经皮穿刺急诊体外循环心肺复苏的实验研究
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摘要
课题背景
经皮穿刺体外循环(percutaneous cardiopulmonary bypass PCPB)又称经皮穿刺支持系统(percutaneous cardiopulmonary supportPCPS)，是在局部麻醉和非开胸条件下快速建立的床旁辅助循环支持系统，是体外循环(心肺转流)的形式之一。经皮周围大静脉穿刺插入引流导管至近右心房处，引流出静脉血，经人工肺氧合后经动力泵泵入周围大动脉，它能够部分代替心肺功能、迅速纠治各种原因所致的呼吸心跳骤停引起的呼吸循环功能衰竭，保证重要脏器的灌注，帮助患者渡过危险期，改善预后。Philips等最早报道了PCPS的应用，此后引入临床，至今发展迅速，但国内应用不多。
PCPS经皮穿刺插管难度大，受插管口径的限制其血流量常达不到要求的流量，长时间转流引起红细胞破坏，穿刺血管远端缺血及费用较高限制了它在临床上的广泛应用。
因此本实验的目的在于通过动物实验探索如何建立快捷、有效、便利、经济的经皮心肺支持系统，确定其疗效，为今后的临床应用打下基础。
资料与方法
利用作者单位李海林医师自行研制的经皮穿刺体外循环插管及鼓泡式氧合器、动脉滤器、泵管、管道连接的一体化无菌密闭系统。使用前消毒并预充。将15只杂种犬随机分为有搏动经皮穿刺插管组(A组)5只、无搏动经皮穿刺插管组(B组)5只、无搏动切开插管组(C组)5只。腹腔麻醉后，气管切开，插入气管插管备用。右侧股动脉、静脉穿入7F导管各1根，与多功能监护仪相连接连续监测股动脉压及中心静脉压。静脉注射肝素3mg／kg，使全血活化凝固时间(ACT)大于400s。
A组选择左股动脉、股静脉为穿刺点，插入体外循环插管，并紧密结合，外固定。插管成功后堵塞气管，犬窒息致心脏停搏后8min时与ECPB机管路连接开始ECPB。
B组用窒息方法使犬心脏停搏8min后开始常规心肺复苏(cardiopulmonary resuscitation CPR)，并同时在股动静脉走行方向用穿刺针盲穿的方法建立体外循环，并与ECPB机管路连接开始ECPB。
C组用窒息方法使犬心脏停搏8min后开始常规CPR，同时手术切开左股动、静脉，插入相应体外循环动、静脉插管，与人工心肺机管路连接后进行ECPB。
于ECPB前、中监测心电波形、有创动脉压(ABP)、中心静脉压(CVP)、无创血氧饱和度(SPO_2)；ABL510型血气分析仪每0.5小时监测动、静脉血气1次；观察ECPB建立时间，动脉循环流量、创口渗血量及自主循环恢复(ROSC)情况(有QRS心电波形，触及大动脉搏动，持续1小时以上为ROSC)。ECPB动脉流量50～100ml／kg，转流60min或自主循环恢复(ROSC)停机。
结果
3组犬均建立体外循环，建立时间以A组及B组为短，(P＜0.05)，渗血量以A组及B组为少(P＜0.01)，而动脉流量、平均动脉压、中心静脉压在3组间比较无显著性差异。体外循环前后3组动物的PCO_2、PO_2的变化均差异有显著性，3组动物间的血流动力学及血气变化差异无显著性。ROSC在A组及B组均高，而C组则明显下降。
结论
经皮穿刺周围大血管插管能快速建立体外循环，使动物心肺复苏的自主循环恢复率显著提高。
Introduction: The percutaneous cardiopulmonary bypass (PCPB), one kind of CPB , also named percutaneous cardiopulmonary support (PCPS), is an auxiliary circulation support system at bedside under local anesthesia and non-open-thorax. Catheter is inserted into right atrium by percutaneous cannulation via periphery large vein and venous blood is drained to artificial pump. After oxygenation, the oxygenated blood is pumped into periphery large artery. PCPS can partly replace the function of heart and lungs , support patients with cardiac arrest due to kinds of causes .This temporary support can maintain adequate tissue perfusion and help the patients get through the dangerous stage and improve prognosis. Philips et al. firstly reported the application of PCPS. Then it was brought into clinic and developed promptly, but seldom applied in China.
