Pro: Heparin-coated circuits should be used for cardiopulmonary bypass.
Pro: Heparin-coated circuits should be used for cardiopulmonary bypass.
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优点：体外循环应使用肝素涂层回路。
DOI：
10.1213/01.ane.0000242530.81421.cc
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发表时间：
2006
影响因子：
5.7
通讯作者：
M. Jessen
中科院分区：
文献类型：
--
作者：
M. Jessen
Michael E.心脏外科手术中使用心肺转流术（CPB），最早是在半个多世纪前进行的，能够纠正以前无法治疗的心脏缺陷，并预示着缺血性心脏病、瓣膜疾病和先天性心脏畸形治疗的革命性进展。然而，这项创新技术的经验使人们认识到，体外循环也会产生不良影响。CPB最突出的有害特征涉及其对炎症反应的强烈刺激，当严重时，许多人认为这与患者发病率和死亡率的增加有关（1）。这种反应包括补体激活（2）、纤维蛋白溶解（3）、激肽释放酶-激肽（4）和凝血级联反应（5）的启动、细胞因子水平升高（6）以及中性粒细胞和血小板的激活。CPB期间的中性粒细胞活化表现为多形核细胞计数波动（7）、循环中性粒细胞弹性蛋白酶水平升高（8）以及促进中性粒细胞与内皮细胞结合的粘附糖蛋白表达增加（9）。中性粒细胞的激活被认为是术后并发症的原因，包括毛细血管渗漏综合征（10）、微血管肺损伤（11）和其他（12）。CPB对炎症级联反应和血小板活化的影响（13）也可能导致心脏手术后遇到的出血问题。临床上已采用多种措施来降低炎症反应的强度，包括给予糖皮质激素（14）、非甾体类抗炎药（15）或前列腺素E1（16）。许多研究已经检查了丝氨酸蛋白酶抑制剂抑肽酶（17）或其他抗纤维蛋白溶解药物（18）的使用，以减少炎症和改善结果。其他策略包括白细胞去除（19）或施用针对内皮粘附抗原（20）或针对补体级联反应（21）的单克隆抗体。在最极端的形式中，一些外科医生通过使用“非体外循环”技术进行冠状动脉搭桥手术来改变手术以完全避免CPB（22）。外科医生、麻醉师、灌注师和制造商已经开发了其他方法来改变一些可能引发炎症过程的因素。膜式氧合器已经取代了气泡式氧合器，离心泵已经取代了滚子泵，并且在CPB期间现在使用不太深的低温。但是，从CPB材料的角度来看，最大的影响可能来自对CPB电路合成表面的修改。虽然已经开发了多种表面改性，但最大的经验是使用肝素涂层的CPB表面。1963年，Gott（23）报道了肝素与用阳离子表面活性剂冲洗的表面的离子键合，首次描述了肝素涂层表面。1983年，Larm等人（24）描述了一种通过共价键合过程连接肝素的替代方法。这些过程及其相关制造技术的发展导致了目前临床使用的两种主要形式的肝素涂层回路（HCC）的开发：Carmeda生物活性表面（Medtronic，Minneapolis，MN），其使用共价端点连接的肝素，以及Duraflo II系统（Edwards Lifesciences，Irvine，CA），其通过离子键在回路组件上保持肝素涂层。来自德克萨斯州达拉斯德克萨斯大学西南医学中心心血管和胸外科的不同形式。接受出版：2006年8月9日。地址通信和重印要求迈克尔E。德克萨斯大学西南医学中心（达拉斯，5323 Harry Hines Boulevard，达拉斯，TX）心血管和胸外科医学博士Dr. Ellen。电邮地址是迈克尔。jessen@utsouthwestern.edu.版权所有© 2006国际麻醉研究学会
Michael E. Jessen, MD The use of cardiopulmonary bypass (CPB) for cardiac surgical operations, first performed over half a century ago, enabled the correction of previously untreatable cardiac defects and heralded revolutionary advances in the treatment of ischemic heart disease, valvular disorders, and congenital cardiac malformations. Experience with this innovative technology, however, led to the realization that extracorporeal circulation can also produce adverse effects. The most prominent deleterious feature of CPB relates to its intense stimulation of the inflammatory response, which, when severe, is believed by many to be associated with an increase in patient morbidity and mortality (1). This response includes activation of complement (2), initiation of fibrinolytic (3), kallikrein-kinin (4), and coagulation cascades (5), an increase in cytokine levels (6), and activation of neutrophils and platelets. Neutrophil activation during CPB is evidenced by fluctuations in polymorphonuclear cell counts (7), an increase in circulating neutrophil elastase levels (8), and increased expression of adhesive glycoproteins which facilitate neutrophil binding to endothelium (9). Activation of neutrophils are believed to contribute to postoperative complications, including capillary-leak syndrome (10), microvascular lung injury (11), and others (12). The effects of CPB on inflammatory cascades and activation of platelets (13) may also contribute to bleeding problems encountered after cardiac surgery. A variety of measures