婴幼儿左向右分流型先天性心脏病合并重症肺炎的体外循环管理
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摘要
目的:探讨婴幼儿左向右分流型先天性心脏病合并重症肺炎的体外循环管理方法。方法:回顾性分析2013年5月至2017年6月我院收治的78例左向右分流型先天性心脏病合并重症肺炎患儿的临床资料,患者均接受急诊或亚急诊手术。术中应用浅低温、进口膜肺进行体外循环,经主动脉根部顺行灌注康斯特保护液(HTK液)进行心肌保护,术中应用常规超滤联合改良超滤技术。结果:体外循环时间为45~68 min,平均(50.24±12.45)min,主动脉阻断时间为10~60 min,平均(23.56±10.68)min。心脏自动复跳76例(97%)。转流结束后改良超滤时间为8~15 min,平均(10.45±3.24)min。术后死亡3例(3.8%)。结论:婴幼儿左向右分流型先天性心脏病合并重症肺炎常危及患儿生命,早期手术可获得理想的治疗效果。体外循环采用常规超滤联合改良超滤技术、合适的膜式氧合器、精确的预充及血液稀释、良好的心肌保护等措施是提高手术成功率的重要保障。
Objective:To explore the extracorporeal circulation(ECC)management for infants with left-to-right shunt congenital heart disease complicated by severe pneumonia. Methods:A total of 78 in-patients with left-to-right shunt congenital heart disease complicated by severe pneumonia from May2013 to June 2017 were retrospectively analysed.All the patients received emergency or sub-emergency cardiac operations.The operations were performed with mild hypothermic extracorporeal circulation.Imported oxygenator and ultrafilter were used in all patients.The anterograde perfusion of histidinetryptophan-ketoglutarate solution through aortic root was applied for myocardial protection.Conventional and modified ultrafiltration were applied in all cases. Results:The cardiopulmonary bypass time was 45~68(50.24±12.45)min.The aorta crossclamping time was 10~60(23.56±10.68) min.Seventy-six patients had spontaneous cardiac resuscitation(97%). The modified ultrafiltration time was 8~15(10.45±3.24)min.Three cases died after operation(3.8%).Conclusions:Infants with left-to-right shunt congenital heart disease complicated by severe pneumonia are often life-threatening.Emergency or sub-emergency cardiac operations were effective for most of these patients.Combined conventional ultrafiltration with modified ultrafiltration,suitable oxygenation,reasonable priming perfusion and hemodilution,and excellent myocardial protection are important guarantees for improving success rate of operation.
Objective:To explore the extracorporeal circulation(ECC)management for infants with left-to-right shunt congenital heart disease complicated by severe pneumonia. Methods:A total of 78 in-patients with left-to-right shunt congenital heart disease complicated by severe pneumonia from May2013 to June 2017 were retrospectively analysed.All the patients received emergency or sub-emergency cardiac operations.The operations were performed with mild hypothermic extracorporeal circulation.Imported oxygenator and ultrafilter were used in all patients.The anterograde perfusion of histidinetryptophan-ketoglutarate solution through aortic root was applied for myocardial protection.Conventional and modified ultrafiltration were applied in all cases. Results:The cardiopulmonary bypass time was 45~68(50.24±12.45)min.The aorta crossclamping time was 10~60(23.56±10.68) min.Seventy-six patients had spontaneous cardiac resuscitation(97%). The modified ultrafiltration time was 8~15(10.45±3.24)min.Three cases died after operation(3.8%).Conclusions:Infants with left-to-right shunt congenital heart disease complicated by severe pneumonia are often life-threatening.Emergency or sub-emergency cardiac operations were effective for most of these patients.Combined conventional ultrafiltration with modified ultrafiltration,suitable oxygenation,reasonable priming perfusion and hemodilution,and excellent myocardial protection are important guarantees for improving success rate of operation.
引文
[1]郑景浩,刘玉洁.新生儿危重先天性心脏病急症治疗进展[J].中华临床医师杂志(电子版),2013,7(13):5719-5720.
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[5]Young RW.Prevention of lung injury in cardiac surgery:a review[J].J Extra Corpor Technol,2014,46(2):130-141.
[6]段大为,杨景学.婴幼儿体外循环的特殊性[J].中华胸心血管外科杂志,2001,17(3):185-187.
[7]Sever K,Tansel T,Basaran M,et al.The benefits of continuous ultrafiltration in pediatric cardiac surgery[J].Scand Cardiovasc J,2004,38(5):307-311.
[8]王洪斌,任新英,安勇,等.常规超滤结合改良超滤在婴儿体外循环中的应用[J].心肺血管病杂志,2009,28(5):363.
[9]王葵亮,曹倩,泮思林,等.低预充体外循环方法对低体重婴幼儿心脏手术影响的初步研究[J].中国体外循环杂志,2017,15(04):193-195.
[10]马兰,王加利,张涛,等.10公斤以下婴幼儿心脏直视术的体外循环管理[J].中国体外循环杂志,2015,13(2):105-107.
[11]Wedgwood S,Mcmullan DM,Bekker JM,et al.Role for endothelin-1-induced superoxide and peroxynitrite production in rebound pulmonary hypertension associated with inhaled nitric oxide therapy[J].Circ Res,2001,89(4):357-364.
[12]Lin YZ,Huang JB,Li XW,et al.Clinical comparative analysis of histidine-tryptophan-ketoglutarate solution and St.Thomas crystalloid cardioplegia:a 12-year study from a single institution[J].Exp Ther Med,2017,14(3):2677-2682.
[2]韩喆,王建明.婴幼儿室间隔缺损合并重症肺炎的外科治疗[J].中国胸心血管外科临床杂志,2016,23(11):1066-1069.
[3]李玖军,刘春峰,袁壮,等.婴幼儿先天性心脏病合并重症肺炎的治疗[J].中国当代儿科杂志,2009,11(8):635-637.
[4]包敏,潘广玉,刘晨,等.复杂重症先天性心脏病婴幼儿合并肺部感染的手术治疗[J].中华外科杂志,2014,52(7):489-496.
[5]Young RW.Prevention of lung injury in cardiac surgery:a review[J].J Extra Corpor Technol,2014,46(2):130-141.
[6]段大为,杨景学.婴幼儿体外循环的特殊性[J].中华胸心血管外科杂志,2001,17(3):185-187.
[7]Sever K,Tansel T,Basaran M,et al.The benefits of continuous ultrafiltration in pediatric cardiac surgery[J].Scand Cardiovasc J,2004,38(5):307-311.
[8]王洪斌,任新英,安勇,等.常规超滤结合改良超滤在婴儿体外循环中的应用[J].心肺血管病杂志,2009,28(5):363.
[9]王葵亮,曹倩,泮思林,等.低预充体外循环方法对低体重婴幼儿心脏手术影响的初步研究[J].中国体外循环杂志,2017,15(04):193-195.
[10]马兰,王加利,张涛,等.10公斤以下婴幼儿心脏直视术的体外循环管理[J].中国体外循环杂志,2015,13(2):105-107.
[11]Wedgwood S,Mcmullan DM,Bekker JM,et al.Role for endothelin-1-induced superoxide and peroxynitrite production in rebound pulmonary hypertension associated with inhaled nitric oxide therapy[J].Circ Res,2001,89(4):357-364.
[12]Lin YZ,Huang JB,Li XW,et al.Clinical comparative analysis of histidine-tryptophan-ketoglutarate solution and St.Thomas crystalloid cardioplegia:a 12-year study from a single institution[J].Exp Ther Med,2017,14(3):2677-2682.