先天性心脏病肺炎合并心力衰竭患儿雾化硝普钠临床疗效观察

发布时间：2018-07-24 18:45

【摘要】：目的：目前国内婴幼儿死因中,先天性畸形己上升至首位,而先天性心脏病（congenital heart diseases,CHD）又占主要成分，严重影响患儿的正常生长发育,若不及时行手术治疗,就会因反复呼吸道感染、肺动脉高压或心力衰竭而失去治疗的最佳时机。而先心病患儿肺炎合并心衰是儿科重症监护病房（PICU）中最常见的危重症之一。在先心病肺炎合并心衰的发病机制中，肺动脉高压早已得到肯定，目前尚无有效降低肺动脉高压的药物应用于临床。硝普钠是常用的血管扩张药物和外源性一氧化氮供体，在应用其雾化吸入方面,国外的学者进行动物试验比较多。本文通过观察分析本院80例肺炎合并心衰的先天性心脏病患儿硝普钠雾化治疗后临床体征、肱动脉血压及CRP数值变化程度来进一步评估雾化硝普钠的疗效及其对体循环动脉压的影响，为其临床应用提供新的途径和理论依据。方法：以2010年3月-2011年12月期间，我院儿科病房收治的先心病肺炎合并心衰患儿80例为研究对象，入选标准为符合小儿心力衰竭诊断标准的先天性心脏病肺炎患儿，入院后均经心脏彩超证实患有先天性心脏病合并肺动脉高压：肺动脉收缩压（PASP）30mmHg(4Kpa)或肺动脉平均压（PAMP）20mmHg(2.67Kpa)。其中男42例，女38例；年龄2月～6月37例，6月～1岁26例，1～2岁17例。先天性心脏病类型：单纯房间隔缺损（ASD）及单纯室间隔缺损(VSD)41例，房间隔缺损合并室间隔缺损23例，动脉导管未闭（PDA）10例，法洛四联症（TOF）6例。80例患儿入院前均未接受任何特殊治疗，入院后将其随机分为两组，即常规治疗组（n=40例）和硝普钠雾化组（n=40例），两组之间年龄、性别、先心病类型及肺动脉压力之间均无显著差异，具有可比性，常规治疗组给予镇静、吸氧、强心、利尿、改善循环、抗感染等常规治疗，硝普钠雾化组即在常规治疗的基础上加用硝普钠雾化吸入（生理盐水2ml+硝普钠5mg/次2-3次/日）。由同一测量人员使用同一听诊器、秒表及标尺测定患儿自入院第一日至出院日的呼吸、心律及肝脏触诊大小，每天测量数次，记录其数值及恢复至正常水平（即小于诊断标准中各指标的水平）所需的时间。并由同一专业人员使用同一台式水银血压计测量患儿雾化硝普钠前、中、后的肱动脉血压水平，为便于表示取其平均动脉压即舒张压+1/3脉压差表示，记录其值大小。两组患儿自入院第一日起每日一次指端采血，测其CRP数值并记录（以CRP8mg/L为异常），检测时间为晨起7-9点。所有数据用SPSS13.0统计软件进行统计学处理，并进行方差齐性及正态分布的检验，结果用均数±标准差（X±S）表示，两组间均数的比较采用t检验，两组以上的比较采用多个均数比较的方差分析，P0.05表示差异有统计学意义。结果：常规治疗组40例患儿，，呼吸频率快持续时间为（44.29±5.17）h，心率快持续时间为（50.00±6.96）h，硝普钠雾化组40例患儿，其值分别为（24.56±5.14）h和（32.60±4.67）h，两组分别比较均有显著差异（P0.01）,提示雾化硝普钠可有效降低患儿的呼吸频率及心率。所观察测量的另一个指标肝脏触诊肿大持续时间，常规治疗组40例为（40.21±7.56）h，硝普钠雾化组40例为（44.13±8.36）h，两组之间比较有显著性差异（P0.05），此结果提示雾化硝普钠对肿大肝脏的回缩亦有促进作用。硝普钠雾化组40例患儿中，平均肱动脉压雾化前为（64.35±3.08）mmHg,开始雾化后5min为（64.48±3.37）mmHg,停雾化后5min为（64.55±3.97）mmHg，三组之间比较无显著性差异（P0.05），即硝普钠雾化吸入对体循环动脉平均压影响不大。常规治疗组CRP数值高持续时间为（7.60±1.25）天，硝普钠雾化组为（7.44±1.21）天，两组比较无显著差异（P0.05）,提示硝普钠雾化治疗对肺炎的感染过程无明显影响。结论： 1硝普钠雾化可有效降低先心病肺炎心衰患儿的呼吸频率。 2硝普钠雾化可有效降低先心病肺炎心衰患儿的心率。 3硝普钠雾化对先心病肺炎心衰患儿肿大肝脏的回缩起促进作用。 4硝普钠雾化降肺动脉压力的同时不影响体循环平均动脉压，安全性高。 5硝普钠雾化对先心病肺炎心衰患儿的肺炎感染过程无影响。因此，先天性心脏病肺炎合并心力衰竭患儿的治疗决策中，可在常规治疗的基础上加用硝普钠的雾化，这对早期缓解患儿心力衰竭症状有明确的疗效，且操作方便，安全性高。
[Abstract]:Objective: in the current cause of infant death, congenital malformation has risen to the first, and congenital heart diseases (CHD) is the main component, which seriously affects the normal growth and development of the children. If no surgical treatment is performed in time, the best treatment will be lost due to recurrent respiratory infection, pulmonary hypertension or heart failure. Pneumonia combined with heart failure in children with congenital heart disease is one of the most common critical diseases in the pediatric intensive care unit (PICU). In the pathogenesis of heart failure with congenital heart disease, pulmonary hypertension has long been affirmed. At present, there is no effective drug to reduce pulmonary hypertension. The source of nitric oxide donor, in the application of atomization inhalation, the foreign scholars conducted more animal tests. In this paper, the clinical signs, the brachial artery blood pressure and the CRP value changes were observed and analyzed to evaluate the efficacy of the nebulized sodium nitroprusside in 80 children with congenital heart disease with heart failure in our hospital. And its effect on systemic circulation arterial pressure, and provide a new way and theoretical basis for its clinical application.
Methods: 80 children with congenital heart disease and heart failure treated in the pediatric ward of our hospital from March 2010 -2011 to December were selected as the children with congenital heart disease pneumonia in accordance with the diagnostic criteria of children's heart failure. All patients were confirmed to have congenital heart disease with pulmonary artery hypertension after admission. Systolic pressure (PASP) 30mmHg (4Kpa) or mean pulmonary artery pressure (PAMP) 20mmHg (2.67Kpa). Among them, there were 42 males and 38 females, 37 cases of age from February to June, 26 cases from June to 1 years, 17 cases of 1~2 years, and 41 cases of atrial septal defect (ASD) and simple ventricular septal defect (VSD), 23 cases of atrial septal defect combined with ventricular septal defect, and patent ductus arteriosus closure. PDA) 10 cases, 6 cases of tetralogy of Fallot (TOF) had not received any special treatment before admission. After admission, they were randomly divided into two groups, namely, the routine treatment group (n=40) and sodium nitroprusside atomization group (n=40). There was no significant difference between the two groups between the age, sex, the type of congenital heart disease and the pulmonary