Hogue Charles W, Palin Christopher A, Arrowsmith Joseph E
Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University Medical School, 600 North Wolfe Street, Tower 711, Baltimore, MD 21205, USA.
Anesth Analg. 2006 Jul;103(1):21-37. doi: 10.1213/01.ANE.0000220035.82989.79.
Neurologic complications after cardiac surgery are of growing importance for an aging surgical population. In this review, we provide a critical appraisal of the impact of current cardiopulmonary bypass (CPB) management strategies on neurologic complications. Other than the use of 20-40 microm arterial line filters and membrane oxygenators, newer modifications of the basic CPB apparatus or the use of specialized equipment or procedures (including hypothermia and "tight" glucose control) have unproven benefit on neurologic outcomes. Epiaortic ultrasound can be considered for ascending aorta manipulations to avoid atheroma, although available clinical trials assessing this maneuver are limited. Current approaches for managing flow, arterial blood pressure, and pH during CPB are supported by data from clinical investigations, but these studies included few elderly or high-risk patients and predated many other contemporary practices. Although there are promising data on the benefits of some drugs blocking excitatory amino acid signaling pathways and inflammation, there are currently no drugs that can be recommended for neuroprotection during CPB. Together, the reviewed data highlight the deficiencies of the current knowledge base that physicians are dependent on to guide patient care during CPB. Multicenter clinical trials assessing measures to reduce the frequency of neurologic complications are needed to develop evidence-based strategies to avoid increasing patient morbidity and mortality.
对于日益老龄化的手术人群而言，心脏手术后的神经系统并发症愈发重要。在本综述中，我们对当前体外循环（CPB）管理策略对神经系统并发症的影响进行了批判性评估。除了使用20 - 40微米的动脉管路过滤器和膜式氧合器外，基本CPB装置的更新改进或专用设备或程序的使用（包括低温和“严格”血糖控制）对神经学结局的益处尚未得到证实。对于升主动脉操作可考虑采用主动脉超声检查以避免动脉粥样硬化，尽管评估该操作的现有临床试验有限。CPB期间管理流量、动脉血压和pH值的当前方法有临床研究数据支持，但这些研究纳入的老年或高危患者较少，且早于许多其他当代实践。尽管有一些关于某些阻断兴奋性氨基酸信号通路和炎症的药物益处的有前景的数据，但目前尚无药物可推荐用于CPB期间的神经保护。综合来看，所综述的数据凸显了当前医生在CPB期间指导患者护理所依赖的知识库的不足之处。需要开展多中心临床试验来评估降低神经系统并发症发生率的措施，以制定基于证据的策略，避免增加患者的发病率和死亡率。
