本文選題：體外循環(huán) + 缺血性腸壞死��； 參考：《蘭州大學(xué)》2015年碩士論文

【摘要】：目的：體外循環(huán)心臟術(shù)后缺血性腸壞死屬于罕見并發(fā)癥,其發(fā)病率雖低,但由于早期診斷困難,治療棘手,該并發(fā)癥病死率非常高。本文通過病例報(bào)告旨在探討其病因、發(fā)病機(jī)制、病理生理變化、臨床特點(diǎn)、輔助檢查方法、診治進(jìn)展等。方法：回顧了1例體外循環(huán)心臟直視術(shù)后缺血性腸壞死病人的臨床病歷資料,并根據(jù)近年來關(guān)于本并發(fā)癥研究進(jìn)展予以進(jìn)一步論述。設(shè)計(jì)：病例報(bào)告。病例：患者女,62歲,以“風(fēng)濕性心臟病,二尖瓣狹窄并閉鎖不全,三尖瓣閉鎖不全,主動(dòng)脈瓣閉鎖不全,心房纖顫,2型糖尿病”收住,入院后為排除冠脈病變查冠狀動(dòng)脈造影提示：左側(cè)冠脈前降支中段處約75%狹窄。于全麻、低溫、體外循環(huán)下行“冠狀動(dòng)脈搭橋術(shù)、二尖瓣聯(lián)合三尖瓣機(jī)械瓣膜置換術(shù)”。術(shù)后出現(xiàn)腹脹、腹痛、血便、感染性休克,經(jīng)診斷性腹腔穿刺后明確診斷為急性腹膜炎,遂急診于全麻下施行剖腹探查術(shù)。再次術(shù)后病人仍存在循環(huán)不穩(wěn)定、休克、嚴(yán)重感染、全身多臟器功能衰竭,后搶救無效死亡。結(jié)果：患者搶救無效死亡。討論：在應(yīng)激情況下腸道作為中心器官,不僅容易受到各種致傷因素的直接破壞,而且能夠造成后續(xù)損傷。體外循環(huán)心臟術(shù)后缺血性腸壞死的一般發(fā)病規(guī)律可以大致總結(jié)為：腸道遭受缺血及缺氧性損害；腸道黏膜屏障功能完整性的喪失；腸腔中的致病菌、內(nèi)毒素等有害物質(zhì)彌散入血液循環(huán)：激發(fā)體內(nèi)炎性因子失控性釋放并引起全身炎性反應(yīng)綜合征；當(dāng)體內(nèi)促炎和抗炎反應(yīng)平衡狀態(tài)破壞后引起多臟器系統(tǒng)功能衰竭,導(dǎo)致機(jī)體再次損傷。根據(jù)相關(guān)文獻(xiàn)及書籍記載,體外循環(huán)措施的改進(jìn)、丙泊酚、中藥、烏司他定、腸三葉因子、氨甲環(huán)酸等防治手段的應(yīng)用能夠減輕上述環(huán)節(jié)中損傷因素的作用,因此提示在一定程度上可以預(yù)防或改善心肺轉(zhuǎn)流術(shù)后缺血性腸壞死的預(yù)后,具有一定臨床價(jià)值。結(jié)論：體外循環(huán)心臟術(shù)后缺血性腸壞死發(fā)病率雖低,但起病隱匿,缺乏特征性臨床表現(xiàn),病情進(jìn)展快,病死率極高,使得早期及時(shí)診斷與治療困難。因此避免腸道缺血缺氧損傷及避免腸道黏膜屏障受損應(yīng)作為預(yù)防該并發(fā)癥的關(guān)鍵。
[Abstract]:Objective: ischemic intestinal necrosis after cardiopulmonary bypass (CPB) is a rare complication. Although its incidence is low, the mortality of this complication is very high due to the difficulty of early diagnosis and difficult treatment. This article aims to discuss the etiology, pathogenesis, pathophysiological changes, clinical characteristics, auxiliary examination methods, diagnosis and treatment progress. Methods: the clinical data of one patient with ischemic intestinal necrosis after open heart surgery under cardiopulmonary bypass (CPB) were reviewed. Design: case report. Case: a 62-year-old woman with rheumatic heart disease, mitral stenosis and atresia, tricuspid atresia, aortic atresia, atrial fibrillation type 2 diabetes mellitus, Coronary angiography showed that 75% of the left anterior descending coronary artery stenosis was found in the middle segment of the left anterior descending coronary artery. Under general anesthesia, hypothermia, cardiopulmonary bypass coronary artery bypass grafting, mitral valve combined with tricuspid mechanical valve replacement. Abdominal distension, abdominal pain, blood stool and septic shock occurred after operation. Acute peritonitis was clearly diagnosed after abdominal puncture and emergency laparotomy was performed under general anesthesia. After operation, the patients still had unstable circulation, shock, severe infection, systemic multiple organ failure, and then died. Results: the patients died after rescue. Discussion: as a central organ under stress, intestinal tract is not only easily damaged by various injury factors, but also can cause subsequent injury. The general pathogenesis of ischemic intestinal necrosis after cardiopulmonary bypass heart surgery can be summarized as follows: intestinal ischemia and hypoxic damage, loss of intestinal mucosal barrier functional integrity, intestinal cavity pathogens, Endotoxin and other harmful substances diffuse into the blood circulation: stimulate the uncontrolled release of inflammatory factors in the body and cause systemic inflammatory response syndrome; when the balance of pro-inflammatory and anti-inflammatory response in the body is destroyed, it causes multiple organ system failure, Cause the body to damage again. According to the relevant literature and books, the improvement of cardiopulmonary bypass measures, the application of propofol, Chinese medicine, ulinastatin, intestinal trefoil factor, and carbamicylic acid can reduce the role of injury factors in the above links. It is suggested that the prognosis of ischemic intestinal necrosis after cardiopulmonary bypass can be prevented or improved to a certain extent and has certain clinical value. Conclusion: although the incidence of ischemic intestinal necrosis after cardiopulmonary bypass heart surgery is low, the onset of the disease is concealed, the characteristic clinical manifestations are lacking, the disease progresses quickly and the mortality is very high, which makes early diagnosis and treatment difficult. Therefore, avoiding intestinal ischemia and hypoxia injury and intestinal mucosal barrier damage should be the key to prevent this complication.
【學(xué)位授予單位】：蘭州大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2015
【分類號(hào)】：R654.2

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本文編號(hào)：2078318