Schneider Susan, Sakert Tamara, Lucke John, McKeown Peter, Sharma Ajeet
Department of Cardiovascular Perfusion, VA Medical Center, Asheville, USA.
Perfusion. 2006 Mar;21(2):117-20. doi: 10.1191/0267659106pf853oa.
Cardiopulmonary bypass (CPB) poses great risks for hypercoagulable patients and requires management techniques to ensure an optimal outcome free from thrombotic events. This case report reviews perfusion management techniques that may contribute to a safer CPB experience for a patient deficient in both protein C and protein S. A patient with heterozygous protein C deficiency is at increased risk of thrombosis, especially in the venous circulation. Since it is an essential cofactor for activated protein C, deficiency of free protein S is also linked to a hypercoagulable condition. A 52-year-old male presented to our institution with a past medical history of hypercoagulable state, multiple deep vein thromboses, pulmonary embolisms, and stroke. He was scheduled for two-vessel coronary artery bypass graft surgery to be followed by right carotid endarterectomy (RCEA) before discharge. The anesthesia and perfusion teams worked closely together to ensure that fresh frozen plasma (FFP) was given intraoperatively at appropriate times. Heparin dose response and protamine dosage was determined with hemostasis management system (HMS) analysis. The closed CPB circuit and cannulae were Carmeda bonded. Rapid autologous priming, along with the use of a hemoconcentrator, kept the hematocrit above 21 during CPB. Zero-balance ultrafiltration and leukocyte depletion were initiated during rewarming to aid in attenuation of the inflammatory response. To conserve coagulation factors, all pump blood was ultrafiltrated post-CPB and returned to the patient. Laboratory samples drawn on postoperative day (POD) one measured normal protein C activity with subnormal protein S activity. On POD six, the patient underwent RCEA and he was discharged on POD eight without complications.
体外循环（CPB）对高凝状态患者构成巨大风险，需要相应的管理技术来确保获得无血栓事件的最佳结果。本病例报告回顾了一些灌注管理技术，这些技术可能有助于为蛋白C和蛋白S均缺乏的患者提供更安全的体外循环体验。杂合子蛋白C缺乏的患者发生血栓形成的风险增加，尤其是在静脉循环中。由于游离蛋白S是活化蛋白C的重要辅助因子，游离蛋白S的缺乏也与高凝状态有关。一名52岁男性因有高凝状态、多次深静脉血栓形成、肺栓塞和中风的既往病史前来我院就诊。他计划接受双支冠状动脉搭桥手术，出院前再接受右侧颈动脉内膜切除术（RCEA）。麻醉和灌注团队密切合作，确保术中在适当时间给予新鲜冰冻血浆（FFP）。通过止血管理系统（HMS）分析确定肝素剂量反应和鱼精蛋白用量。体外循环闭合回路和插管采用卡美达涂层处理。快速自体预充，同时使用血液浓缩器，使体外循环期间血细胞比容保持在21以上。复温期间启动零平衡超滤和白细胞去除，以减轻炎症反应。为保存凝血因子，所有泵出的血液在体外循环后进行超滤并回输给患者。术后第1天采集的实验室样本显示蛋白C活性正常，但蛋白S活性低于正常水平。术后第6天，患者接受了右侧颈动脉内膜切除术，术后第8天出院，无并发症发生。