There are many problems limit the wide use of PCPS in clinic : the difficulty of percutaneous cannulation ; low flow volume due to small
diameter catheter ; breakage of the red cell due to long term bypass ; the shortage of perfusion of the distal extremity and expensive cost.
Therefore the aim of this experiment is to investigate how to establish PCPS which is prompt, effective ,convenient and economic ; To definite the therapeutic effect ; To do the groundwork for the clinical application in future.
Material and Methods: A sterile airtight system , invented by Li Hailin , which consists of percutaneously inserted tubes for CPB, bubble oxygenator ,arterial colander, pump tubes ,prime solution and popelines. Fifteen dogs were randomly separated into three groups named A 、 B and C ,and each group contained 5 dogs. The dogs in A group had heart beat and were treated with percutaneously puncture; The B group had no heart beat and was treated with percutaneously puncture; The C group also had no heart beat and was treated with intubation by cut open. Tracher incision and intubation was inserted after abdomen anesthesia. Two 7F tubes were inserted into right femora artery and vein, and femoral artery pressure and central vein pressure were continuously measured by monitor attached with them. 3mg/kg heparin was injected and ACT >400s.
In group A, after the tube was inserted into left femoral artery and vein ,the dogs were suffocated and 8 minutes later ECPB started .
In group B, normal CPR and ECPB with blindly puncture in left
artery and vein were started after cardiac arrest exceeded 8 minutes with suffocation.
In group C, normal CPR and ECPB with incision of the left artery and vein were started after cardiac arrest exceeded 8 minutes with suffocation.
The electrocardiogram, ABP, CVP, SPO_2 were monitored continuously before and during ECPB. The artery and venous gas analysis were recorded per 0.5 hour with ABL510. The formation time of the ECPB, volume of flow , leakage amount of the wound, ROSC(QRS wave and pulsation of the great artery existed more than 1 hour) were recorded.The flow rate of ECPB 50～100ml/kg. The machine stopped after 60 min pumping or ROSC recovered.
Results: The formation of ECPB was successful in three groups . The formation time in group A and B was significantly shorter than that in group C (P<0.05) ; The leakage amount in group A and B was significantly fewer than that in group C (P<0.01) ; There were no significant differences among three groups in Arterial flow , MAP, CVP; There were significantly differences of PCO2 and PO_2 before and after bypass; There were no significant differences in changes of hemodynamic and arterial blood gas among three groups; The ROSC in group A and B was improved significantly than that in group C.
Conclusion: The formation of ECPB can be rapidly reached through
percutaneous puncturing peripheral blood vessel and the ROSC of CPR was remarkably improved on animals.
经皮穿刺体外循环(percutaneous cardiopulmonary bypass PCPB)又称经皮穿刺支持系统(percutaneous cardiopulmonary supportPCPS)，是在局部麻醉和非开胸条件下快速建立的床旁辅助循环支持系统，是体外循环(心肺转流)的形式之一。经皮周围大静脉穿刺插入引流导管至近右心房处，引流出静脉血，经人工肺氧合后经动力泵泵入周围大动脉，它能够部分代替心肺功能、迅速纠治各种原因所致的呼吸心跳骤停引起的呼吸循环功能衰竭，保证重要脏器的灌注，帮助患者渡过危险期，改善预后。Philips等最早报道了PCPS的应用，此后引入临床，至今发展迅速，但国内应用不多。
PCPS经皮穿刺插管难度大，受插管口径的限制其血流量常达不到要求的流量，长时间转流引起红细胞破坏，穿刺血管远端缺血及费用较高限制了它在临床上的广泛应用。
因此本实验的目的在于通过动物实验探索如何建立快捷、有效、便利、经济的经皮心肺支持系统，确定其疗效，为今后的临床应用打下基础。
