先天性心脏病术后患者ICU恢复差异性研究

发布时间：2018-03-23 10:49

本文选题：先天性心脏病　切入点：营养状况　出处：《北京协和医学院》2017年博士论文

【摘要】：目的:通过对阜外医院PICU先天性心脏病患儿营养状况的评估以及分析其与术后临床预后的关系,探讨先天心脏病患儿营养不良发生率与临床结局的关系,为先天性心脏病规范化营养风险评估及营养支持治疗提供理论依据。方法:选取2015年1月-2016年1月于阜外医院小儿外科中心先天性心脏病2岁以下手术患儿,选取患儿均给予先天性心脏病手术风险分级(RACHS-1分级)。研究设定了入选标准及排除标准,收集患儿术前、术中及术后临床资料,对术前营养状况进行评估,了解先天性心脏病患儿营养状况,对比营养不良患儿与非营养不良患儿在临床指标上的差异,分析影响或加重先天性心脏病营养不良患儿的危险因素,明确先天性心脏病营养不良与临床预后的关联性。结果:入选患儿共532例,其中男性306例,女性226例,手术年龄(中位数)9月,手术时体重(中位数)7.8kg,出生体重(中位数)3.2kg,身高73.0± 17.1cm,术前血红蛋白Hgb 128.2±28.3g/L,术前血清白蛋白42.3±3.7g/L,体外循环时间94.6±71.4min,主动脉阻断时间57.0±42.1min,机械通气时间(中位数)11小时,ICU滞留时间2天,出现并发症情况94例,占总数17%,其中死亡16例,占总数3%。营养不良患儿309例,非营养不良患儿223例,两组间比较术前、术中及术后数据,术前RACHS-1分级无明显差异,两组间术前体重、身高,出生体重存在统计学差异。术前化验方面,术前血红蛋白Hgb,血清白蛋白无统计学差异。在术后指标方面,营养不良组术后机械通气时间明显延长,存在统计学差异,而ICU滞留时间不存在统计学差异,P值为0.059,接近存在统计学意义P值。术后并发症,营养不良组60例,占组内病例总数19.4%,非营养不良组出现并发症34例,占组内病例总数15.22%,两组比较发生率无明显差异。经多因素分析,发现先天性心脏病患儿营养不良的群体中,年龄、低出生体重可以加剧营养不良程度。将并发症进行细化研究,营养不良组患儿二次插管率及死亡率明显多于非营养不良组患儿,且具有统计学意义,其它并发症两组间比较差异不大。结论:先天性心脏病婴幼儿中营养不良患儿比例偏高,营养不良严重程度与手术年龄,低出生体重有关,营养不良患儿先天性心脏病术后机械通气时间延长,二次插管率及死亡率高于非营养不良患儿,未来需要完善营养评价体系,制定完整的先天性心脏病营养支持策略,以期改善临床预后。目的:分析阜外医院小儿左冠状动脉起源于肺动脉(Anomalous Left Coronary Artery From the Pulmonary Artery,ALCAPA)的外科治疗早期结果,并总结此类疾病早期治疗经验,以明确心脏功能变化与术后预后的关系。方法:选取2012年1月至2016年12月阜外医院小儿外科中心收治左冠状动脉起源异常手术患儿共65例,其中男性37例,女性28例,收集患儿术前心功能指标,术前一般资料,术中体外循环时间,主动脉阻断时间,是否给予二尖瓣成形,术后超声心功能情况、术后左室舒张末径大小,术后呼吸机时间、ICU滞留时间、术后并发症等术后相关指标。对所有65例患儿按照术前射血分数(简称EF)30%分组,EF30%患儿26例,其余为39例,比较两组间相关监测指标的差异。结果:总共入选患儿65例,其中男性37例,女性28例,手术年龄(中位数)12月,术前体重(中位数)8.5kg,术前射血分数(EF)44.23±22.6%,左室舒张末径大小39.69±7.73mm,体外循环时间121.67±56.04min,主动脉阻断时间(中位数)67min,22例患儿因二尖瓣反流重而行二尖瓣成形,呼吸机支持时间(中位数)24h,ICU滞留时间(中位数)3天,死亡2例,二次插管7例,ECMO辅助3例,延迟关胸8例,腹膜透析6例。对于以射血分数EF 30%作为患儿分组指标,EF30%患儿26例,其余为39例,比较两组术前情况,EF30%组患儿年龄、术前体重明显小于EF≥30%组,而EF≥30%组患儿术前左室舒张末径大小小于EF30%组患儿,且具有统计学差异。两组间体外循环时间、主动脉阻断时间,术中予ECMO辅助病例无明显差异,EF≥30%组术中行二尖瓣成形数量明显多于EF30%组。EF30%组患儿呼吸机支持时间和ICU滞留时间明显多于EF≥30%组,且具有统计学差异。术后并发症方面比较,EF30%组患儿二次插管、腹膜透析、延迟关胸数量明显多于EF≥30%组,具有统计学差异。死亡率比较,总体死亡病例2人,均为EF30%组患儿,两组间比较无统计学差异。总体患儿自身对照,拔管时射血分数EF较于术前无明显差异,而出院时EF较术前存在明显差异。左室舒张末径大小比较,拔管时左室舒张末径大小明显小于术前左室舒张末径大小,出院时左室舒张末径大小明显小于术前左室舒张末径大小。结论:左冠状动脉起源于肺动脉的小儿患者早期结果满意,大部分患者心脏功能和二尖瓣反流都会有不同程度的改善。极差的心脏功能对术后早期结果有明显影响,射血分数EF30%患儿术后ICU时间、呼吸机使用时间明显延长,二次插管、延迟关胸、肾替代治疗危险系数明显增加,将经历较长的延迟恢复的过程。
[Abstract]:Objective: to assess the PICU of Fuwai Hospital in children with congenital heart disease and to analyze the nutritional status and the relationship between clinical prognosis after operation of congenital heart disease in children with nutrition, adverse incidence and clinical outcome of congenital heart disease, in order to regulate the nutritional risk assessment and nutritional support treatment and provide a theoretical basis. Methods: January 2015 -2016 in January in the pediatric surgery center of Fuwai Hospital of congenital heart disease in children under 2 years old children were given surgery, selection of surgical treatment of congenital heart diseases risk classification (RACHS-1 classification). The study set inclusion criteria and exclusion criteria, the clinical data were collected before, during and after surgery, the preoperative nutritional status assessment, understanding the nutritional status of children with congenital heart disease, differences in clinical indicators on the comparison of malnourished children and non malnourished children, or aggravate the influence analysis