心脏术后早期心搏骤停的原因分析和救治体会
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摘要
目的：通过总结分析心脏术后患者心搏骤停的发生原因和救治方法，为临床防治提供依据。
方法：回顾性调查1994年5月～2003年3月在我院施行的心脏手术1320例，其中术后第1个24小时内发生心搏骤停24例。课题研究对24例心搏骤停病例的资料进行统计和原因分析，并对救治方法及其结果进行探讨。
结果：术后发生心搏骤停的病例以风湿性心瓣膜病居多(58.3％)，冠心病次之(20.8％)，各种先心病占20.8％。导致心搏骤停的原因有低心排综合征11例、电解质紊乱7例、心脏压塞3例、出血2例、不明原因1例。主要抢救措施包括心脏按压、人工呼吸、心血管兴奋药物应用、电击除颤、床边开胸和心肺复苏后综合治疗。抢救后心脏复跳18例，占75％；心肺脑复苏成功并治愈出院
浙江大学医学硕士学位论文
15例，占62．5％，无遗留神经系统并发症；死亡7例，因多器官功
能衰竭放弃治疗2例。
结论：
1．本组风湿性心脏病和冠心病术后发生心搏骤停的比率较高，
分别为ss3o，o和ic．so，o。致使心脏术后心搏骤停的原因主要有低心
排综合征、电解质紊乱、心脏压塞和出血。其中风湿性心脏病主要为
低心排综合征和电解质紊乱，冠心病则主要是低心排综合征。因此，
对于重症风湿性心脏病应重视围术期治疗。对于冠心病术后出现低心
排综合征时，如果应用正性肌力药物效果不佳，更应及时使用主动脉
内囊反搏。
2．心脏手术后第1个24小时的时间段，遇有血压低、心率快
的患者，应及时进行床边超声心动图检查，对指导治疗和预防心搏骤
停的发生极有帮助。出现室性心律失常的患者，应特别注意电解质紊
乱和重视低 钾低 镁的及时纠正。
3．抢救成功率主要取决于抢救的及时性和有效性。在紧急情况
下，先胸外心脏按压后人工呼吸可能更为实用；开胸心脏按压由原切
口进入，时机选择在胸外按压无效后5N10分钟后为宜；反复肾上腺
素的应用可增加心脏复跳率；心脏复跳后的后期处理极为重要，主要
措施包括抗心律夫常药物的选择、钾和镁的补充、主动脉内囊反搏的
及时使用、以及重视脑复苏的综合治疗。
Objective: To assess the incidence of causes precipitating sudden cardiac arrest in cardiac surgery patients during the immediate postoperative period. Offer help for clinical prevention and treatment of sudden cardiac arrest. Methods: Data on all cardiac surgical patients who suffered a sudden cardiac arrest during the first 24 after surgery from May 1994 to March 2003 in our hospital were collected retrospectively. Analysis the causes and treatments of the sudden cardiac arrest. Result: Cardiac arrest occurred in the first 24h after surgery. The case of cardiac arrest include rheumatic heart
disease (58.3%), coronary heart disease (20.8%) and all kinds of congenital heart disease(20.8%). The causes of sudden cardiac arrest include low cardiac output(ll cases), electrolyte disturbance(7 cases), tamponade(3 cases), bleeding(2 cases), unclear cause(l case). Main ways of resuscitation are closed-chest cardiopulmonary resuscitation, artificial respiration, electron-trapping, medication, open-chest cardiopulmonary resuscitation and advanced treatment after resuscitation. Of 1,320 patients undergoing cardiac surgery over nine years, 24 patients(1.81%) had cardiac arrest. Of these, 15 patients (62.5%)were successfully resuscitated. Conclusion: 1.Among various disease, the incidence of cardiac arrest of rheumatic heart disease and coronary heart disease are higher than others. The causes of cardiac arrest are different among these diseases such as low cardiac output, electrolyte disturbance, tamponade and bleeding. The causes of rheumatic heart disease are low cardiac output and electrolyte disturbance. The main cause of coronary heart disease is low cardiac output syndrome. Therefore, we should pay attention to perioperative
therapy of severe rheumatic heart disease. For the coronary heart disease, application of IABP(Intra-aortic balloon Counterpulsation) timely is necessary when drugs such as epinephrine have no use in a coronary heart disease case with low output syndrome. 2.In the first 24 after surgery, we should give emphasis to measurement of electrolyte and reclaim hypokaliemia and hypomagnesemia in time. Bedside UCG is useful in realizing cardiac systolic function and tamponade in time. 3.Survival incidence of cardiac arrest rest with timely and efficiently resuscitation. Closed-chest resuscitation is more useful than artificial respiration in emergency time. The open-chest cardiopulmonary resuscitation may be chose 5-10min after closed-chest cardiopulmonary resuscitation. Repeated standard doses of epinephrine can enhance survival rate. The treatment after resuscitation is necessary for forbidding reappear of cardiac arrest such as balance of electrolyte, anti-arrhythmia treatment, among which cerebral resuscitation is most important.