资料与方法
利用作者单位李海林医师自行研制的经皮穿刺体外循环插管及鼓泡式氧合器、动脉滤器、泵管、管道连接的一体化无菌密闭系统。使用前消毒并预充。将15只杂种犬随机分为有搏动经皮穿刺插管组(A组)5只、无搏动经皮穿刺插管组(B组)5只、无搏动切开插管组(C组)5只。腹腔麻醉后，气管切开，插入气管插管备用。右侧股动脉、静脉穿入7F导管各1根，与多功能监护仪相连接连续监测股动脉压及中心静脉压。静脉注射肝素3mg／kg，使全血活化凝固时间(ACT)大于400s。
A组选择左股动脉、股静脉为穿刺点，插入体外循环插管，并紧密结合，外固定。插管成功后堵塞气管，犬窒息致心脏停搏后8min时与ECPB机管路连接开始ECPB。
B组用窒息方法使犬心脏停搏8min后开始常规心肺复苏(cardiopulmonary resuscitation CPR)，并同时在股动静脉走行方向用穿刺针盲穿的方法建立体外循环，并与ECPB机管路连接开始ECPB。
C组用窒息方法使犬心脏停搏8min后开始常规CPR，同时手术切开左股动、静脉，插入相应体外循环动、静脉插管，与人工心肺机管路连接后进行ECPB。
于ECPB前、中监测心电波形、有创动脉压(ABP)、中心静脉压(CVP)、无创血氧饱和度(SPO_2)；ABL510型血气分析仪每0.5小时监测动、静脉血气1次；观察ECPB建立时间，动脉循环流量、创口渗血量及自主循环恢复(ROSC)情况(有QRS心电波形，触及大动脉搏动，持续1小时以上为ROSC)。ECPB动脉流量50～100ml／kg，转流60min或自主循环恢复(ROSC)停机。
结果
3组犬均建立体外循环，建立时间以A组及B组为短，(P＜0.05)，渗血量以A组及B组为少(P＜0.01)，而动脉流量、平均动脉压、中心静脉压在3组间比较无显著性差异。体外循环前后3组动物的PCO_2、PO_2的变化均差异有显著性，3组动物间的血流动力学及血气变化差异无显著性。ROSC在A组及B组均高，而C组则明显下降。
结论
经皮穿刺周围大血管插管能快速建立体外循环，使动物心肺复苏的自主循环恢复率显著提高。
Introduction: The percutaneous cardiopulmonary bypass (PCPB), one kind of CPB , also named percutaneous cardiopulmonary support (PCPS), is an auxiliary circulation support system at bedside under local anesthesia and non-open-thorax. Catheter is inserted into right atrium by percutaneous cannulation via periphery large vein and venous blood is drained to artificial pump. After oxygenation, the oxygenated blood is pumped into periphery large artery. PCPS can partly replace the function of heart and lungs , support patients with cardiac arrest due to kinds of causes .This temporary support can maintain adequate tissue perfusion and help the patients get through the dangerous stage and improve prognosis. Philips et al. firstly reported the application of PCPS. Then it was brought into clinic and developed promptly, but seldom applied in China.
There are many problems limit the wide use of PCPS in clinic : the difficulty of percutaneous cannulation ; low flow volume due to small
diameter catheter ; breakage of the red cell due to long term bypass ; the shortage of perfusion of the distal extremity and expensive cost.
Therefore the aim of this experiment is to investigate how to establish PCPS which is prompt, effective ,convenient and economic ; To definite the therapeutic effect ; To do the groundwork for the clinical application in future.
Material and Methods: A sterile airtight system , invented by Li Hailin , which consists of percutaneously inserted tubes for CPB, bubble oxygenator ,arterial colander, pump tubes ,prime solution and popelines. Fifteen dogs were randomly separated into three groups named A 、 B and C ,and each group contained 5 dogs. The dogs in A group had heart beat and were treated with percutaneously puncture; The B group had no heart beat and was treated with percutaneously puncture; The C group also had no heart beat and was treated with intubation by cut open. Tracher incision and intubation was inserted after abdomen anesthesia. Two 7F tubes were inserted into right femora artery and vein, and femoral artery pressure and central vein pressure were continuously measured by monitor attached with them. 3mg/kg heparin was injected and ACT >400s.
In group A, after the tube was inserted into left femoral artery and vein ,the dogs were suffocated and 8 minutes later ECPB started .
In group B, normal CPR and ECPB with blindly puncture in left
artery and vein were started after cardiac arrest exceeded 8 minutes with suffocation.
