6月龄以下危重婴儿室间隔缺损手术治疗的近期预后分析

发布时间：2018-02-13 00:45

本文关键词： 室间隔缺损危重病外科手术治疗预后　出处：《安徽医科大学》2014年硕士论文　论文类型：学位论文

【摘要】：目的 1.探讨影响6月龄以下危重婴儿室间隔缺损手术治疗近期预后的相关危险因素； 2.针对性地强化术前病情评估、外科操作技术、体外循环和心肌保护、术后监护等措施； 3.减少术后并发症的发生和提高手术的效果；方法回顾性分析2009.1-2011.12间161例小婴儿（≤6月）室间隔缺损急或亚急诊手术治疗近期预后的情况，其中，男83例，女78例，年龄（4.1±1.3）月，体重（5.5±1.1）kg，有中度及以上肺动脉高压148例。部分患儿合并ASD或功能性单心房、PDA、COA、中度以上的二尖瓣返流、无顶冠状静脉窦等。术前均有持续或反复肺炎、心功能不全史，经儿内科、PICU等反复治疗63例，部分术前需呼吸机辅助，治疗好转或无效时直接转入心外科手术，其中1例持续到外科手术时。均采用气管插管静脉复合麻醉、膜式氧合器和改良超滤、浅或中低温转流，其中4例联合深低温/停循环。室间隔缺损用心包补片间断（或连续）修补，同时处理合并的其它畸形，如结扎PDA、修补ASD、二或三尖瓣整形、纠治CoA、扩大肺动脉等；酌情放置左或右房和肺动脉测压管、临时起博导线。术后呼吸机支持，常规应用多巴胺、米力农，必要时加异丙肾上腺素、硝酸甘油等。术后存活156例。其中出现严重并发症27例，包括持续低心排3例、恶性室性早博、心跳骤停、再次气管插管、败血症等各1例,再开胸探查止血2例、大量气胸4例、呼吸道感染（同时痰培养有致病菌生长）16例，均经及时处理治愈。死亡5例，直接原因是严重低心排、肺出血、多器官功能衰竭等。根据治疗过程和结果，将患儿分为预后好和预后差二组。后者包括术后死亡和严重并发症者，如低心排、恶性心律失常、心脏停搏、再次气管插管、需清创的切口或纵隔感染，胸腔引流量多和时间长（≥5天）、正性肌力药物评分（inotrope score;IS）＞20、血液和或痰培养有致病菌生长、急性肾功能不全需腹膜或血透析、再次开胸探查、ALT和或AST500U／L、CICU监护时间＞4天、中等量以上气胸、胸腔积液和乳糜胸等。根据上述描述，进入预后好组97例、预后差组60例。将手术时的年龄、体重、有无心内合并畸形和气管狭窄、术前感染情况、肺动脉高压程度、转流和主动脉阻断时间、室间隔缺损直径、呼吸机支持时间、胸引量、正性肌力药物评分（inotropescore;IS）、监护时间等因素进行统计学分析，再把分布不同的可能因素纳入多因素非条件Logistic回归模型中进行分析，最后筛选出影响预后的危险因素。结果本组研究的161例人数中，死亡5例，死亡率3.1%。单因素分析结果显示：体重、呼吸机支持时间、胸引量、心内合并的其他畸形、肺动脉高压程度、有无气管狭窄只在单因素分析中有差异。多因素Logistic逐步回归分析而转流和主动脉阻断时间、IS、监护时间在单、多因素分析中均有不同，P值分别是0.000-0.001、0.000-0.042，差异有统计学意义。结论转流时间长、主动脉阻断时间长、IS高、监护时间长是影响手术治疗近期预后的主要危险因素。监护时间是一个间接的危险因素，是患儿病情的综合体现。影响小婴儿室间隔缺损急或亚急诊手术治疗近期预后的可能危险因素很多，，术前完备的评估病情、术中满意的矫治畸形、术后有力的生命支持、并发症的及时发现和处理都是十分必要的。
[Abstract]:objective
1. to investigate the risk factors related to the short-term prognosis of critical infant ventricular septal defect under the influence of 6 month old.
2. to strengthen the preoperative assessment, surgical technique, cardiopulmonary bypass and myocardial protection, and postoperative monitoring.
3. to reduce the incidence of postoperative complications and to improve the effect of the operation.
Method
A retrospective analysis of 161 cases of infant 2009.1-2011.12 (up to June) of ventricular septal defect or sub acute emergency surgical treatment prognosis, among them, male 83 cases, female 78 cases, age (4.1 + 1.3), weight (5.5 + 1.1) kg, moderate and above of 148 patients with pulmonary hypertension. Patients with ASD or functional single atrium, PDA, COA, moderate mitral regurgitation, unroofed coronary sinus. All patients have persistent or recurrent pneumonia, heart failure history, the Department of Pediatrics, PICU repeated treatment in 63 cases, partial preoperative ventilator treatment required, or invalid directly into the heart surgery, including 1 cases of surgery. To adopt tracheal intubation intravenous anesthesia, membrane oxygenator and modified ultrafiltration in low temperature, shallow or bypass, among which 4 cases were combined with deep hypothermic circulatory arrest. Heart / VSD patch (intermittent or continuous) repair, at the same time to deal with the It is such as deformity, ligation of PDA, repair ASD, two or three tricuspid valve surgery, correction of CoA, expansion of pulmonary artery; appropriate placement of left or right atrial and pulmonary artery catheter, temporary pacemaker wire. Ventilator