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Open heart operation on neonates with critical congenital heart disease 推荐 CAJ下载 PDF

Objective To summarize the experience of open heart operation on neonates with critical and complex congenital heart diseases and evaluate the methods of perioperative management. Methods From May 2001 to January 2003, 12 patients of neonates with congenital heart diseases underwent emergency operation. Their operating ages ranged from 6 to 30 days, the body weights were 2.8 to 4.5 kg. Their diagnoses included D-transposition of the great arteries in 4 cases, ventricular septal defect with atrial septal defect in 5 cases, complete atrioventricular septal defect, obstructed supracardiac total anomalous pulmonary venous drainage and cardiac rhabdomyomas in 1 case respectively. 12 cases were operated under moderate or deep hypothermic cardiopulmonary bypass. Results All cases were observed in ICU for 2-11 days and discharged 7-19 days after operation. The postoperative complications included low cardiac output, mediastinal infection, respiratory distress syndrome, systemic capillary leak syndrome and acute renal failure. All cases were cured and the follow-up (from 6 months to 2 years) showed satisfactory outcome. Conclusion A particular cardiopulmonary bypass and proper perioperative management is very important to ensure the successful outcome. Peritoneal dialysis is an effective and safe method for treating acute renal failure after cardiac operation in neonates.

The Duration of Postoperative Mechanical Ventilation in Infants with Weight Lower than 10 kg Having Undergone Congenital Cardiac Surgery

目的　探讨≤10 kg体重婴幼儿心脏直视术后呼吸机使用时间的相关因素。 方法　从2005年3月－2011年6月，选择纳入接受心脏直视手术的体重≤10 kg的先天性心脏病婴幼儿，分析各项围术期指标与术后呼吸机使用时间的关系，讨论该类婴幼儿术后呼吸机使用时间决策。 结果　共纳入体重≤10 kg的婴幼儿42例，呼吸机使用时间（42.74 ± 52.55） h，中位数20.88 h;发现术后2 h入量（mL/kg），术后4、8、16 h总入量（mL/kg）与术后呼吸机使用时间相关（P＜0.05），术后呼吸机使用时间与患儿ICU入住时间约成线性相关（P＜0.05）。 结论　影响低体重婴幼儿心脏直视术后呼吸机使用时间是术后液体管理，实施“限制性液体管理”治疗策略可能会促进患儿的术后快速康复。术后液体管理如何具体影响患儿呼吸机使用时间，影响患儿的预后，尚需进一步研究。Objective　To evaluate the factors related to the postoperative mechanical ventilation (MV) duration in low-weight infants weighing less than 10 kg having undergone open cardiac surgery. Methods　From March 2005 to June 2011, infants less than 10 kg undergoing congenital cardiac surgery were included in this research. We analyzed the relationship between various peri-operative indexes and the duration of MV, and discussed the decision for ventilation time for these infant patients. Results　A total of 42 infants were included in our study. The ventilation time was (42.74 ±52.55) hours with a median of 20.88 hours. The postoperative second-hour fluid intake and the total intake of fluid at hour 4, 8, and 16 were related to the duration of mechanical ventilation (P＜0.05). And the ventilation time had a linear relationship with the ICU-stay time (P＜0.05). Conclusions　The postoperative fluid management is associated with the duration of mechanical ventilation for low-weight infants having undergone open cardiac surgery. “Fluid controlling management” may facilitate quick recovery of the infant patients. However, as for how the fluid should be managed, how the fluid management influences ventilation time and the prognosis, more research is needed.

Nursing Experience of Noninvasive Ventilation for Infants with Congenital Heart Disease after Surgery

