主动脉内球囊反搏在危重症心脏病患者的应用及对应用时机的研究

发布时间：2018-08-27 11:37

【摘要】：背景与目的在现代社会,随着物质生活水平提高,人们不断追求高品质的生活,同时,各种危重症心脏病的发病率也在不断增加,使得心脏手术成为挽救患者生命、改善患者生存状态的重要保证。科技飞速发展,越来越多的机械辅助循环手段出现,使重症患者心功能改善,明显提高了生存质量,在接受心脏手术的同时,各种辅助手段也成为拯救患者生命的重要保证。主动脉内球囊反搏(Intra-aorticballoon pump,IABP)就是众多机械辅助循环装置的一种,而且应用广泛,对于临床中出现的各种危重症心脏病具有很好的辅助治疗作用。IABP的适应症包括:急性心肌梗塞(AMI)合并心源性休克、药物治疗无效、持续或者反复发生的严重心肌缺血、心绞痛反复发作、在冠状动脉造影前后或由于心肌梗塞导致的血流动力学不稳定,以及在高危外科手术或介入手术围术期出现的各种危险情况下对患者进行辅助治疗。对于危重症心脏病患者应用IABP辅助后,最直接的作用就是可以增加舒张期主动脉内压力,从而增加了冠状动脉血流,增加心肌收缩力,减轻心脏收缩时左心室后负荷,最终达到改善外周循环、增加全身重要器官血液灌注、改善心功能的目的。然而,患者病情的严重程度将界定应用IABP的最适时机,同时,在IABP应用过程中应注意预防并发症的发生。本文结合患者的病例资料,探讨IABP在危重症心脏病中的应用指征、应用时机、临床效果以及辅助后对患者的影响,为IABP辅助能今后在临床工作中更好地为患者服务提供经验及参考依据。方法统计分析我院2015年1月至2016年12月期间共15例应用IABP辅助的危重症心脏病患者的临床病例资料、诊断、治疗方法、结果及预后。其中男性患者9例,女性患者6例,年龄最小者41岁,最大80岁(平均62.1岁);主要合并症有高血压(7例)和糖尿病(5例)。给予IABP辅助时机的选择:术前预防性放置9例,术中在手术室放置2例,术后入监护室(ICU)后放置4例,应用时间12小时-72小时(平均42小时)。IABP反搏机型号DataScope Cl00,均选用经皮改良Seldinger股动脉穿刺技术插管,选择与患者自身情况对应的触发模式。分别统计应用IABP前和应用2小时后血流动力学指标,如心率(HR)、收缩压、舒张压、平均动脉压(MAP)、中心静脉压(CVP)、心排指数(CI),以及末梢循环情况、24h尿排泄量、强心药物用量、围术期死亡等,并对患者进行术后随访,观察其临床结果和预后。结果临床给予IABP辅助患者共15例,其中,14例临床效果明显,心功能显著改善,并痊愈出院;1例临床效果不明显,最终死于低心排综合征。治疗中9例患者采取预防性应用IABP辅助,术后恢复良好,均痊愈出院,被动性应用患者6例,有1例死亡。15例均无相关并发症发生。结论1.IABP可增加舒张期主动脉内压力,增加了冠状动脉血流,减轻心脏收缩时左心室后负荷,从而改善外周循环、提高患者心功能,对围手术期血流动力学不稳定的危重症心脏病临床成效显著。2.预防性应用IABP有助于减少术中手术操作对血流动力学的影响,提高危重患者行手术时的安全性。同时,对于危重心脏手术患者,术前辅助的意义要明显好于术中及术后补救性置入。3.患者使用IABP辅助后应及时评估辅助治疗效果,并根据患者病情变化做出相应调整,同时注意预防并发症,如已发生则及时处理。4.应用IABP辅助后血流动力学稳后可考虑撤出IABP。撤出球囊导管时要缓慢降低反搏比例,以使患者的心功能有一个逐渐适应的过程。意义IABP在辅助危重症心脏病治疗过程中展现了强大的改善循环作用,因此是一种有效的机械辅助手段。IABP的使用可以使患者病死率大大降低,同时由于IABP的操作方法和设备的改良,发生相关并发症的几率很小,几乎不发生严重并发症。早期应用IABP临床效果显著,预防性主动应用IABP比被动性应用要产生更好的远期效果。由于本研究的样本量有限,且为回顾性分析,因此,对于IABP辅助治疗的长期效果仍需进一步深入研究。随着临床经验的积累总结以及对IABP使用的进一步探索,未来IABP将会更加广泛地为患者服务,会有更多的患者因此受益。
[Abstract]:BACKGROUND & OBJECTIVE In modern society, with the improvement of material living standard, people are constantly pursuing high quality of life. At the same time, the incidence of various critical heart diseases is also increasing. Heart surgery has become an important guarantee to save patients'lives and improve their living conditions. Intra-aortic balloon pump (IABP) is one of many mechanical assisted circulatory devices, which is widely used in clinical practice. Indications for IABP include acute myocardial infarction (AMI) with cardiogenic shock, ineffective drug therapy, persistent or recurrent severe myocardial ischemia, recurrent angina pectoris, and hemodynamic instability before and after coronary angiography or due to myocardial infarction. The most direct role of IABP in critically ill patients is to increase diastolic aortic pressure, thereby increasing coronary artery blood flow, increasing myocardial contractility, and reducing cardiac contraction. However, the severity of the patient's condition will define the optimal time for the application of IABP. At the same time, attention should be paid to the prevention of complications during the application of IABP. This article discusses the role of IABP in improving peripheral circulation, increasing systemic blood perfusion and improving cardiac function. The application indications, application timing, clinical effect and the influence of adjuvant therapy on patients with critical heart disease provide experience and reference