方法：回顾性调查1994年5月～2003年3月在我院施行的心脏手术1320例，其中术后第1个24小时内发生心搏骤停24例。课题研究对24例心搏骤停病例的资料进行统计和原因分析，并对救治方法及其结果进行探讨。
结果：术后发生心搏骤停的病例以风湿性心瓣膜病居多(58.3％)，冠心病次之(20.8％)，各种先心病占20.8％。导致心搏骤停的原因有低心排综合征11例、电解质紊乱7例、心脏压塞3例、出血2例、不明原因1例。主要抢救措施包括心脏按压、人工呼吸、心血管兴奋药物应用、电击除颤、床边开胸和心肺复苏后综合治疗。抢救后心脏复跳18例，占75％；心肺脑复苏成功并治愈出院
浙江大学医学硕士学位论文
15例，占62．5％，无遗留神经系统并发症；死亡7例，因多器官功
能衰竭放弃治疗2例。
结论：
1．本组风湿性心脏病和冠心病术后发生心搏骤停的比率较高，
分别为ss3o，o和ic．so，o。致使心脏术后心搏骤停的原因主要有低心
排综合征、电解质紊乱、心脏压塞和出血。其中风湿性心脏病主要为
低心排综合征和电解质紊乱，冠心病则主要是低心排综合征。因此，
对于重症风湿性心脏病应重视围术期治疗。对于冠心病术后出现低心
排综合征时，如果应用正性肌力药物效果不佳，更应及时使用主动脉
内囊反搏。
2．心脏手术后第1个24小时的时间段，遇有血压低、心率快
的患者，应及时进行床边超声心动图检查，对指导治疗和预防心搏骤
停的发生极有帮助。出现室性心律失常的患者，应特别注意电解质紊
乱和重视低 钾低 镁的及时纠正。
3．抢救成功率主要取决于抢救的及时性和有效性。在紧急情况
下，先胸外心脏按压后人工呼吸可能更为实用；开胸心脏按压由原切
口进入，时机选择在胸外按压无效后5N10分钟后为宜；反复肾上腺
素的应用可增加心脏复跳率；心脏复跳后的后期处理极为重要，主要
措施包括抗心律夫常药物的选择、钾和镁的补充、主动脉内囊反搏的
及时使用、以及重视脑复苏的综合治疗。
Objective: To assess the incidence of causes precipitating sudden cardiac arrest in cardiac surgery patients during the immediate postoperative period. Offer help for clinical prevention and treatment of sudden cardiac arrest. Methods: Data on all cardiac surgical patients who suffered a sudden cardiac arrest during the first 24 after surgery from May 1994 to March 2003 in our hospital were collected retrospectively. Analysis the causes and treatments of the sudden cardiac arrest. Result: Cardiac arrest occurred in the first 24h after surgery. The case of cardiac arrest include rheumatic heart
disease (58.3%), coronary heart disease (20.8%) and all kinds of congenital heart disease(20.8%). The causes of sudden cardiac arrest include low cardiac output(ll cases), electrolyte disturbance(7 cases), tamponade(3 cases), bleeding(2 cases), unclear cause(l case). Main ways of resuscitation are closed-chest cardiopulmonary resuscitation, artificial respiration, electron-trapping, medication, open-chest cardiopulmonary resuscitation and advanced treatment after resuscitation. Of 1,320 patients undergoing cardiac surgery over nine years, 24 patients(1.81%) had cardiac arrest. Of these, 15 patients (62.5%)were successfully resuscitated. Conclusion: 1.Among various disease, the incidence of cardiac arrest of rheumatic heart disease and coronary heart disease are higher than others. The causes of cardiac arrest are different among these diseases such as low cardiac output, electrolyte disturbance, tamponade and bleeding. The causes of rheumatic heart disease are low cardiac output and electrolyte disturbance. The main cause of coronary heart disease is low cardiac output syndrome. Therefore, we should pay attention to perioperative
therapy of severe rheumatic heart disease. For the coronary heart disease, application of IABP(Intra-aortic balloon Counterpulsation) timely is necessary when drugs such as epinephrine have no use in a coronary heart disease case with low output syndrome. 2.In the first 24 after surgery, we should give emphasis to measurement of electrolyte and reclaim hypokaliemia and hypomagnesemia in time. Bedside UCG is useful in realizing cardiac systolic function and tamponade in time. 3.Survival incidence of cardiac arrest rest with timely and efficiently resuscitation. Closed-chest resuscitation is more useful than artificial respiration in emergency time. The open-chest cardiopulmonary resuscitation may be chose 5-10min after closed-chest cardiopulmonary resuscitation. Repeated standard doses of epinephrine can enhance survival rate. The treatment after resuscitation is necessary for forbidding reappear of cardiac arrest such as balance of electrolyte, anti-arrhythmia treatment, among which cerebral resuscitation is most important.
