体外循环心脏术后缺血性肠坏死1例并研究进展

发布时间：2018-06-28 14:41

本文选题：体外循环 + 缺血性肠坏死　；参考：《兰州大学》2015年硕士论文

【摘要】：目的：体外循环心脏术后缺血性肠坏死属于罕见并发症,其发病率虽低,但由于早期诊断困难,治疗棘手,该并发症病死率非常高。本文通过病例报告旨在探讨其病因、发病机制、病理生理变化、临床特点、辅助检查方法、诊治进展等。方法：回顾了1例体外循环心脏直视术后缺血性肠坏死病人的临床病历资料,并根据近年来关于本并发症研究进展予以进一步论述。设计：病例报告。病例：患者女,62岁,以“风湿性心脏病,二尖瓣狭窄并闭锁不全,三尖瓣闭锁不全,主动脉瓣闭锁不全,心房纤颤,2型糖尿病”收住,入院后为排除冠脉病变查冠状动脉造影提示：左侧冠脉前降支中段处约75%狭窄。于全麻、低温、体外循环下行“冠状动脉搭桥术、二尖瓣联合三尖瓣机械瓣膜置换术”。术后出现腹胀、腹痛、血便、感染性休克,经诊断性腹腔穿刺后明确诊断为急性腹膜炎,遂急诊于全麻下施行剖腹探查术。再次术后病人仍存在循环不稳定、休克、严重感染、全身多脏器功能衰竭,后抢救无效死亡。结果：患者抢救无效死亡。讨论：在应激情况下肠道作为中心器官,不仅容易受到各种致伤因素的直接破坏,而且能够造成后续损伤。体外循环心脏术后缺血性肠坏死的一般发病规律可以大致总结为：肠道遭受缺血及缺氧性损害；肠道黏膜屏障功能完整性的丧失；肠腔中的致病菌、内毒素等有害物质弥散入血液循环：激发体内炎性因子失控性释放并引起全身炎性反应综合征；当体内促炎和抗炎反应平衡状态破坏后引起多脏器系统功能衰竭,导致机体再次损伤。根据相关文献及书籍记载,体外循环措施的改进、丙泊酚、中药、乌司他定、肠三叶因子、氨甲环酸等防治手段的应用能够减轻上述环节中损伤因素的作用,因此提示在一定程度上可以预防或改善心肺转流术后缺血性肠坏死的预后,具有一定临床价值。结论：体外循环心脏术后缺血性肠坏死发病率虽低,但起病隐匿,缺乏特征性临床表现,病情进展快,病死率极高,使得早期及时诊断与治疗困难。因此避免肠道缺血缺氧损伤及避免肠道黏膜屏障受损应作为预防该并发症的关键。
[Abstract]:Objective: ischemic intestinal necrosis after cardiopulmonary bypass (CPB) is a rare complication. Although its incidence is low, the mortality of this complication is very high due to the difficulty of early diagnosis and difficult treatment. This article aims to discuss the etiology, pathogenesis, pathophysiological changes, clinical characteristics, auxiliary examination methods, diagnosis and treatment progress. Methods: the clinical data of one patient with ischemic intestinal necrosis after open heart surgery under cardiopulmonary bypass (CPB) were reviewed. Design: case report. Case: a 62-year-old woman with rheumatic heart disease, mitral stenosis and atresia, tricuspid atresia, aortic atresia, atrial fibrillation type 2 diabetes mellitus, Coronary angiography showed that 75% of the left anterior descending coronary artery stenosis was found in the middle segment of the left anterior descending coronary artery. Under general anesthesia, hypothermia, cardiopulmonary bypass coronary artery bypass grafting, mitral valve combined with tricuspid mechanical valve replacement. Abdominal distension, abdominal pain, blood stool and septic shock occurred after operation. Acute peritonitis was clearly diagnosed after abdominal puncture and emergency laparotomy was performed under general anesthesia. After operation, the patients still had unstable circulation, shock, severe infection, systemic multiple organ failure, and then died. Results: the patients died after rescue. Discussion: as a central organ under stress, intestinal tract is not only easily damaged by various injury factors, but also can cause subsequent injury. The general pathogenesis of ischemic intestinal necrosis after cardiopulmonary bypass heart surgery can be summarized as follows: intestinal ischemia and hypoxic damage, loss of intestinal mucosal barrier functional integrity, intestinal cavity pathogens, Endotoxin and other harmful substances diffuse into the blood circulation: stimulate the uncontrolled release of inflammatory factors in the body and cause systemic inflammatory response syndrome; when the balance of pro-inflammatory and anti-inflammatory response in the body is destroyed, it causes multiple organ system failure, Cause the body to damage again. According to the relevant literature and books, the improvement of cardiopulmonary bypass measures, the application of propofol, Chinese medicine, ulinastatin, intestinal trefoil factor, and carbamicylic acid can reduce the role of injury factors in the above links. It is suggested that the prognosis of ischemic intestinal necrosis after cardiopulmonary bypass can be prevented or improved to a certain extent and has certain clinical value. Conclusion: although the incidence of ischemic intestinal necrosis after cardiopulmonary bypass heart surgery is low, the onset of the disease is concealed, the characteristic clinical manifestations are lacking, the disease progresses quickly and the mortality is very high, which makes early diagnosis and treatment difficult. Therefore, avoiding intestinal ischemia and hypoxia injury and intestinal mucosal barrier damage should be the key to prevent this complication.
【学位授予单位】：兰州大学
【学位级别】：硕士
【学位授予年份】：2015
【分类号】：R654.2

【参考文献】