主動(dòng)脈內(nèi)球囊反搏在危重癥心臟病患者的應(yīng)用及對(duì)應(yīng)用時(shí)機(jī)的研究
發(fā)布時(shí)間：2018-08-27 11:37
【摘要】：背景與目的在現(xiàn)代社會(huì),隨著物質(zhì)生活水平提高,人們不斷追求高品質(zhì)的生活,同時(shí),各種危重癥心臟病的發(fā)病率也在不斷增加,使得心臟手術(shù)成為挽救患者生命、改善患者生存狀態(tài)的重要保證�？萍硷w速發(fā)展,越來(lái)越多的機(jī)械輔助循環(huán)手段出現(xiàn),使重癥患者心功能改善,明顯提高了生存質(zhì)量,在接受心臟手術(shù)的同時(shí),各種輔助手段也成為拯救患者生命的重要保證。主動(dòng)脈內(nèi)球囊反搏(Intra-aorticballoon pump,IABP)就是眾多機(jī)械輔助循環(huán)裝置的一種,而且應(yīng)用廣泛,對(duì)于臨床中出現(xiàn)的各種危重癥心臟病具有很好的輔助治療作用。IABP的適應(yīng)癥包括:急性心肌梗塞(AMI)合并心源性休克、藥物治療無(wú)效、持續(xù)或者反復(fù)發(fā)生的嚴(yán)重心肌缺血、心絞痛反復(fù)發(fā)作、在冠狀動(dòng)脈造影前后或由于心肌梗塞導(dǎo)致的血流動(dòng)力學(xué)不穩(wěn)定,以及在高危外科手術(shù)或介入手術(shù)圍術(shù)期出現(xiàn)的各種危險(xiǎn)情況下對(duì)患者進(jìn)行輔助治療。對(duì)于危重癥心臟病患者應(yīng)用IABP輔助后,最直接的作用就是可以增加舒張期主動(dòng)脈內(nèi)壓力,從而增加了冠狀動(dòng)脈血流,增加心肌收縮力,減輕心臟收縮時(shí)左心室后負(fù)荷,最終達(dá)到改善外周循環(huán)、增加全身重要器官血液灌注、改善心功能的目的。然而,患者病情的嚴(yán)重程度將界定應(yīng)用IABP的最適時(shí)機(jī),同時(shí),在IABP應(yīng)用過(guò)程中應(yīng)注意預(yù)防并發(fā)癥的發(fā)生。本文結(jié)合患者的病例資料,探討IABP在危重癥心臟病中的應(yīng)用指征、應(yīng)用時(shí)機(jī)、臨床效果以及輔助后對(duì)患者的影響,為IABP輔助能今后在臨床工作中更好地為患者服務(wù)提供經(jīng)驗(yàn)及參考依據(jù)。方法統(tǒng)計(jì)分析我院2015年1月至2016年12月期間共15例應(yīng)用IABP輔助的危重癥心臟病患者的臨床病例資料、診斷、治療方法、結(jié)果及預(yù)后。其中男性患者9例,女性患者6例,年齡最小者41歲,最大80歲(平均62.1歲);主要合并癥有高血壓(7例)和糖尿病(5例)。給予IABP輔助時(shí)機(jī)的選擇:術(shù)前預(yù)防性放置9例,術(shù)中在手術(shù)室放置2例,術(shù)后入監(jiān)護(hù)室(ICU)后放置4例,應(yīng)用時(shí)間12小時(shí)-72小時(shí)(平均42小時(shí))。IABP反搏機(jī)型號(hào)DataScope Cl00,均選用經(jīng)皮改良Seldinger股動(dòng)脈穿刺技術(shù)插管,選擇與患者自身情況對(duì)應(yīng)的觸發(fā)模式。分別統(tǒng)計(jì)應(yīng)用IABP前和應(yīng)用2小時(shí)后血流動(dòng)力學(xué)指標(biāo),如心率(HR)、收縮壓、舒張壓、平均動(dòng)脈壓(MAP)、中心靜脈壓(CVP)、心排指數(shù)(CI),以及末梢循環(huán)情況、24h尿排泄量、強(qiáng)心藥物用量、圍術(shù)期死亡等,并對(duì)患者進(jìn)行術(shù)后隨訪,觀察其臨床結(jié)果和預(yù)后。結(jié)果臨床給予IABP輔助患者共15例,其中,14例臨床效果明顯,心功能顯著改善,并痊愈出院;1例臨床效果不明顯,最終死于低心排綜合征。治療中9例患者采取預(yù)防性應(yīng)用IABP輔助,術(shù)后恢復(fù)良好,均痊愈出院,被動(dòng)性應(yīng)用患者6例,有1例死亡。15例均無(wú)相關(guān)并發(fā)癥發(fā)生。結(jié)論1.IABP可增加舒張期主動(dòng)脈內(nèi)壓力,增加了冠狀動(dòng)脈血流,減輕心臟收縮時(shí)左心室后負(fù)荷,從而改善外周循環(huán)、提高患者心功能,對(duì)圍手術(shù)期血流動(dòng)力學(xué)不穩(wěn)定的危重癥心臟病臨床成效顯著。2.預(yù)防性應(yīng)用IABP有助于減少術(shù)中手術(shù)操作對(duì)血流動(dòng)力學(xué)的影響,提高危重患者行手術(shù)時(shí)的安全性。同時(shí),對(duì)于危重心臟手術(shù)患者,術(shù)前輔助的意義要明顯好于術(shù)中及術(shù)后補(bǔ)救性置入。3.患者使用IABP輔助后應(yīng)及時(shí)評(píng)估輔助治療效果,并根據(jù)患者病情變化做出相應(yīng)調(diào)整,同時(shí)注意預(yù)防并發(fā)癥,如已發(fā)生則及時(shí)處理。4.應(yīng)用IABP輔助后血流動(dòng)力學(xué)穩(wěn)后可考慮撤出IABP。撤出球囊導(dǎo)管時(shí)要緩慢降低反搏比例,以使患者的心功能有一個(gè)逐漸適應(yīng)的過(guò)程。意義IABP在輔助危重癥心臟病治療過(guò)程中展現(xiàn)了強(qiáng)大的改善循環(huán)作用,因此是一種有效的機(jī)械輔助手段。IABP的使用可以使患者病死率大大降低,同時(shí)由于IABP的操作方法和設(shè)備的改良,發(fā)生相關(guān)并發(fā)癥的幾率很小,幾乎不發(fā)生嚴(yán)重并發(fā)癥。早期應(yīng)用IABP臨床效果顯著,預(yù)防性主動(dòng)應(yīng)用IABP比被動(dòng)性應(yīng)用要產(chǎn)生更好的遠(yuǎn)期效果。由于本研究的樣本量有限,且為回顧性分析,因此,對(duì)于IABP輔助治療的長(zhǎng)期效果仍需進(jìn)一步深入研究。隨著臨床經(jīng)驗(yàn)的積累總結(jié)以及對(duì)IABP使用的進(jìn)一步探索,未來(lái)IABP將會(huì)更加廣泛地為患者服務(wù),會(huì)有更多的患者因此受益。
[Abstract]:BACKGROUND & OBJECTIVE In modern society, with the improvement of material living standard, people are constantly pursuing high quality of life. At the same time, the incidence of various critical heart diseases is also increasing. Heart surgery has become an important guarantee to save patients'lives and improve their living conditions. Intra-aortic balloon pump (IABP) is one of many mechanical assisted circulatory devices, which is widely used in clinical practice. Indications for IABP include acute myocardial infarction (AMI) with cardiogenic shock, ineffective drug therapy, persistent or recurrent severe myocardial ischemia, recurrent angina pectoris, and hemodynamic instability before and after coronary angiography or due to myocardial infarction. The most direct role of IABP in critically ill patients is to increase diastolic aortic pressure, thereby increasing coronary