artery pressure, which was comparable in the routine treatment group. Sedative, oxygen inhalation, cardio, diuresis, improvement of circulation, anti infection and other routine treatment, sodium nitroprusside atomization inhalation with sodium nitroprusside (2ml+ sodium nitroprusside 5mg/ times 2-3 times per day) on the basis of conventional treatment. The same surveyor used the same stethoscope, stopwatch and scale to determine the respiratory rate of the children from the first day to the discharge day. The law and the size of the liver palpation were measured several times a day, and the time needed to record its value and restore to the normal level (that is, the level below the diagnostic criteria). And the same professional mercury sphygmomanometer was used to measure the blood pressure level of the brachial artery before and after atomization of sodium nitroprusside, in order to facilitate the mean arterial pressure. The diastolic pressure +1/3 pulse pressure difference was expressed and recorded the value of the value. Two groups of children from the first day from admission to the first day of blood sampling, measured its CRP value and recorded (with CRP8mg/L as abnormality), the detection time was 7-9 in the morning. All data were statistically processed with SPSS13.0 statistical software, and the test of homogeneity of variance and normal distribution, the results were all used The number of standard deviations (X + S) indicated that the comparison of the average number between the two groups was compared with the t test, and the comparison of the two groups was compared with the analysis of the variance of multiple mean numbers, and the difference was statistically significant in P0.05.
Results: 40 children in the routine treatment group, the fast duration of respiratory frequency was (44.29 + 5.17) h, the fast duration of heart rate was (50 + 6.96) H and 40 cases of sodium nitroprusside group were (24.56 + 5.14) H and (32.60 + 4.67) h respectively, and there were significant differences (P0.01) in the two groups respectively (P0.01), suggesting that nebulized sodium nitroprusside could effectively reduce the respiratory rate of children. And heart rate. Another indicator of measurement of liver palpation and swelling duration, 40 cases (40.21 + 7.56) h in the conventional treatment group and 40 cases (44.13 + 8.36) h in the sodium nitroprusside group (44.13 + 8.36) h, there was a significant difference between the two groups (P0.05). The results suggested that the atomization of sodium nitroprusside could also promote the retracting of the large liver. The sodium nitroprusside atomization group had 40 children. The average brachial artery nebulization was (64.35 + 3.08) mmHg before atomization, and 5min was (64.48 + 3.37) mmHg after atomization, and 5min was (64.55 + 3.97) mmHg after atomization. There was no significant difference between the three groups (P0.05), that is, the mean pressure of the body circulatory artery was not significant with the atomization inhalation of sodium nitroprusside. The high duration of CRP values in the routine treatment group was (7.60 + 1.25) days. Sodium prusside atomization group was (7.44 + 1.21) days, there was no significant difference between the two groups (P0.05), suggesting that atomization treatment with sodium nitroprusside did not significantly affect the infection process of pneumonia.
Conclusion:
1 sodium nitroprusside atomization can effectively reduce the respiratory rate of children with CHF.
2 sodium nitroprusside atomization can effectively reduce the heart rate of children with CHF.
3 sodium nitroprusside atomization promotes the enlargement of liver in children with congenital heart disease and pneumonia with heart failure.
4 nitroprusside atomization reduces pulmonary artery pressure without affecting the mean arterial pressure of systemic circulation.
5 sodium nitroprusside atomization has no effect on pneumonia infection in children with congenital heart disease and pneumonia.
Therefore, in the treatment decision of children with congenital heart disease pneumonia and heart failure, the atomization of sodium nitroprusside can be added on the basis of conventional treatment. It has a clear effect on early relieving the symptoms of heart failure in children, and it is easy to operate and has high safety.
【学位授予单位】：河北医科大学
【学位级别】：硕士
【学位授予年份】：2012
【分类号】：R725.4

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