of congenital heart disease The risk factors of malnutrition in children with congenital heart disease, clear malnutrition and clinical prognostic relevance. Results: all the 532 cases, including 306 cases of male, female 226 cases, age at surgery (median) in September, at the time of surgery (median weight 7.8kg), birth weight (median) height 3.2kg, 73 + 17.1cm preoperative hemoglobin, Hgb 128.2 + 28.3g/L, preoperative serum albumin was 42.3 + 3.7g/L, 94.6 + 71.4min cardiopulmonary bypass time, aortic clamping time was 57 + 42.1min, mechanical ventilation time (median) 11 hours, ICU retention time of 2 days, complications of 94 cases, accounting for 17% of the total, including 16 cases of death, accounting for 3%. malnutrition in 309 children with non malnourished children in 223 cases, two groups preoperative, intraoperative and postoperative data, RACHS-1 grade had no significant difference between the two groups before surgery, preoperative weight, height, birth weight, there was a significant difference between the preoperative laboratory tests, Preoperative hemoglobin Hgb, no significant difference in serum albumin. Postoperative index, malnutrition group, postoperative mechanical ventilation time was significantly prolonged, there was significant difference, while the ICU residence time does not exist significant differences, the P value is 0.059, close to the P value had statistical significance. The postoperative complications, malnutrition group 60 cases, accounting for in 19.4% cases, complications occurred in 34 cases of non malnutrition group, accounting for the total number of cases in group 15.22%, two groups there was no significant difference. After multivariate analysis, found that the age group of malnutrition in children with congenital heart disease, low birth weight, can aggravate the degree of malnutrition. The detailed study of complications the two time, intubation rate and mortality rate of malnutrition group were significantly more than the non malnutrition group, and have statistical significance, other complications between the two groups has no significant difference. Conclusion: congenital heart disease in infants The children in the high proportion of children with malnutrition, malnutrition and the severity of the operative age, low birth weight, malnutrition in children with congenital heart disease after prolonged mechanical ventilation, intubation rate and death rate two times higher than that of non malnourished children, the future need to improve the nutrition evaluation system, develop a complete congenital heart disease and nutritional support the strategy, in order to improve the clinical prognosis. Objective: to analyze the Fuwai Hospital pediatric left coronary artery originated from pulmonary artery (Anomalous Left Coronary Artery From the Pulmonary Artery, ALCAPA) of the early surgical treatment results, and summarize the experience of treatment of this disease early, with prognosis of surgery and changes of cardiac function after clear. Methods: from January 2012 to December 2016 pediatric surgery center of Fuwai Hospital were abnormal origin of left coronary artery surgery were 65 cases, male 37 cases, female 28 cases, collected from Children preoperative heart function index, preoperative general data, intraoperative extracorporeal circulation time, aortic clamp time, whether