artery blood flow, increasing myocardial contractility, and reducing cardiac contraction. However, the severity of the patient's condition will define the optimal time for the application of IABP. At the same time, attention should be paid to the prevention of complications during the application of IABP. This article discusses the role of IABP in improving peripheral circulation, increasing systemic blood perfusion and improving cardiac function. The application indications, application timing, clinical effect and the influence of adjuvant therapy on patients with critical heart disease provide experience and reference basis for IABP assistant therapy to better serve patients in clinical work in the future. The main complications were hypertension (7 cases) and diabetes (5 cases). Four patients were placed behind the chamber (ICU) for 12 hours to 72 hours (average 42 hours). The IABP counterpulsation machine DataScope Cl00 was used for catheterization by percutaneous modified Seldinger femoral artery puncture technique. The trigger modes corresponding to the patient's own conditions were selected. Diastolic blood pressure, mean arterial pressure (MAP), central venous pressure (CVP), cardiac output index (CI), peripheral circulation, 24-hour urinary excretion, cardiotonic drug dosage, perioperative mortality, etc. were followed up and their clinical results and prognosis were observed. Results 15 patients were assisted by IABP. Of them, 14 had obvious clinical effects and cardiac function. In the treatment, 9 patients received prophylactic application of IABP, all recovered well and discharged. 6 patients received passive application, and 1 patient died. All 15 patients had no related complications. Conclusion 1. IABP can increase intra-aortic pressure during diastole and increase intra-aortic pressure. Coronary artery blood flow, reduce the left ventricular afterload during cardiac contraction, thereby improving peripheral circulation, improve cardiac function of patients, perioperative hemodynamic instability of critical heart disease clinical results are significant. 2. Prophylactic application of IABP helps to reduce the impact of intraoperative operation on hemodynamics, improve the operation of critical patients. At the same time, for patients with critical heart surgery, the significance of preoperative adjuvant is obviously better than intraoperative and postoperative remedial implantation. 3. Patients with IABP adjuvant treatment should be timely assessed after the use of adjuvant treatment, and make corresponding adjustments according to the patient's condition, while paying attention to the prevention of complications, if it has occurred, timely treatment. 4. Application of IABP adjuvant treatment. After hemodynamic stabilization, it may be considered to withdraw the IABP. When withdrawing the balloon catheter, the proportion of counterpulsation should be slowly lowered so as to make the patient's heart function have a gradual process of adaptation. Significance IABP has shown a strong role in improving circulation during the adjuvant treatment of critical heart disease, so it is an effective mechanical assistant method. The mortality rate was greatly reduced, and the incidence of related complications was very low due to the improvement of IABP operation methods and equipment. Early application of IABP had significant clinical effect, and the long-term effect of prophylactic active application of IABP was better than that of passive application. Retrospective analysis shows that the long-term effects of IABP adjuvant therapy need to be further studied. With the accumulation of clinical experience and further exploration of the use of IABP, IABP will be more widely used in the future and will benefit more patients.
