025)和缺血性肝炎(P=0.032)的发生率在L组中更高.两组患者在血制品的输注量上并无统计学差异.E组在住院期间的全因死亡率低于L组(52.3％ [34/65]vs 78.9％[15/19],P=0.038),ECMO辅助时间和ICU停留时间、住院间时两组无显著差异.结论 心脏术后早期建立ECMO的患者生存率高,且急性肾衰、缺血性肝炎等并发症发生率较低.

Objective To observe neuropsychological development status in children after surgical treatment of congenital heart diseases(CHDs)and analyze the risk factors. Methods 89 children who received outpatient review in Fuwai Hospital from September 2015 to March 2016 after surgical treatment of CHDs were recruited in this study and 90 normal children were recruited as the control group. The children with CHDs were divided into simple CHDs group(RACHS- 1 score≤2)and com-plex CHDs group(RACHS- 1 score≥3)according to RACHS- 1 classification. Neuropsychological development status was meas-ured according to pediatric-psychological mental test scale developed by Capital institute of pediatrics,Beijing and statistical a-nalysis was compared. Results The measurements of neuropsychological development showed the normal children behaved better than the children with CHDs(P < 0. 05). The simple CHDs group achieved better distribution of development quotient than complex CHDs group(P = 0. 032)and there was no difference between the normal control group and simple CHDs group (P = 0. 420). Multivariate regression analysis indicated that younger age at cardiac surgery,lower preoperative blood urea ni-trogen(BUN),higher preoperative creatinine(Cr)and prolonged duration of cardiopulmonary bypass(CPB)accounted for low-er scores in the test scale(P < 0. 05). Conclusion Distinct neuropsychological difficulties could be present especially in chil-dren with complex CHDs. Younger age at cardiac surgery,preoperative BUN,Cr and CPB duration were perioperative factors that were associated with long-time neuropsychological development.

目的:探讨体外膜肺氧合(ECMO)联合持续性肾替代治疗(CRRT)对心外科危重患者预后的影响.方法:回顾分析2010年1月至2014年12月期间,67例接受ECMO治疗的成人患者,男性50例(74.6％),平均年龄(47.25±14.82)岁,根据患者是否接受CRRT治疗分为单纯ECMO组与ECMO联合CRRT组,比较两组ECMO时间、ICU时间、呼吸机时间、院内病死率情况以及并发症发生情况.结果:单纯接受ECMO治疗的患者35例,病死率28.6％;接受ECMO联合CRRT治疗的患者32例,病死率56.2％;两组间比较差异有统计学意义(P =0.022).ECMO联合CRRT组多器官功能衰竭(MODS)发生率高于单纯ECMO组,两组比较差异有统计学意义(P =0.048).在输入血制品方面,单纯ECMO组输入红细胞14(5,37)U、ECMO联合CRRT组输入红细胞29(18,37)U,两组比较差异有统计学意义(P=0.025).结论:ECMO联合CRRT治疗组患者病死率高(56.2％vs.28.6％,P=0.022),MODS发生率增高(18.7％vs.2.8％,P=0.048),红细胞输入量增高[29(18,37)vs.14(5,37),P=0.025].

目的 探讨模拟训练在体外循环临床教学中对提高医师基本技能以及应对体外循环中意外事件能力的培训价值,为临床教学改革和完善提供科学依据.方法 10名低年资体外循环医师参与本模拟训练,两人一组,使用高仿真体外循环模拟设备设计5种不同的体外循环意外场景.指导老师引导每组学员对场景进行分析与讨论,探讨每种场景所产生的原因及处理措施,并提出预防方法.对学员的评估预判、专业知识、临床操作及协作交流进行综合评分.一个月后重复训练并综合评分,与前期评分比较.结果 与首次训练相比较,学员的评估预判能力、专业知识、临床操作及协作交流各方面表现均有所改善,评分得到了极显著地提高(P＜0.01).结论 体外循环模拟教学可以有助于提升体外循环医师的临床思维、操作技能以及以应对及预防突发意外事件的能力,可取得较为理想的教学效果.

Objective To summarize and analyze early outcomes of 67 consecutive extracorporeal membrane oxygenation (ECMO) cases performed in Fuwai Hospital, and to interrogate the effects of combining extra - corporeal membrane oxygenation (ECMO) with intra-aortic balloon pump(IABP) on the treatment of critically ill adult patients. Methods We retrospectively analyzed 67 adult patients who received ECMO treatment from January 2010 to December 2014. The patients were divided into ECMO group and combined ECMO and IABP group and their outcomes were compared. Results Forty-two patients were in ECMO group, with the mortality of 38.1％ while 25 patients were in combined ECMO and IABP group, with the mortality of 48％. More hemolytic cases were observed in combined group (28％ vs 4.8％, P = 0.011). Conclusions Combined ECMO and IABP treatment does not increase mortality in patients, but it may increase the incidence of hemolysis.