In group C, normal CPR and ECPB with incision of the left artery and vein were started after cardiac arrest exceeded 8 minutes with suffocation.
The electrocardiogram, ABP, CVP, SPO_2 were monitored continuously before and during ECPB. The artery and venous gas analysis were recorded per 0.5 hour with ABL510. The formation time of the ECPB, volume of flow , leakage amount of the wound, ROSC(QRS wave and pulsation of the great artery existed more than 1 hour) were recorded.The flow rate of ECPB 50～100ml/kg. The machine stopped after 60 min pumping or ROSC recovered.
Results: The formation of ECPB was successful in three groups . The formation time in group A and B was significantly shorter than that in group C (P<0.05) ; The leakage amount in group A and B was significantly fewer than that in group C (P<0.01) ; There were no significant differences among three groups in Arterial flow , MAP, CVP; There were significantly differences of PCO2 and PO_2 before and after bypass; There were no significant differences in changes of hemodynamic and arterial blood gas among three groups; The ROSC in group A and B was improved significantly than that in group C.
Conclusion: The formation of ECPB can be rapidly reached through
percutaneous puncturing peripheral blood vessel and the ROSC of CPR was remarkably improved on animals.
引文
[1] Phillips SJ, Ballentine B, Slonine D, et al. Percutaneous initiation of cardiopulmonary bypass[J]. Ann of Thorac Surg, 1983, 36(2): 223-225.
[2] 黄培志，周光华，薛军，等．心肺转流行心肺复苏的实验研究．急诊医学，1997，6(1)：7-9．
[3] 李忠东，景华，牛冬梅，等．急诊体外循环的临床应用．医学研究生学报，2003，16(11)：831-832．
[4] 游庆军，沈振亚，蒋锡初，等．急诊体外循环在普胸外科中的临床应用．中华急诊医学杂志，2003，12(11)781．
[5] Ullrich R, Knelfel W, Fuchs M, et al. Portable cardiopulmonary support (ECPS) in the emergency room. Anesthesia, 1998, 53(suppl.2):6-8.
[6] 梁继河，刘建平，等．经皮穿刺体外循环与急诊体外循环支持．中国循环杂志，1993，8：377．
[7] ANASTASIADIS K. Mechanical support of the circulatory system [J]. Hellenic J cardiol ,2003,44:341-347.
[8] Steven J, Phillips MD, Bruce Ballentine CP, et al. Percutaneous initiation cardiopulmonary bypass. The annals of Thoracic Surgery, 1983, 36 (2):223-225.
[9] Martin GB, River EP, Paradis NA, et al. Emergency department cardiopulmonary bypass in the treatment of human cardiac arrest. Chest, 1998, 113 (3): 743-751.
[10]Ullrivh R, Kneifel W, Fuchs M, et al. Portable cardiopulmonary support (ECPS) in the emergency room. Anaesthesia, 1998, 53 (2) :80.
1. Phillips SJ, Ballentine B, Slonine D, et al. Percutaneous initiation of cardiopulmonary bypass[J]. Ann of Thorac Surg, 1983, 36(2) : 223-225.
2. Phillips S J, Zef RH, Konglahwom C, Percutaneous cardiopulmonary bypass: application and indication for Hse[J]. Ann Thorac Surg, 1989, 47(1): 121-123.
3．李宏，陶登顺，易定华，等。急诊体外循环灌注管位置对心肺复苏效果的影响[J]。中国急救医学，2001，21(11)：626-627．
4. Fukumoto H, Nishimoto T, Morita H,et al. Emergency application of percutaneous Cardiopulmonary support system[J]. The Japanese Journal of Acute Medicine, 1994, 18(13):1869.
5. Iwama T, Hashimoto N, Todaka T, et al. Resection of a large, high-flow arteriovenous malformation during hypotension and hypothermia induced by a percutaneous cardiopulmonary support system. Case report [J]. J Neurosurg, 1997, 87(3):440—444.
6. Sakai M, Ohteki H, Doi K, et al. Clinical application and indications for percutaneous cardiopulmonary bypass support in cardiopulmonary failure of various etiologies[J]. J Jpn Soc Intens Care Med, 1996, 7(7):345-351.
