Esper Stephen A, Subramaniam Kathirvel, Tanaka Kenichi A
UPMC, Pittsburgh, PA, USA.
UPMC, Pittsburgh, PA, USA
Semin Cardiothorac Vasc Anesth. 2014 Jun;18(2):161-76. doi: 10.1177/1089253214532375.
The techniques and equipment of cardiopulmonary bypass (CPB) have evolved over the past 60 years, and numerous numbers of cardiac surgical procedures are conducted around the world using CPB. Despite more widespread applications of percutaneous coronary and valvular interventions, the need for cardiac surgery using CPB remains the standard approach for certain cardiac pathologies because some patients are ineligible for percutaneous procedures, or such procedures are unsuccessful in some. The ageing patient population for cardiac surgery poses a number of clinical challenges, including anemia, decreased cardiopulmonary reserve, chronic antithrombotic therapy, neurocognitive dysfunction, and renal insufficiency. The use of CPB is associated with inductions of systemic inflammatory responses involving both cellular and humoral interactions. Inflammatory pathways are complex and redundant, and thus, the reactions can be profoundly amplified to produce a multiorgan dysfunction that can manifest as capillary leak syndrome, coagulopathy, respiratory failure, myocardial dysfunction, renal insufficiency, and neurocognitive decline. In this review, pathophysiological aspects of CPB are considered from a practical point of view, and preventive strategies for hemodilutional anemia, coagulopathy, inflammation, metabolic derangement, and neurocognitive and renal dysfunction are discussed.
在过去60年里，体外循环（CPB）技术和设备不断发展，全球范围内众多心脏外科手术都采用CPB进行。尽管经皮冠状动脉和瓣膜介入治疗应用更为广泛，但对于某些心脏疾病，使用CPB进行心脏手术仍是标准方法，因为一些患者不适合进行经皮手术，或者此类手术在部分患者中不成功。心脏手术患者老龄化带来了诸多临床挑战，包括贫血、心肺储备功能下降、长期抗血栓治疗、神经认知功能障碍和肾功能不全。使用CPB会引发涉及细胞和体液相互作用的全身炎症反应。炎症途径复杂且冗余，因此，这些反应可能会被极大放大，导致多器官功能障碍，表现为毛细血管渗漏综合征、凝血病、呼吸衰竭、心肌功能障碍、肾功能不全和神经认知功能衰退。在本综述中，从实际角度探讨了CPB的病理生理学方面，并讨论了针对血液稀释性贫血、凝血病、炎症、代谢紊乱以及神经认知和肾功能障碍的预防策略。