目的:本研究拟通过构建幼猪体外循环(CPB)脑灌注血流/压力动物模型,探讨CPB期间动脉血压、灌注流量对脑血流自动调节的影响.方法:20只,幼猪,随机分五组:对照组、高血压高流量组、高血压低流量组、低血压高流量组、低血压低流量组.在CPB开始前10min、CPB开始后10min、升主动脉阻断后30min和升主动脉开放后10min 4个时间点检测血清S100钙结合蛋白B(S100 B)和神经元特异性烯醇化酶(NSE)浓度.免疫组织化学检测大脑海马组织缺氧诱导因子-1α(HIF-1α)、凋亡诱导因子(AIF)和Caspase-3的表达.结果:在升主动脉阻断期间,低流量灌注动物脑灌注流量远远低于高流量组(P =0.009),低流量低血压组rSO2低于其他各组rSO2值(P＜0.05),血清S100B水平显著高于高血压低流量组(P =0.032).海马组织HIF-1α、AIF和Caspase-3的表达无组间差异.结论:低CPB血流可以造成全身和脑灌注不足,脑血管自我调节机制不能抵消低流量造成的脑灌注不足损伤.维持较高的动脉灌注压力,有助于在一定程度上代偿脑灌注不足引起的缺氧状况.

目的:体外膜肺氧合(ECMO)已经越来越多的应用于严重心肺衰竭的患者.急性肾功能衰竭(肾衰)是 ECMO 辅助过程中常见的严重并发症.本研究的目的为通过回顾分析我院 ECMO 病历资料,研究 ECMO 支持过程中急性肾衰的危险因素,以期为预防急性肾衰的发生提供理论依据.

Objective To explore the incidence rate,risk factors and outcome of hyperbilirubinemia in adult cardiac patients supported by extracorporeal membrane oxygenation(ECMO).Methods Clinical data of 89 adult cardiac patients with ECMO in Fuwai Hospital were retrospectively analyzed.All patients were divided into normal group,high bilirubin group and severe high bilirubin group.In a multiple linear regression analysis,logarithmic transformation was performed for non-normally distributed variables.Results The incidence rate of hyperbilirubinemia was 73％,including 30 cases in high bilirubin group and 35 cases in severe high bilirubin group.A multiple linear regression analysis showed that lg(peak TBIL+1)was significantly associated with lg(peak AST+1)(P=0.001),lg(peak free hemoglobin +1)(P=0.003)and TBIL before ECMO(P=0.009).There was also a linear correlation between peak TBIL and TBIL before ECMO support(P=0.011),peak AST(P=0.004)and peak free hemoglobin during ECMO(P<0.001).The patients in severe high bilirubin group had lower platelets during ECMO,and the survival rate was the lowest.Conclusion Hyperbilirubinemia remains common in patients with ECMO,and is associated with low platelet and a high rate of in-hospital mortality.Hemolysis and liver dysfunction during ECMO support and high bilirubin level before ECMO are risk factors of hyperbilirubinemia.

Objective To evaluate the platelet function and blood coagulation of patients received thoracic aortic procedures with deep hypothermic circulatory arrest (DHCA),and to investigate their influencing factors.Methods The study consisted of 50 patients scheduled for aorta replacement undergoing DHCA between June 2014 and March 2015.Patients with re-operation,prescription antiplatelet drugs within 7 days before operation,onset time over 30 days and hematological diseases were excluded.Function of platelet and coagulation were tested by thrombelastogram (TEG) at two intervals,namely after anesthesia induction (T1) and 5 mins after protamine neutralization (T2).Blood routine examination and coagulating time test were also included.Results Compared with before cardiopulmonary bypass (CPB),MA value and fibrinogen (FIB) significantly reduced on T2 (P<0.001,P<0.001).Platelet count and hemoglobin concentration were both statistically decreased after protamine neutralization(P<0.001,P<0.001).There was a liner relationship between platelet function and platelet count before CPB (r=0.76,P=0.008).The correlation between function of platelet before operation and onset time was quadratic curve relationship (R2=0.551,P<0.001).Multivariate logistic regression analysis revealed that female (OR=0.097,P=0.047) and body mass index (OR=1.197,P=0.036) were risk factors associated with platelet transfusion at the end of CPB,while the function of platelet (OR=0.852,P=0.026) before surgery was a protective factor.The area under the ROC curve of MA before surgery on platelet transfusion was 0.843 (95％CI: 0.660-1.000,P=0.004).The specificity of MA<59.95mm was 75％,the sensitivity was 93％.Conclusion The levels of FIB and platelet function significantly decreased at the end of CPB,while most of patients'' platelet functions were at normal range.Blood platelet transfusion might be more reasonable for patients of female,lower BMI and MA <59.95mm before surgery.