7. Kitaura Y, Deguchi H,Ukimura A ,et al. Clinicopathological features of influenza myocarditis and pericarditis[J]. Nippon Rinsho, 1997, 55(10) :2706-2713.
8. Kato S, Morimoto S, Hiramitsu S,et al. Use of percutaneous cardiopulmonary support of patients with fulminant myocarditis and cardiogenic shock for improving prognosis [J].Am J Cardiol, 1999,83(4):623-625.
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17. Tadashi K, Tetsuro M,Shinichi T.Emergent pulmonary thromboendarterectomy with percutaneous cardiopulmonary support system for chronic thromboembolic pulmonary hypertension[J]. Eur J Cardio-thorac Surg, 2003, 24(4):656-658.
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27. Peter Safar ,Wilhelm Behringer ,Bemd W.Cerebral resuscitation potentials for cardiac arrest[J] .Crit care Med, 2002, 30 (4): 140-144.
[2] 黄培志，周光华，薛军，等．心肺转流行心肺复苏的实验研究．急诊医学，1997，6(1)：7-9．
[3] 李忠东，景华，牛冬梅，等．急诊体外循环的临床应用．医学研究生学报，2003，16(11)：831-832．
[4] 游庆军，沈振亚，蒋锡初，等．急诊体外循环在普胸外科中的临床应用．中华急诊医学杂志，2003，12(11)781．
[5] Ullrich R, Knelfel W, Fuchs M, et al. Portable cardiopulmonary support (ECPS) in the emergency room. Anesthesia, 1998, 53(suppl.2):6-8.
[6] 梁继河，刘建平，等．经皮穿刺体外循环与急诊体外循环支持．中国循环杂志，1993，8：377．
[7] ANASTASIADIS K. Mechanical support of the circulatory system [J]. Hellenic J cardiol ,2003,44:341-347.
[8] Steven J, Phillips MD, Bruce Ballentine CP, et al. Percutaneous initiation cardiopulmonary bypass. The annals of Thoracic Surgery, 1983, 36 (2):223-225.
[9] Martin GB, River EP, Paradis NA, et al. Emergency department cardiopulmonary bypass in the treatment of human cardiac arrest. Chest, 1998, 113 (3): 743-751.
[10]Ullrivh R, Kneifel W, Fuchs M, et al. Portable cardiopulmonary support (ECPS) in the emergency room. Anaesthesia, 1998, 53 (2) :80.
1. Phillips SJ, Ballentine B, Slonine D, et al. Percutaneous initiation of cardiopulmonary bypass[J]. Ann of Thorac Surg, 1983, 36(2) : 223-225.
2. Phillips S J, Zef RH, Konglahwom C, Percutaneous cardiopulmonary bypass: application and indication for Hse[J]. Ann Thorac Surg, 1989, 47(1): 121-123.
3．李宏，陶登顺，易定华，等。急诊体外循环灌注管位置对心肺复苏效果的影响[J]。中国急救医学，2001，21(11)：626-627．
4. Fukumoto H, Nishimoto T, Morita H,et al. Emergency application of percutaneous Cardiopulmonary support system[J]. The Japanese Journal of Acute Medicine, 1994, 18(13):1869.
5. Iwama T, Hashimoto N, Todaka T, et al. Resection of a large, high-flow arteriovenous malformation during hypotension and hypothermia induced by a percutaneous cardiopulmonary support system. Case report [J]. J Neurosurg, 1997, 87(3):440—444.
6. Sakai M, Ohteki H, Doi K, et al. Clinical application and indications for percutaneous cardiopulmonary bypass support in cardiopulmonary failure of various etiologies[J]. J Jpn Soc Intens Care Med, 1996, 7(7):345-351.
7. Kitaura Y, Deguchi H,Ukimura A ,et al. Clinicopathological features of influenza myocarditis and pericarditis[J]. Nippon Rinsho, 1997, 55(10) :2706-2713.
8. Kato S, Morimoto S, Hiramitsu S,et al. Use of percutaneous cardiopulmonary support of patients with fulminant myocarditis and cardiogenic shock for improving prognosis [J].Am J Cardiol, 1999,83(4):623-625.
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