support after operation, the routine application of dopamine, milrinone, if necessary with isoproterenol, nitroglycerin. Postoperative survival in 156 cases. Among them 27 cases had severe complications, including persistent low cardiac output in 3 cases, malignant ventricular premature beat, cardiac arrest, re intubation, sepsis and other 1 cases, 2 cases of open thoracotomy bleeding, 4 cases of massive pneumothorax, respiratory tract infection (and sputum culture of pathogenic bacteria) 16 patients were cured after timely treatment. 5 cases of death, is the direct cause of severe low cardiac, pulmonary hemorrhage, multiple organ failure. According to the treatment process and results, the patients were divided into two groups of good prognosis and poor prognosis. The latter include postoperative death and serious complications, such as low cardiac output, malignant arrhythmia Often, cardiac arrest, re intubation, need debridement or incision infection of mediastinum, chest drainage and long time (5 days), inotrope score (inotrope score; IS, 20), and the blood or sputum culture of pathogenic bacteria, acute renal insufficiency to peritoneal or blood dialysis, re thoracotomy, and ALT or AST500U / L, CICU monitoring time more than 4 days, moderate pneumothorax, pleural effusion and chylothorax. According to the above description, into the good prognosis group of 97 cases, 60 cases of poor prognosis group. The age at the time of surgery, weight, heart malformation and tracheal stenosis, preoperative infection, pulmonary hypertension, bypass and aortic clamping time, diameter of VSD, ventilator time, chest drainage volume, inotrope score (inotropescore; IS), monitoring time and other factors were analyzed, then the distribution of different factors in multiple factors The conditional Logistic regression model was analyzed and the risk factors affecting the prognosis were selected.
Result
The number of this group of 161 cases, 5 cases died, the mortality rate of 3.1%. single factor analysis results showed that: weight, duration of mechanical ventilation, chest, heart and other associated malformations, the degree of pulmonary hypertension, with tracheal stenosis only in univariate analysis there are differences. Multivariate Logistic regression analysis and flow and aortic clamp time, IS, monitoring time in single and multi factor analysis were different, the P value is 0.000-0.001,0.000-0.042 respectively, the difference was statistically significant.
conclusion
Bypass time, aortic clamping time, high IS, long time monitoring is a major risk of surgical treatment prognosis factors. The monitoring time is an indirect risk factor, is a comprehensive reflection of children with the disease. Many risk factors that might influence the infant acute ventricular septal defect or subemergency surgical treatment prognosis complete, preoperative assessment of the disease, patients with deformity, strong life support after operation, complications timely detection and treatment are necessary.

【学位授予单位】：安徽医科大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R726.5

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