to give the mitral valve, cardiac function of ultrasound after operation, postoperative left ventricular end diastolic diameter, postoperative ventilation time, ICU stay time, postoperative complications related to all 65 indicators. Patients according to preoperative ejection fraction (EF) of 30% groups, 26 cases of children with EF30%, the remaining 39 cases, the difference between the two groups of related monitoring indicators. Results: a total of 65 cases of patients, including male 37 cases, female 28 cases, age at surgery (median) in December, preoperative weight 8.5Kg (median), preoperative ejection fraction (EF) 44.23 + 22.6%, left ventricular end diastolic diameter was 39.69 + 7.73mm, 121.67 + 56.04min cardiopulmonary bypass time, aortic clamping time (median 67min), 22 cases with mitral regurgitation and tricuspid valve repair two weight, ventilation support time (median 24h). IC U retention time (median 3 days), 2 cases of death, two ECMO assisted intubation in 7 cases, 3 cases of delayed sternal closure in 8 cases, 6 cases of peritoneal dialysis. The ejection fraction with EF 30% as indicators, 26 cases of children with EF30%, the remaining 39 cases, compared two groups before operation. EF30% group of children with age, preoperative weight was less than that of EF = 30% and EF = 30% group, group with preoperative left ventricular end diastolic diameter less than EF30% group, and has statistically significant difference between the two groups. The cardiopulmonary bypass time, aortic clamping time, intraoperative ECMO assistance to cases had no obvious difference, EF = 30% group underwent mitral valvuloplasty significantly more than the number of EF30% group.EF30% group of children with ventilator support time and ICU retention time was more than EF = 30% group, and has statistically significant difference. Compared complication after operation, patients in group EF30% were two times of intubation, peritoneal dialysis, delayed sternal closure number were lower than that in the EF = 30% group, statistically The overall mortality difference. Compared with 2 deaths, were EF30% group, no significant difference between the two groups. The children with their own control, extubation compared with preoperative ejection fraction EF had no obvious difference, and the discharge EF are obviously different. Compared with the preoperative left ventricular end diastolic diameter, pull when the left ventricular end diastolic diameter was significantly less than the preoperative left ventricular end diastolic diameter, left ventricular end diastolic diameter was significantly smaller than the size of preoperative left ventricular end diastolic diameter. Conclusion: the origin of the left coronary artery from the pulmonary artery in children patients with satisfactory results, most patients with cardiac function and mitral regurgitation are will have different degrees of improvement. Poor cardiac function in early postoperative results have obvious effect, ICU time scores of EF30% patients after ejection, ventilator time prolonged, two times of intubation, delayed sternal closure, renal replacement therapy significantly increased the number of dangerous system, It will undergo a longer process of delayed recovery.

【学位授予单位】：北京协和医学院
【学位级别】：博士
【学位授予年份】：2017
【分类号】：R726.5

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