【摘要】　目的　总结先天性心脏病术后无创通气的监护。　方法　2008年1-12月胸外ICU 36例先天性心脏病术后患儿，在使用无创通气前后监测血压、心率、呼吸及血气变化。　结果　与无创通气前相比，无创通气后30 min、1 h、2 h的指标均恢复到满意水平，循环稳定。　结论　通过采用无创通气，80%的患儿避免了再次插管，缩短有创通气时间，同时避免了相关的呼吸道并发症，缩短了患儿住院时间，节省了医疗费用，提升了先天性心脏病患儿术后成活率。【Abstract】　Objective　To summarize the nursing experience of noninvasive ventilation for infants with congenital heart disease after the surgery.　Methods　A total of 36 patients who underwent noninvasive ventilation from January to December 2008 were enrolled. The blood pressure, heart rate, respiration, and blood gas were recorded and analyzed before and after noninvasive ventilation.　Results　Compared with the results before noninvasive ventilation, all of the indexes returned to a satisfying level and the circulation kept stable 30 minutes, one hour, and two hours after noninvasive ventilation.　Conclusion　Noninvasive ventilation may avoid reintubation, shorten the invasive ventilatory time, decrease the respiratory complications, shorten the time of hospitalization, save the medical expenses, and promote the survival rate of infants with congenital heart disease.

Efficacy of Humidified High Flow Nasal Cannula for Respiratory Failure after Ventilator Weaning in Post-operative Children with Congenital Heart Disease

Objective To explore the efficacy of humidified high flow nasal cannula ( HHFNC) for respiratory failure after ventilator weaning in post-operative newborns and infants with congenital heart disease. Methods FromJanuary 2010 to August 2010, 33 newborns and infants [ ( 7. 8 ±8. 4) months, range 3 days to 36 months; weight ( 6. 6 ±3. 6) kg, range 2. 2 to 19. 6 kg] were treated with HHFNC ( 22 cases) and routine oxygen therapy ( 11 cases) for respiratory failure following ventilator weaning after operation of congenital heart disease. Symptoms, blood oxygen saturation ( SpO2 ) , partial pressure of oxygen( PaO2 ) , partial pressure of carbondioxide ( PaCO2 ) , incidence rate of re-intubation, duration of ICU, and hospital stay were assessed and compared between the HHFNC group and the routine oxygen therapy group.Results There were no statistical significance in the duration of ICU, hospital stay, duration of mechanical ventilation, or infection rate between the HHFNC group and the routine oxygen therapy group ( P gt; 0. 05) . But the incidence rate of re-intubation was lower in the HHFNC group than that in the routine oxygen therapy group. Meanwhile SpO2 and PaO2 increased and PaCO2 decreased significantly in the HHFNC group ( P lt;0. 05) . Conclusion HHFNC shows a clinical improvement rapidly and efficiently in preventing respiratory failure after ventilator weaning in post-operative newborns and infants with congenital heart disease.

先天性心脏病合并肺动脉瓣感染性心内膜炎的外科治疗

目的　探讨先天性心脏病合并肺动脉瓣感染性心内膜炎的外科治疗方法和效果。　方法　2009年1月至2012年1月第二军医大学长海医院收治先天性心脏病合并肺动脉瓣感染性心内膜炎患者6例，男1例，女5例；年龄8～41 （24.8±11.8）岁。动脉导管未闭（PDA）4例，PDA合并先天性主动脉瓣狭窄1例，室间隔缺损（VSD）合并三尖瓣反流1例。3例行PDA结扎＋肺动脉内赘生物清除术，1例行PDA结扎＋肺动脉瓣赘生物切除术，1例行PDA结扎＋肺动脉瓣赘生物切除术＋主动脉瓣置换术（AVR，置换19 mm CarboMetics环上机械主动脉瓣），1例肺动脉瓣膜破坏严重，行VSD修补＋右心室流出道赘生物清除＋右心室流出道拓宽＋三尖瓣成形术＋肺动脉生物瓣置换术（置换27 mm HancockⅡ型生物瓣）。　结果　6例患者术后均恢复良好，无围术期死亡和心内膜炎复发。所有患者复查超声心动图提示，未见赘生物、残余漏、瓣周漏等并发症。术后随访6个月～3年中，患者临床症状完全消失，均无明显不适。术后心功能恢复至Ⅰ级5例，Ⅱ级1例。　结论　对于先天性心脏病合并肺动脉瓣感染性心内膜炎患者，正确把握手术时机，积极行外科手术治疗是最有效的治疗方法。