【學(xué)位授予單位】：山東大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R654.2
本文編號(hào)：2207154
[Abstract]:BACKGROUND & OBJECTIVE In modern society, with the improvement of material living standard, people are constantly pursuing high quality of life. At the same time, the incidence of various critical heart diseases is also increasing. Heart surgery has become an important guarantee to save patients'lives and improve their living conditions. Intra-aortic balloon pump (IABP) is one of many mechanical assisted circulatory devices, which is widely used in clinical practice. Indications for IABP include acute myocardial infarction (AMI) with cardiogenic shock, ineffective drug therapy, persistent or recurrent severe myocardial ischemia, recurrent angina pectoris, and hemodynamic instability before and after coronary angiography or due to myocardial infarction. The most direct role of IABP in critically ill patients is to increase diastolic aortic pressure, thereby increasing coronary artery blood flow, increasing myocardial contractility, and reducing cardiac contraction. However, the severity of the patient's condition will define the optimal time for the application of IABP. At the same time, attention should be paid to the prevention of complications during the application of IABP. This article discusses the role of IABP in improving peripheral circulation, increasing systemic blood perfusion and improving cardiac function. The application indications, application timing, clinical effect and the influence of adjuvant therapy on patients with critical heart disease provide experience and reference basis for IABP assistant therapy to better serve patients in clinical work in the future. The main complications were hypertension (7 cases) and diabetes (5 cases). Four patients were placed behind the chamber (ICU) for 12 hours to 72 hours (average 42 hours). The IABP counterpulsation machine DataScope Cl00 was used for catheterization by percutaneous modified Seldinger femoral artery puncture technique. The trigger modes corresponding to the patient's own conditions were selected. Diastolic blood pressure, mean arterial pressure (MAP), central venous pressure (CVP), cardiac output index (CI), peripheral circulation, 24-hour urinary excretion, cardiotonic drug dosage, perioperative mortality, etc. were followed up and their clinical results and prognosis were observed. Results 15 patients were assisted by IABP. Of them, 14 had obvious clinical effects and cardiac function. In the treatment, 9 patients received prophylactic application of IABP, all recovered well and discharged. 6 patients received passive application, and 1 patient died. All 15 patients had no related complications. Conclusion 1. IABP can increase intra-aortic pressure during diastole and increase intra-aortic pressure. Coronary artery blood flow, reduce the left ventricular afterload during cardiac contraction, thereby improving peripheral circulation, improve cardiac function of patients, perioperative hemodynamic instability of critical heart disease clinical results are significant. 2. Prophylactic application of IABP helps to reduce the impact of intraoperative operation on hemodynamics, improve the operation of critical patients. At the same time, for patients with critical heart surgery, the significance of preoperative adjuvant is obviously better than intraoperative and postoperative remedial implantation. 3. Patients with IABP adjuvant treatment should be timely assessed after the use of adjuvant treatment, and make corresponding adjustments according to the patient's condition, while paying attention to the prevention of complications, if it has occurred, timely treatment. 4. Application of IABP adjuvant treatment. After hemodynamic stabilization, it may be considered to withdraw the IABP. When withdrawing the balloon catheter, the proportion of counterpulsation should be slowly lowered so as to make the patient's heart function have a gradual process of adaptation. Significance IABP has shown a strong role in improving circulation during the adjuvant treatment of critical heart disease, so it is an effective mechanical assistant method. The mortality rate was greatly reduced, and the incidence of related complications was very low due to the improvement of IABP operation methods and equipment. Early application of IABP had significant clinical effect, and the long-term effect of prophylactic active application of IABP was better than that of passive application. Retrospective analysis shows that the long-term effects of IABP adjuvant therapy need to be further studied. With the accumulation of clinical experience and further exploration of the use of IABP, IABP will be more widely used in the future and will benefit more patients.
【學(xué)位授予單位】：山東大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R654.2
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