basis for IABP assistant therapy to better serve patients in clinical work in the future. The main complications were hypertension (7 cases) and diabetes (5 cases). Four patients were placed behind the chamber (ICU) for 12 hours to 72 hours (average 42 hours). The IABP counterpulsation machine DataScope Cl00 was used for catheterization by percutaneous modified Seldinger femoral artery puncture technique. The trigger modes corresponding to the patient's own conditions were selected. Diastolic blood pressure, mean arterial pressure (MAP), central venous pressure (CVP), cardiac output index (CI), peripheral circulation, 24-hour urinary excretion, cardiotonic drug dosage, perioperative mortality, etc. were followed up and their clinical results and prognosis were observed. Results 15 patients were assisted by IABP. Of them, 14 had obvious clinical effects and cardiac function. In the treatment, 9 patients received prophylactic application of IABP, all recovered well and discharged. 6 patients received passive application, and 1 patient died. All 15 patients had no related complications. Conclusion 1. IABP can increase intra-aortic pressure during diastole and increase intra-aortic pressure. Coronary artery blood flow, reduce the left ventricular afterload during cardiac contraction, thereby improving peripheral circulation, improve cardiac function of patients, perioperative hemodynamic instability of critical heart disease clinical results are significant. 2. Prophylactic application of IABP helps to reduce the impact of intraoperative operation on hemodynamics, improve the operation of critical patients. At the same time, for patients with critical heart surgery, the significance of preoperative adjuvant is obviously better than intraoperative and postoperative remedial implantation. 3. Patients with IABP adjuvant treatment should be timely assessed after the use of adjuvant treatment, and make corresponding adjustments according to the patient's condition, while paying attention to the prevention of complications, if it has occurred, timely treatment. 4. Application of IABP adjuvant treatment. After hemodynamic stabilization, it may be considered to withdraw the IABP. When withdrawing the balloon catheter, the proportion of counterpulsation should be slowly lowered so as to make the patient's heart function have a gradual process of adaptation. Significance IABP has shown a strong role in improving circulation during the adjuvant treatment of critical heart disease, so it is an effective mechanical assistant method. The mortality rate was greatly reduced, and the incidence of related complications was very low due to the improvement of IABP operation methods and equipment. Early application of IABP had significant clinical effect, and the long-term effect of prophylactic active application of IABP was better than that of passive application. Retrospective analysis shows that the long-term effects of IABP adjuvant therapy need to be further studied. With the accumulation of clinical experience and further exploration of the use of IABP, IABP will be more widely used in the future and will benefit more patients.
【学位授予单位】：山东大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R654.2

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