婴幼儿复杂先天性心脏病术后机械通气时间延长的危险因素分析
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摘要
目的探讨婴幼儿复杂先天性心脏病术后机械通气时间延长(prolonged mechanical ventilation,PMV)的危险因素。方法回顾性分析2016年1月至2017年12月北京安贞医院小儿心外科收治的150例复杂先天性心脏病患儿,男80例,女70例,年龄≤6个月,RACHS-1分级≥3级。收集患儿一般资料、相关病史、手术类型、术前合并症及治疗情况、术中心肺转流(cardiopulmonary bypass, CPB)时间、深低温及血气指标;术后延迟关胸、放置起搏器情况;术后24 h内最低OI、最高正性肌力药剂量评分值(VIS评分)、拔管失败及术后并发症情况。采用Logistic回归模型分析婴幼儿复杂先天性心脏病术后PMV的危险因素。结果 42例(28%)患儿存在术后PMV。单因素分析显示,年龄、体重、RACHS-1分级、既往紫绀、既往肺炎、急诊手术、术前机械通气支持、术前射血分数(ejection fraction, EF)、深低温、CPB时间>132 min、术中最低pH、术中最高血糖浓度高、术中最高乳酸浓度高、延迟关胸、应用起搏器、术后24 h内最高VIS评分和最低OI及术后并发症是婴幼儿复杂先天性心脏病术后PMV的危险因素(P<0.05)。多因素Logistic回归分析显示,CPB时间>132 min(OR=11.04,95%CI 2.07～58.96,P=0.005),术中最高乳酸浓度过高(OR=1.53,95%CI 1.07～2.20,P=0.021)和拔管失败(OR=17.28,95%CI 2.46～121.20,P=0.004)是婴幼儿复杂先天性心脏病术后PMV的独立危险因素。结论 CPB时间>132 min、术中最高乳酸浓度过高和拔管失败可作为预测婴幼儿复杂先天性心脏病术后PMV的危险因素。
Objective To investigate the risk factors for postoperative prolonged mechanical ventilation in neonates and young infants with complicated congenital heart disease. Methods A retrospective analysis of 150 children(80 males and 70 females, aged ≤ 6 months, RACHS-1 grade ≥ 3) with complex congenital heart disease who were admitted to Children's Heart Surgery Department of Anzhen Hospital from January 2016 to December 2017 was conducted. These data were collected: the demographic data, history of cardicvascular-related diseases, type of surgery, preoperative complications, CPB, CPB time, deep hypothermia, blood gas index, delayed chest closure(DCC), pacemaker; minimum oxygenation index in the first 24 h after operation, maximum vasoactive-inotropic score(VIS), failed extubation and postoperative complications. Logistic regression model was used to analyze the risk factors of prolonged mechanical ventilation within neonates and young infants after complicated congenital heart surgery. Results Forty-two patients(28%) required PMV with mechanical ventilation ≥ 72 h. Univariate analysis showed age, weight, RACHS-1 grade, previous history of cyanosis, history of pneumonia, emergency surgery, preoperative mechanical ventilation, preoperative EF, deep hypothermia, CPB time > 132 min, intraoperative minmum pH value, intraoperative maximum blood glucose and lactic acid concentrations, DCC, application of pacemakers, maximum VIS within 24 h after surgery, minimal OI and postoperative complications may be the risk factors of prolonged postoperative mechanical ventilation in neonates and young infants with complicated congenital heart disease(P < 0.05). Multivariate Logistic regression analysis showed that the CPB time >132 min(OR = 11.04, 95% CI 2.07-58.96, P = 0.005), intraoperative maximum lactate(OR = 1.53, 95% CI 1.07-2.20, P = 0.021) and failed extubation(OR = 17.28, 95% CI 2.46-121.20, P = 0.004) were independent risk factors for prolonged postoperative mechanical ventilation in neonates and young infauts with complicated congenital heart disease. Conclusion CPB time >132 min, intraoperative maximum lactic acid concentration and failure of extubation can be used as predictors of prolonged postoperative mechanical ventilation in neonates and young infants with complicated congenital heart disease.
Objective To investigate the risk factors for postoperative prolonged mechanical ventilation in neonates and young infants with complicated congenital heart disease. Methods A retrospective analysis of 150 children(80 males and 70 females, aged ≤ 6 months, RACHS-1 grade ≥ 3) with complex congenital heart disease who were admitted to Children's Heart Surgery Department of Anzhen Hospital from January 2016 to December 2017 was conducted. These data were collected: the demographic data, history of cardicvascular-related diseases, type of surgery, preoperative complications, CPB, CPB time, deep hypothermia, blood gas index, delayed chest closure(DCC), pacemaker; minimum oxygenation index in the first 24 h after operation, maximum vasoactive-inotropic score(VIS), failed extubation and postoperative complications. Logistic regression model was used to analyze the risk factors of prolonged mechanical ventilation within neonates and young infants after complicated congenital heart surgery. Results Forty-two patients(28%) required PMV with mechanical ventilation ≥ 72 h. Univariate analysis showed age, weight, RACHS-1 grade, previous history of cyanosis, history of pneumonia, emergency surgery, preoperative mechanical ventilation, preoperative EF, deep hypothermia, CPB time > 132 min, intraoperative minmum pH value, intraoperative maximum blood glucose and lactic acid concentrations, DCC, application of pacemakers, maximum VIS within 24 h after surgery, minimal OI and postoperative complications may be the risk factors of prolonged postoperative mechanical ventilation in neonates and young infants with complicated congenital heart disease(P < 0.05). Multivariate Logistic regression analysis showed that the CPB time >132 min(OR = 11.04, 95% CI 2.07-58.96, P = 0.005), intraoperative maximum lactate(OR = 1.53, 95% CI 1.07-2.20, P = 0.021) and failed extubation(OR = 17.28, 95% CI 2.46-121.20, P = 0.004) were independent risk factors for prolonged postoperative mechanical ventilation in neonates and young infauts with complicated congenital heart disease. Conclusion CPB time >132 min, intraoperative maximum lactic acid concentration and failure of extubation can be used as predictors of prolonged postoperative mechanical ventilation in neonates and young infants with complicated congenital heart disease.