引文
1．JI Shang-yi，ZhU Lang-biao，LI Gong-song，et al(姬尚义，朱朗标，李功宋，等)．Resuscitation of 8 cases of Cardiac arrest shortly after open-heart surgery[J]. Chinese Journal of Thoracic and Cardiovascular Surgery(中华胸心血管外科杂志)，1990，6(2)：83-84． (in Chinese)
2．Gorlach G, Podzuweit T, Lohmann E, et al. Factors determining ventricular fibrillation after induced Cardiac arrest[J]. Thorac Cardiovasc Surg, 1991, 31: 140-142.
3．YU Wei-yong, HOU Ming-jun, WANG Lian-cai, et al(于伟勇，侯明君，王连才，等)．The analysis and prevention of risk factors determining severe ventricular arrhythmias during perioperative period in patients with giant left ventricle undergoing cardiac valve surgery[J]. Chinese Journal of Cardiac Arrhythmia(中华心律失常学杂志)，2002, 6(3):151-154. (in Chinese)
4．Bommer WJ，Follette D，Pollock NG，et al．Tamponade in patients undergoing cardiac surgery: a Clinical-echocardiographic diagnosis. Am Heart J,
1995,130; 1216-1223.
5. Pach MS, Boinean JP. Microfibrosis produces electrical load variations due to lose of side-to-side cell connection: a major mechanism of structural heart disease arrhythmias[J]. Pacing Clin Eletrophysio, 1997, 20:397-413.
6. HUANG Cong-xin, CHEN Bang-chang(黄从新，程邦昌). Modern cardiopulmonary and cerebral resuscitation[M]. Beijing: People's Health Publishing House, 1997.142-145,491. (in Chinese)
7. WANG Chao-yang, SHAO Guo-feng, SHEN Wei-yu, et al(汪朝阳，邵国丰，沈韦羽，等)。Resuscitation of cardiac arrest after cardiac surgery[J].Chinese Heart Journal[心脏杂志], 2001, 13 (1): 79. (in Chinese)
8. CHAO Zhen-nan, FANG Ju(巢振南，房居). Modern clinical emergency medicine[M]. Beijing: People's Health Publishing House, 1997.180-187. (in Chinese)
9. Berg RA, Kern KB, Hilwig RW, et al. Assisted ventilation does not improve outcome in a porcine model of single-rescuer bystander cardiopulmonary resuscitation. Circulation, 1997,95: 1635-1641.
10. Anthi A, Tzelepis GE, Alivezates P, et al. Unexpected cardiac arrest after cardiac surgery: incidence, predispesing causes and outcome of open chest cardiopulmonary resuscitation[J]. Chest, 1998, 113(1):15-19.
11. Boczar ME, Howard MA, Rivers EP, et al. A technique revisited: hemodynamic comparison of closed- and open- chest cardiac massage during human cardiopulmonary resuscitation[J]. Crit Care Med, 1995, 23:498-503.
12. ZHU Shui-bo, ZHANG Dian-tang, YIN Gui-lin,et al(朱水波，张殿堂，殷桂林，等). Resuscitation of cardiac arrest after extracorporeal open heart surgery[J]. Chinese Journal of Thoracic and Cardiovascular Surgery [中华胸心血管外科杂志], 1995, 11(4):227-228. (in Chinese)
13. James TN, Charles BC, Jay S, et al. Treatment of prolonged ventricular fibrillation [J]. Circulation, 1992,85(1):281-287.
