婴幼儿室间隔缺损合并重症肺炎急症手术的应用价值

发布时间：2018-03-13 19:09

本文选题：先天性室间隔缺损　切入点：婴幼儿　出处：《河北医科大学》2016年硕士论文　论文类型：学位论文

【摘要】：目的:室间隔缺损(ventricular septal defect,VSD)是先天性心脏病中最常见类型,占全部先天性心脏病的20%~57%[1],一般通过手术的治疗可以获得良好的效果。无特殊并发症的先心病婴幼儿可以在学龄前选择根治手术治疗。但婴幼儿期由于年龄小、体重低、全身各个脏器发育不成熟,同时存在心内解剖畸形,大量的左向右分流,导致肺循环充血、肺动脉高压,进一步造成心肺功能损害,在早期容易出现反复呼吸道感染进而迅速发展为重症肺炎,甚至死亡。部分患儿经内科系统治疗后未见明显好转,甚至并发多脏器衰竭,危及患儿生命。近年来,随着手术方式、麻醉、体外循环等技术的提高以及监护设备的不断完善,逐渐扩大了先心病手术适应症,现普遍认为对婴幼儿先天性心脏病肺炎进展为呼吸衰竭并发心力衰竭者经内科治疗无明显好转时建议尽早手术,有助于阻断心内左向右分流,缓解炎症,避免重要脏器损害。故选择2014年1月~2015年4月我院收治室间隔缺损合并肺炎患儿共60例,依据是否带气管插管行急症手术分为两组,均行手术治疗,效果良好。分析其临床诊治资料,并探讨手术时机以及围手术期的治疗以有效的降低死亡率,减少住院天数,改善患儿生存质量。方法:回顾性分析2014年1月至2015年4月我院收治的1岁以下室间隔缺损合并肺炎患儿60例其中男26例,女34例,年龄0.7~10(4.5±2.3)个月,体质量3.3~10.67(5.07±2.04)kg,依据是否带气管插管行急症手术治疗分为急症手术组和择期手术组,各30例。患儿均在全麻体外循环下行VSD修补术,同期矫治心内合并畸形,观察临床指标,并进行比较。结果:择期手术组30例中患儿术后经积极改善心功能不全,控制感染,营养支持等综合治疗后29例治愈出院,占96.6%,1例患儿家属因经济问题放弃治疗,其余术后恢复良好。手术后至出院时间为6~16 d,平均为(9.50±3.27)d,CICU滞留时间为2C15(6.4±3.2)d,呼吸机辅助时间为9~335h(88.1±60.9)h,总住院天数9~29(15.5±5.1)d。带机行急症手术组30例患儿中28例治愈出院,围手术期死亡1例,早期随访死亡1例,病死率6%。手术后至出院时间为6~17 d,平均为(9.60±2.41)d,CICU滞留时间为4~16(7.3±2.7)d,呼吸机辅助时间为23.7~219.8h(101.5±44.7)h,总住院天数12~34(20.7±6.4)d。对比两组的主动脉阻断时间、体外循环时间、术后呼吸机辅助时间,ICU滞留时间未见明显差异。术后并发症主要为再次气管插管、心律失常、肺不张、乳糜胸、手术切口感染。两组患儿门诊随访6个月体重、身高、患病情况,两组患儿术后生长发育均明显加快,体质较前增强,发生感染性疾病几率明显减少。术后1~2个月心脏专科门诊随访心脏彩超示心功能均恢复良好。结论:婴幼儿室间隔缺损合并肺炎,大部分经内科保守治疗可痊愈而择期手术。但部分患儿因年龄小、缺损大、肺炎重,心功能不能控制时,应尽早进行手术治疗,降低死亡率,改善患儿生存质量,减轻家庭负担。
[Abstract]:Objective: ventricular septal defect (ventricular septal defect, VSD) is the most common type of congenital heart disease, congenital heart disease accounted for 20%~57%[1], usually by surgical treatment can get good results. No special complications in infants with congenital heart disease in preschool choose radical surgery. But due to the small age infants low weight, various body organs, development is not mature, exist within the heart anatomic deformity, a left to right shunt, leading to pulmonary congestion, pulmonary hypertension, heart and lung function caused further damage in early phase is prone to recurrent respiratory tract infection and the rapid development of severe pneumonia, and even death. Some patients after medical treatment system there was no obvious improvement, even complicated with multiple organ failure, endangering the lives of children. In recent years, with surgery, anesthesia, cardiopulmonary bypass technique and the improvement of monitoring equipment Continue to improve, gradually expanded the indications for surgery of congenital heart disease, it is generally believed that the development of pneumonia in infants with congenital heart disease complicated with heart failure patients for respiratory failure after medical treatment was not improved when the proposed operation as soon as possible, to help block the left to right shunt heart, relieve inflammation, avoid damage to important organs. The choice of ~2015 in January 2014 in April, children in our hospital were ventricular septal defect complicated with pneumonia in 60 cases, according to whether with tracheal intubation in emergency operation were divided into two groups, underwent surgical treatment, the effect is good. To analyze the clinical data, and to investigate the timing of surgery and perioperative treatment to reduce mortality, reduce hospitalization time, improve the quality of the survival of children. Methods: a retrospective analysis from January 2014 to April 2015 in our hospital room under the age of 1 VSD with pneumonia in 60 cases including 26 cases of male, female 34 cases, aged 0.7~10 (4.5. 2.3) months, the body weight of 3.3~10.67 (5.07 + 2.04) kg, according to whether with tracheal intubation in emergency operation treatment is divided into emergency surgery group and elective surgery group, 30 cases each. The patients were under general anesthesia under extracorporeal circulation VSD repair treatment at the same time, heart malformation, clinical observation index, and compared. Results: 30 cases of elective surgery group in patients after active heart dysfunction, infection control, nutritional support after the comprehensive treatment of 29 cases were cured, accounting for 96.6%, 1 cases of children with their families because of economic problems to give up treatment, the rest recovered well after operation. After the operation to discharge time was 6~16 D, average (9.50 + 3.27) d, CICU for 2C15 retention time (6.4 + 3.2) d, 9~335h ventilation time (88.1 + 60.9) h, the total length of stay in 9~29 (15.5 + 5.1) d. with emergency surgery group 30 cases 28 cases were cured, 1 cases of perioperative death, follow-up 1 cases of early death, the mortality rate was 6% . after surgery to discharge time was 6~17 D, average (9.60 + 2.41) d, CICU for 4~16 retention time (7.3 + 2.7) d, 23.7~219.8h ventilation time (101.5 + 44.7) h, the total length of stay in 12~34 (20.7 + 6.4) d. between two groups of aortic clamp time and cardiopulmonary bypass between the ventilation time after operation, the ICU residence time had no significant difference. The main complications were again tracheal intubation, arrhythmia, pulmonary atelectasis, chylothorax, incision infection. Two groups of children with outpatient follow-up 6 months of weight, height, the prevalence of children in two groups after operation were significantly accelerated growth and development, physical fitness compared with the previous increase of infectious diseases rate decreased significantly. After 1~2 months of cardiology outpatient follow-up echocardiogram showed cardiac function recovered well. Conclusion: ventricular septal defect in infants with pneumonia, most can be cured by conservative treatment and elective surgery. But some patients because of When the age is small, the defect is large, the pneumonia is heavy and the heart function can not be controlled, the operation should be carried out as soon as possible to reduce the death rate, improve the quality of the children's life and reduce the family burden.

【学位授予单位】：河北医科大学
【学位级别】：硕士
【学位授予年份】：2016
【分类号】：R726.5

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