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• Case Presentation:

A 55-year-old Jehovah Witness female with a past medical history of hypertension and obesity presented to an outside hospital with severe chest pain. Imaging revealed a Stanford Type A dissection extending into the left common carotid artery, left subclavian artery and axillary arteries, and distally into the common iliac artery and bilateral internal iliac arteries. The thoracic aorta was dilated to 5.2cm. The patient was emergently transferred to our institution via Life Flight and admitted to the ICU where esmolol and nicardipine infusions were initiated. After “Jehovah Witness special discussing”, patient agree to have auto blood transfusion and CPB within connected circus. She was taken to the operating room emergently. Operative course consisted of resection and graft replacement of the ascending and proximal transverse aortic arch, repair of the remaining transverse arch, aortic valve repair, and aortic root reconstruction with DHCA. Blood conservation strategy are 1, Reduce blood loss at all kind way; 2, Avoid hemodilution by maximal lower cardiopulmonary bypass (CPB) primer volume even cut and shortened the CPB tubing. 3, intraoperative autologous blood transfusion: using both of autologous platelet-rich plasma (aPRP) technique which reserved coagulation factors and platelets and cell saver technique reserved red blood cell. 4, Tranexamic acid infusion before incision and 0.3 MCG /kg of DDAVP given with aPRP transfusion after revered heparin by protamine. Chest is closed without evidence of bleeding. Patient is transferred to CVICU on fast track Extubation protocol. The patient received total 800ml of aPRP , 675ml cell saver and, 1200ml of crystalloid. Estimated blood loss was 500ml with normal arterial blood gas (ABG). Patient was extubated 3.5 hours post operation.

专家提问：

• 周少凤教授提出的临床问题：

1.What are some blood conservation strategies in major “blood” surgery, such as cardiovascular surgery?

2.Who is involved in blood conversation practice?

3.Why do we need to emphasize blood conservation in cardiovascular surgery?

4.When do blood transfusions happen most during cardiovascular surgery?

5.How many common techniques are there for auto blood transfusions in cardiovascular surgery?

6.Why is pre-donation of blood is not recommended?7.Describe the autologous platelet rich plasma technique.

8.What is acute Normovolemic hemodilution?

9.What is the role of intraoperative cell saver in blood conservation, advantages and disadvantages?

10.What is the difference between coagulopathy and microvascular bleeding?

• 童传耀教授提出的临床问题：

手术前评估：

1. 简单介绍耶和华见证人的宗教背景

2. 为什么耶和华见证人会拒绝接受血制品

3. 主动脉瘤破裂是怎样分类的？有几种分类方法？

4. 这个病人手术前为什么给予艾思洛尔和尼卡地平？假如你们医院没有这两个药， 可以用什么药来替代？

5. 手术前你会用吗啡来治疗她的胸背痛吗？控制她的疼痛重要吗，为什么？

6. 假如其他情况稳定， 你会让病人自己移动从病床爬到手术台上去吗？

7. 这个病人的主动脉瘤破裂是否可以考虑用支架置入方法治疗？

8. 临床上怎样决定主动脉瘤破裂时需要同时进行主动脉瓣的置换或修补？

9. 这个病人的主动脉病变是原先就有的，还是继发于主动脉瘤的破裂？

10. 如果是主动脉瘤的破裂引起的，是否会影响冠状动脉的血供， 手术前有哪些方法可以监测？

11. 你会在手术前做哪些准备来减少这个病人手术中的失血？

12. 你会手术前放置有创动脉导管吗？放置在那里，这有关系吗？

手术中管理：

1. 怎样进行麻醉诱导，麻醉药的选择？危急情况下的抢救药物的配备？

2. 麻醉的诱导一定要等外科医生到达手术室后才开始吗？

3. 体外循环的预充液一般是用什么样的液体，容量一般是多少？怎样来减少血液稀释？

4. 主动脉瘤破裂时，体外循环的动脉灌流插管一般是放在哪里（主动脉根部或主动脉弓的远段？）

5. 什么是超低温心脏骤停DHCA？麻醉医生怎样协助达到预想的温度？怎样进行生命体征的监测？

6. 能描述一般是怎样进行复温的？整个过程中怎样进行脑保护和脑功能的监测？

7. 什么是血液回输器，它有哪些功能和它的工作原理？有谁进行操作？

8. 血液回输器能分离出血小板吗？

9. 为什么手术前静脉给止血方酸，剂量？

10. 手术中需要监测病人的出凝血指标，举例说明有哪些常用的方法？

11. 鱼精蛋白是怎样中和肝素的？怎样监测肝素中和的有效性？为什么要在给肝素中和给DDAVP？

12. 心脏大血管/体外循环手术中最常见的凝血功能障碍的特点是什么？

13. TEE对这个手术有帮助吗， 请简单举1-2例子？

14. 这样的动脉瘤手术会造成脊髓损伤吗， 为什么？脊髓损伤的临床表现的特征是什么？

15. 手术中可以应用哪些方法减少减轻脊髓损伤？特殊的神经监测会有帮助吗？

16. 怎样一个大动脉瘤的手术，发生肾功能损伤的可能性是多少？用什么方法监测和评估肾功能损伤的程度？

手术后管理：

1. 一般情况下，怎样的病人会在手术后多少时间拔气管导管？为什么（是顾虑循环不稳定，呼吸功能不全，出血？）

2. 这个病人在手术后3个小时就拔管了，你认为是什么样的努力取得了怎样的良好预后？

3. 通过这个病例的讨论， 你最大收获是什么？

已经讨论过的病例：