引文
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[8] Li S, Zhang Y, Li S, et al. Risk factors associated with prolonged mechanical ventilation after corrective surgery for tetralogy of Fallot. Congenit Heart Dis, 2015, 10(3):254-262.
[9] O’Connor E, Fraser JF. The interpretation of perioperative lactate abnormalities in patients undergoing cardiac surgery. Anaesth Intensive Care, 2012, 40(4):598-603.
[10] Shu Q, Shi SS, Zhang XH, et al. Risk factors of failed extubation after open-heart surgery in infants. World J Pediatr, 2005, 1(1):69-72.
[11] Hoskote A, Cohen G, Goldman A, et al. Tracheostomy in infants and children after cardiothoracic surgery: Indications, associated risk factors, and timing. J Thorac Cardiovasc Surg, 2005, 130(4):1086-1093.
[12] Marwali EM, Budiwardhana N, Sastroasmoro S, et al. Prediction model for length of intubation with assisted mechanical ventilation in pediatric heart surgery. Intensive Care Med, 2013, 16(3):74-82.
[13] Roodpeyma S, Hekmat M, Dordkhar M, et al. A prospective observational study of paediatric cardiac surgery outcomes in a postoperative intensive care unit in Iran. J Pak Med Assoc, 2013, 63(1):55-59.
[14] Mittnacht AJ, Thanjan M, Srivastava S, et al. Extubation in the operating room after congenital heart surgery in children. J Thorac Cardiovasc Surg, 2008, 136(1):88-93.
[15] Polito A, Patorno E, Costello JM, et al. Perioperative factors associated with prolonged mechanical ventilation after complex congenital heart surgery. Pediatr Crit Care Med, 2011, 12(3):e122-e126.
[2] Kanter RK, Bove EL, Tobin JR, et al. Prolonged mechanical ventilation of infants after open heart surgery. Crit Care Med, 1986, 14(3):211-214.
[3] Newburger JW, Wypij D, Bellinger DC, et al. Length of stay after infant heart surgery is related to cognitive outcome at age 8 years. J Pediatr, 2003, 143(1):67-73.
[4] Beamer S, Ferns S, Edwards L, et al. Early extubation in pediatric heart surgery across a spectrum of case complexity: Impact on hospital length of stay and chest tube days. Prog Pediatr Cardiol, 2017, 45:63-68.
[5] Jenkins KJ, Gauvreau K, Newburger JW, et al. Consensus-based method for risk adjustment for surgery for congenital heart disease. J Thorac Cardiovasc Surg, 2002, 123(1):110-118.
[6] Székely A, Sápi E, Király L, et al. Intraoperative and postoperative risk factors for prolonged mechanical ventilation after pediatric cardiac surgery. Paediatr Anaesth, 2006, 16(11):1166-1175.
[7] Gaies MG, Jeffries HE, Niebler RA, et al. Vasoactive-inotropic score is associated with outcome after infant cardiac surgery: an analysis from the Pediatric Cardiac Critical Care Consortium and Virtual PICU System Registries. Pediatr Crit Care Med, 2014, 15(6):529-537.
[8] Li S, Zhang Y, Li S, et al. Risk factors associated with prolonged mechanical ventilation after corrective surgery for tetralogy of Fallot. Congenit Heart Dis, 2015, 10(3):254-262.
[9] O’Connor E, Fraser JF. The interpretation of perioperative lactate abnormalities in patients undergoing cardiac surgery. Anaesth Intensive Care, 2012, 40(4):598-603.
[10] Shu Q, Shi SS, Zhang XH, et al. Risk factors of failed extubation after open-heart surgery in infants. World J Pediatr, 2005, 1(1):69-72.
[11] Hoskote A, Cohen G, Goldman A, et al. Tracheostomy in infants and children after cardiothoracic surgery: Indications, associated risk factors, and timing. J Thorac Cardiovasc Surg, 2005, 130(4):1086-1093.
[12] Marwali EM, Budiwardhana N, Sastroasmoro S, et al. Prediction model for length of intubation with assisted mechanical ventilation in pediatric heart surgery. Intensive Care Med, 2013, 16(3):74-82.
[13] Roodpeyma S, Hekmat M, Dordkhar M, et al. A prospective observational study of paediatric cardiac surgery outcomes in a postoperative intensive care unit in Iran. J Pak Med Assoc, 2013, 63(1):55-59.
[14] Mittnacht AJ, Thanjan M, Srivastava S, et al. Extubation in the operating room after congenital heart surgery in children. J Thorac Cardiovasc Surg, 2008, 136(1):88-93.
[15] Polito A, Patorno E, Costello JM, et al. Perioperative factors associated with prolonged mechanical ventilation after complex congenital heart surgery. Pediatr Crit Care Med, 2011, 12(3):e122-e126.