14. Sapin PM, Woelfel AK, Foster JR. Unexpected ventricular tachyarrhythmias soon after cardiac surgery[]].Am J Cardiol,1991,15: 1099-1100.
15. Cause PE. Epinephrine and outcome after cardiac arrest[J].Ann Intern Med, 1999,130(1):942-943.
16. Padosch SA, Martin E, Bottiger BW. Vasopression and epinephrine for cardiac arrest[J]. Lancet, 2001, 358(9298): 2081-2082.
17. Gelman B, Schleien CL, Lohe A, et al. Selective brain cooling in infant piglets after cardiac arrest and resuscitation. Crit Care Med, 1996,24: 1009-1017.
2．Gorlach G, Podzuweit T, Lohmann E, et al. Factors determining ventricular fibrillation after induced Cardiac arrest[J]. Thorac Cardiovasc Surg, 1991, 31: 140-142.
3．YU Wei-yong, HOU Ming-jun, WANG Lian-cai, et al(于伟勇，侯明君，王连才，等)．The analysis and prevention of risk factors determining severe ventricular arrhythmias during perioperative period in patients with giant left ventricle undergoing cardiac valve surgery[J]. Chinese Journal of Cardiac Arrhythmia(中华心律失常学杂志)，2002, 6(3):151-154. (in Chinese)
4．Bommer WJ，Follette D，Pollock NG，et al．Tamponade in patients undergoing cardiac surgery: a Clinical-echocardiographic diagnosis. Am Heart J,
1995,130; 1216-1223.
5. Pach MS, Boinean JP. Microfibrosis produces electrical load variations due to lose of side-to-side cell connection: a major mechanism of structural heart disease arrhythmias[J]. Pacing Clin Eletrophysio, 1997, 20:397-413.
6. HUANG Cong-xin, CHEN Bang-chang(黄从新，程邦昌). Modern cardiopulmonary and cerebral resuscitation[M]. Beijing: People's Health Publishing House, 1997.142-145,491. (in Chinese)
7. WANG Chao-yang, SHAO Guo-feng, SHEN Wei-yu, et al(汪朝阳，邵国丰，沈韦羽，等)。Resuscitation of cardiac arrest after cardiac surgery[J].Chinese Heart Journal[心脏杂志], 2001, 13 (1): 79. (in Chinese)
8. CHAO Zhen-nan, FANG Ju(巢振南，房居). Modern clinical emergency medicine[M]. Beijing: People's Health Publishing House, 1997.180-187. (in Chinese)
9. Berg RA, Kern KB, Hilwig RW, et al. Assisted ventilation does not improve outcome in a porcine model of single-rescuer bystander cardiopulmonary resuscitation. Circulation, 1997,95: 1635-1641.
10. Anthi A, Tzelepis GE, Alivezates P, et al. Unexpected cardiac arrest after cardiac surgery: incidence, predispesing causes and outcome of open chest cardiopulmonary resuscitation[J]. Chest, 1998, 113(1):15-19.
11. Boczar ME, Howard MA, Rivers EP, et al. A technique revisited: hemodynamic comparison of closed- and open- chest cardiac massage during human cardiopulmonary resuscitation[J]. Crit Care Med, 1995, 23:498-503.
12. ZHU Shui-bo, ZHANG Dian-tang, YIN Gui-lin,et al(朱水波，张殿堂，殷桂林，等). Resuscitation of cardiac arrest after extracorporeal open heart surgery[J]. Chinese Journal of Thoracic and Cardiovascular Surgery [中华胸心血管外科杂志], 1995, 11(4):227-228. (in Chinese)
13. James TN, Charles BC, Jay S, et al. Treatment of prolonged ventricular fibrillation [J]. Circulation, 1992,85(1):281-287.
14. Sapin PM, Woelfel AK, Foster JR. Unexpected ventricular tachyarrhythmias soon after cardiac surgery[]].Am J Cardiol,1991,15: 1099-1100.
15. Cause PE. Epinephrine and outcome after cardiac arrest[J].Ann Intern Med, 1999,130(1):942-943.
16. Padosch SA, Martin E, Bottiger BW. Vasopression and epinephrine for cardiac arrest[J]. Lancet, 2001, 358(9298): 2081-2082.
17. Gelman B, Schleien CL, Lohe A, et al. Selective brain cooling in infant piglets after cardiac arrest and resuscitation. Crit Care Med, 1996,24: 1009-1017.