have been used clinically to reduce the intensity of the inflammatory response, including administration of glucocorticoids (14), nonsteroidal inflammatory drugs (15), or prostaglandin E1 (16). Many investigations have examined the use of the serine protease inhibitor, aprotinin (17), or other antifibrinolytic drugs (18) to reduce inflammation and improve outcomes. Other strategies have included leukocyte depletion (19) or administration of monoclonal antibodies directed against endothelial adhesion antigens (20) or against the complement cascade (21). In perhaps the most extreme form, some surgeons alter the operation to avoid CPB altogether by using an “off-pump” technique for coronary bypass surgery (22). Surgeons, anesthesiologists, perfusionists, and manufacturers have developed additional methods to alter some of the factors which can incite the inflammatory process. Membrane oxygenators have replaced bubble oxygenators, centrifugal pumps have replaced roller pumps, and less profound hypothermia is now used during CPB. But probably, the largest impact from a CPB materials standpoint has come by way of modifications to the synthetic surfaces of the CPB circuitry. Although multiple surface modifications have been developed, the largest experience is with CPB surfaces that have been coated with heparin. Heparin-coated surfaces were first described in 1963 when Gott (23) reported an ionic linkage of heparin to a surface rinsed with a cationic surface-active agent. In 1983, Larm et al. (24) described an alterative method of heparin attachment through a covalent bonding process. The evolution of these processes and their associated manufacturing techniques has led to the development of the two main forms of heparin-coated circuits (HCC) in clinical use today: the Carmeda BioActive Surface (Medtronic, Minneapolis, MN), which uses a covalent endpoint-attached heparin, and the Duraflo II system (Edwards Lifesciences, Irvine, CA), which maintains a heparin coating on circuit components through an ionic linkage. The different forms of From the Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas. Accepted for publication: August 9, 2006. Address correspondence and reprint requests to Michael E. Jessen, MD, Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center at Dallas, 5323 Harry Hines Boulevard, Dallas, TX. Address e-mail to michael. jessen@utsouthwestern.edu. Copyright © 2006 International Anesthesia Research Society
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影响因子：
158.5
作者：
CHENOWETH, DE;COOPER, SW;KIRKLIN, JW
通讯作者：
KIRKLIN, JW
抑肽酶在模拟体外灌注过程中抑制接触、中性粒细胞和血小板激活系统。
DOI：
--
发表时间：
1993
期刊：
The Journal of thoracic and cardiovascular surgery
影响因子：
--
作者：
Wachtfogel,YT;Kucich,U;Hack,CE;Gluszko,P;Niewiarowski,S;Colman,RW;EdmundsJr,LH
通讯作者：
EdmundsJr,LH
肝素涂层旁路回路可减少肺损伤。
DOI：
10.1016/0003-4975(93)90882-i
发表时间：
1993
期刊：
The Annals of thoracic surgery
影响因子：
--
作者：
Redmond,JM;Gillinov,AM;Stuart,RS;Zehr,KJ;Winkelstein,JA;Herskowitz,A;Cameron,DE;Baumgartner,WA
通讯作者：
Baumgartner,WA
炎症中因子 XII 的激活和抑制。
DOI：
10.1007/978-3-0348-7397-0_11
发表时间：
1993
期刊：
Agents and actions. Supplements
影响因子：
--
作者：
Colman,RW
通讯作者：
Colman,RW