Vital Organs Protection In Deep Hypothermic Circulation Arrest Surgry:a Clinical Study

Part 1 Improve the effectiveness of cerebral protection in deep hypothermic circulation arrest surgery by developing a new cerebral perfusion methodObjective:To compare the effectiveness of different cerebral perfusion methods on cerebral protection in deep hypothermic circulation arrest surgery.Methods: 80 patients accpeted operation in Renmin hospital of Wuhan univirsity during February,2009 and september,2012 were inculuded according to the predesigned criteria. Those patients were randomized into group A(Unilateral cerebral perfusion group,n=40)and control group B(Bilateral cerebral perfusion group,n=40). Patients in both groups accepted deep hypothermic circulation arrest surgery. Intra-and post- operative time points were chosen to collect serum from patients. S-100? and NSE were detected and compared to estimate the injury of brain in both groups.Results:The baseline data (including age, sex, body weight, hypertention, diabetes mellitus, smoking history, cardiopulmonary bypass time, aorta clamp time and cerebral perfusion time) were not significantly different. The curve of NSE and S-100? showed a same changing trend. Since the cardiopulmonary bypass time began, the serum concentration cardiopulmonary bypass increased and reached their peak at the end of cardiopulmonary bypass. Up to 25min before cerebral perfusion, there was no difference of NSE and S-100? between group A and B. Then both NSE and S-100? went higher in group A (P<0.05)Conclution:Unilateral cerebral perfusion and bilateral cerebral perfusion have the same cerebral protection performance when the perfusion time is shorter than 25min. When the perfusion time goes longer, Bilateral cerebral perfusion can protect the brain better. The perfusion method developed by our group showed less aorta manuplation, higher success rate and less post-operative neurological complication. It is a easy, safe and effective method and worth promoting.Part 2 Strategy of blood protection in deep hypothermic circulation arrest surgeryObjective:To explore the role of artificial heart and lung, blood retrieve and pre-operative autologous blood component separation in deep hypotheremic circulation arrest blood reservatin.Methods: 90 patients who accepted total aortic arch replacement in renmin hospital of wuhan university were randomized into three groups. Group A:Intra-operative blood retrieve olnly;Group B:Intra-operative blood retrieve plus pre-operative autologous blood component separation;Group C: Intra-operative blood retrieve plus artificial heart and lung blood retrieve. Baseline data including age, sex, body weight, Hb concentration, PLT were collected and compared; On 8 time points (pre-operation (T1), Beginning of CPB 30min (T2),30min after CPB began (T3),60min after CPB began (T4), the end of CPB (T5),60min after the end of CPB (T6),2h post operation (T7),4h post operation (T8), determine and compare the Hb concentration and PLT in three groups. Post-operative bleeding volum and blood perfusion volum were also compared among groups.Results:The baseline data of the three groups is not significantly different. Coagulation markers including PT, APTT and Fib were compareed on T 1,7 and 8 and didn't showed a difference. Hb was not different before the end of CPB,and then Hb in group B (T6 124�16g/L?T7 119�15g/L?T8 121�16g/L)is higher than in group A and C. During CPB, PLT of patients in group B (T3 116�21�109/L?T4 88�19�109/L?T5 63�17�109/L, P<0.05) is lower than that of patients in group A and C, and then went higher (T6 126�43�109/L?T7 133�21�109/L?T8 138�24�109/L, P<0.05) than from that of patients in group A and C. The post-operative bleeding volum was lowest in group B (2h 79�33ml,24h 413�226ml, P<0.05 respectively) while there no difference between group A (721�367ml) and C (577�231ml). The blood perfusion volum were less in group B (8.2�2.2u, P<0.05) than in group A and C.Conclusion: Both pre-operative autologous blood component separation and artificial heart and lung blood retrieve are effective in blood preservatin during deep hypothermic circulation arrest, and the former one is even better.Part 3 the risk factors of severe organ injury after deep hpyothermic circulation arrestObjective:To explore the risk factors of severe organ injury after deep hpyothermic circulation arrest by analyse Standford type A aortic dissection patients data.Methods: Clinical data of 128 Standford type A aortic dissection patients were retrospectively analysed. All of those patiens accepted total arch repalcement plus elephant trunk implantation plus different root replacement. Patients were grouped by severe lung/kidney/cerebral dysfunction occurred or not. Data from each group like age,sex,dissection onset-operation intermediate,pre-operative snoring,hypertension, diabetes,pre-operative lowest sao2,pre-operative highest Cr,WBC,CRP,cardio-pulmonary bypass time, aorta clamp time,circulation arrest time,intra-operative highest Lac,blood cell consumption during operation day were compared.Results:Of the 128 patients,3 patients dead post-opertively(2.3%);38 patients experienced cerebral dysfunction (29.6%),32 of them were diagnosed for temporal cerebral dysfunction while 6 of them were diagnosed for stroke; 41 patients experienced lung dysfunction(32.3%),and 3 of them were treated with tracheotomy; 25 patients experienced renal dysfunction(19.5%),and 4 of them experienced CRRT because of renal failure. Single factor analysis revealed that sex (male 78.9%vs 56.7%), pre-operative snoring (31.5% vs 17.8%), pre-operative lowest SaO2 (91.3�5.1% vs 94.1�4.8%), pre-operative highest WBC (14.7�4.8 � 1012/L vs 11.2 � 4.3 �1012/L), CRP (10.07�3.9 mg/L vs 9.5�3.4 mg/L),cardio-pulmonary bypass time (227�57min vs 184�43min),aorta clamp time (71.4�37min vs 55.3 � 40.5 min)are risk factors of post-operative cerebral dysfunction(P<0.05) while age(62 � 13 y vs 55 � 15 y),dissection onset-operation intermediate(5.2 � 2.3d vs 7.5 � 4.6 d),pre-operative snoring(58.5% vs 4.6%), pre-operative lowest SaO2(91.7�4.3% vs 95.5�4.0%), pre-operative highest WBC (15.7�4.6 �1012/L vs 10.3 � 3.7�1012/L), CRP(12.2�5.7mg/L vs 8.4�4.8mg/L),cardio-pulmonary bypass time(235�69min vs 163�54min),blood cell consumption during operation day (11.9�6.2u vs 8.0�3.7u)are risk factors of post-operative lung dysfunction(P<0.05), furthermore, age(64�12y vs 56�17y),pre-operative highest Cr(187�125 ? mmol/L vs 104�63 ? mmol/L), cardio-pulmonary bypass time(224�44min vs 174�39min),blood cell consumption during operation day (10.6 � 4.8u vs 8.3 � 2.4u)are risk factors of post-operative renal dysfunction (P<0.05). Multiple regression analysis revealed that pre-operative lowest SaO2 pre-operative highest CRP and cardio-pulmonary bypass time are independent riskfactors of post-operative lung dysfunction while pre-operative highest Cr and cardio-pulmonary bypass time are independent riskfactors of post-operative renal dysfunction.Conclusions:Pre-operative lowest SaO2 pre-operative highest CRP and cardio-pulmonary bypass time are independent riskfactors of post-operative lung dysfunction while pre-operative highest Cr and cardio-pulmonary bypass time are independent riskfactors of post-operative renal dysfunction. Treatment targeting those risk factors could diminish severe post-operative organ injury and improve prognosis.