复杂先天性心脏病右心室流出道重建困难的处理

目的　探讨复杂先天性心脏病在纠治过程中右心室流出道（RVOT）重建困难的处理方法和其适应证、手术方法、应用中的注意要点。 方法　回顾性分析2008年1月至2010年12月广州市妇女儿童医疗中心26例复杂先天性心脏病患者行手术治疗的临床资料。其中男14例，女12例；年龄（2.9±2.0）岁；体重（12.2±6.0） kg。所有患者在纠治过程中RVOT重建困难，分别采用以下方法进行处理： （1）肺动脉从根部切断与主动脉交叉后吻合于右心室切口； （2）肺动脉从根部切断直接下拉吻合于右心室切口； （3） 肺动脉切断后远心端与右心室切口间的后壁用左心耳或右心耳做后壁，人工补片做前壁，重建RVOT； （4）肺动脉与右心室切口间用自体心包做成的心包卷管道连接。　结果　无手术死亡，无Ⅲ°房室传导阻滞。10例患者因尿少行腹膜透析治疗，心脏压塞和/或胸腔出血开胸止血4例。所有患者随访0.5～3.0年复查：应用肺动脉从根部切断与主动脉交叉后吻合于右心室切口和肺动脉从根部切断直接下拉吻合于右心室切口两种方法的7例患者中肺动脉血流速度加快3例，2.5～3.0 m/s；残留中度以上肺动脉高压5例；中至重度肺动脉反流6例，其中肺动脉血流速度增快2例，残留中度肺动脉高压4例。　结论　以上4种RVOT重建方法在复杂先天性心脏病RVOT重建中应用得当有良好的手术效果；前2种方法有肺动脉血流速度增快的可能性；肺动脉瓣反流与术后肺动脉高压或肺动脉梗阻有关。

同期矫治先天性三尖瓣狭窄合并心内畸形一例

先天性右心房房壁瘤一例

一期全腔静脉-肺动脉连接术治疗复杂先天性心脏病

目的　总结一期全腔静脉-肺动脉连接术（TCPC）治疗复杂先天性心脏病的临床经验。 方法　回顾性分析2002年1月至2011年5月解放军第91中心医院31例复杂先天性心脏病患者行一期TCPC的临床资料，其中男19例，女12例；年龄（7.2±4.5） 岁；体重（23.2±10.7） kg。三尖瓣闭锁19例、单心室5例、肺动脉闭锁2例、右心室发育不良2例、右心室双出口3例。25例采用外管道手术，6例采用心房内通道手术。 结果　术后早期死亡3例（9.7%），死亡原因：低心排血量、多器官功能衰竭、心脏骤停。术后早期并发症发生率为22.6% （7/31），主要为肺水肿、胸腔积液、心律失常、心包积液、蛋白丢失性肠病和低心排血量。术后28例患者均得到随访（100%），平均随访26 （9～87）个月。随访期间再次住院率为14.3% （4/28），其中2例再次出现胸腔积液，经胸腔引流、强心、利尿治疗好转出院；2例因自行停服肠溶阿司匹林后外管道堵塞再次行手术治疗，1例再次手术后因低心排血量死亡。其余患者恢复正常生活。 结论　对适应证明确的复杂先天性心脏病患者一期行TCPC治疗，能获得满意的效果。

婴幼儿患者长时间体外循环风险分析

目的　分析婴幼儿患者长时间体外循环（CPB）对预后的影响。 方法　回顾性分析福建医科大学协和临床学院2008年1月至2011年11月CPB时间＞120 min 308例患者的临床资料，其中男187例，女121例；年龄（1.5±1.2） 岁。CPB中采用浅-中低温技术、深低温停循环、深低温低流量灌注技术。分析术后死亡率等临床结果。 结果　患者呼吸机使用时间12 h～30 d （32.9±41.4） h、对严重低氧血症患者加用3～10 cm H2O呼气末正压。住ICU时间48～1 600 （72.9±50.2） h。病死率9.1% （28/308），死于多器官功能衰竭18例，败血症6例，其它原因4例。CPB时间120～240 min的患者头面部水肿不明显，CPB时间＞240 min的患者轻-中度水肿。术后胸腔引流量55～320 （62.3±109.6） ml。血红蛋白尿发生率11.4% （35/308）。尿少行腹膜透析发生率7.5%（23/308）。结论　婴幼儿患者长时间CPB并发症及病死率高，精细CPB管理、超滤及注意保护重要器官是确切有效的方法。