Objective Ischemic hepatitis (IH) is acute ischemic damage in liver caused by hypoxemia and hypoperfusion. However, the prevalence, risk factors and prognosis of IH during venous-arterial extracorporeal membrane oxygenation (ECMO) were rarely reported. Methods A total of 82 adult patients (≥18 years) with cardiac diseases were enrolled for venous-arterial (VA) ECMO in this study. These patients afflicted with IH and non-IH (NIH) were assigned into two groups. Results A total of 20 patients (24.4%) were afflicted with IH within 24 h during ECMO. In these patients, AST decreased over time, but the levels of total bilirubin (TBIL) increased gradually. The survival rate of IH group was significantly lower than that of NIH group (15%vs 50%, P=0.006). The incidence of acute renal failure was higher in IH group (70.0% vs 41.9%, P=0.029). More albumin was required in IH group (P=0.002). In the multivariable regression model, medical heart failure [(odds ratio, OR)=149.71, 95%CI 6.22-3602.58, P=0.002], peak lactate (OR=1.41, 95%CI 1.14-1.76, P=0.002) and peak TBIL (OR=1.02, 95%CI 1.01-1.04, P=0.010) within the first 24 h during ECMO were risk factors for IH. The survival rate of IH group was significantly lower than that in NIH group (50% vs 15%, P=0.006). Conclusions Patients with medical heart failure, high levels of peak lactate and peak TBIL during ECMO have higher risk to develop IH.

The aims of this study were to evaluate the incidence, risk factors, and outcomes of hyperbilirubinemia in cardiac patients with veno-arterial (VA) ECMO. Data on 89 adult patients with cardiac diseases who received VA ECMO implantation in our hospital were retrospectively reviewed. All patients were divided into the following three groups: 24 in normal group (N, total bilirubin [TBIL] ≤3 mg/dL), 30 in high bilirubin group (HB, 6 mg/dL ≥ TBIL > 3 mg/dL), and 35 in severe high bilirubin group (SHB, TBIL > 6 mg/dL). lg(variables + 1) was performed for nonnormally distributed variables. The incidence of hyperbilirubinemia (>3 mg/dL) was 73%. In a multiple linear regression analysis, lg(peak TBIL + 1) was significantly associated with lg(peak AST + 1) (b-coefficient 0.188, P = 0.001), lg(peak pFHb + 1) (b-coefficient 0.201, P = 0.003), and basic TBIL (b-coefficient 0.006, P = 0.009). Repeated measurement analysis of variance revealed that the main effect for three groups in pFHb and lg(AST + 1) was significant at first 3 days during ECMO. The patients in SHB had low platelets during ECMO and low in-hospital survival rate. Hyperbilirubinemia remains common in patients with VA ECMO and is associated with low platelets and high in-hospital mortality. Hemolysis and liver dysfunction during ECMO and basic high bilirubin levels are risk factors of hyperbilirubinemia.

Objective To evaluate the protective value of cardioplegia solution plus metformin in different cardiac arrest time and concentration of metformin in isolated rat hearts .Methods There were 36 male Sprague–Dawley rats divided into six groups randomly, according to the duration of cardioplegic arrest(30 min or 60min) and the concentrations of metformin(50μmol/L or 100 μmol/L) .Langendorff-perfused Sprague-Dawley rat hearts were perfused for 20 minutes with Krebs-Henseleit buffer followed by 30 or 60 minutes of crystalloid cardioplegia or plus metformin (50 or 100 μmol/L) and 60 minutes of reperfu-sion.The left ventricular performance was recorded at 5 time points.The expressions of AMPKαand phosphorylation of AMPKαwere detected by western Blot.The changes of myocardial mitochondria were observed under transmission electron mi-croscope.Results There were no significant differences in Con(A), 50(A) and 100(A) groups in LVDP, ±dp/dtmax and HR.Compared with Con(B) group subjected to 60 minutes of ischemia followed by 60 minutes of reperfusion, the 100(B) group significantly improved myocardial performance , and the ratio of p-AMPKα/AMPKαwas the highest in all 6 groups.The structure of myocardial mitochondria in 100(B) group was better protected than that of Con(B) group.Conclusion These findings suggested that the left ventricular performance was protected in rat heart perfused by cardioplegia plus 100 μmol/L after 60 minutes cardioplegic arrest .The mechanism may be the activation of AMPK and the protection of structures of myocardial mitochondria.

目的:相较其他建立地点而言,在手术室建立体外膜肺氧合(ECMO)可能更为及时,预后可能较好,但目前尚缺乏相关报临床报道.因此我们期望通过本研究,描述不同建立地点 VA ECMO 患者的特征及预后,以期为临床 ECMO 建立的时机提供相关依据.