先心合并心衰患儿呼吸支持的选择及需机械通气时镇痛镇静的应用
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摘要
研究背景与研究目的：
先天性心脏病(congenital heart diseases, CHD)是指胎儿时期心脏血管发育异常而致的心血管畸形,是小儿最常见的心脏病。据报道国内的发病率约占活产婴儿的5‰-7‰,我国每年约有15万新生婴儿患有各种类型的先心病。先心病是引起小儿充血性心力衰竭(acute congestive heart failure CHF)最常见的原因。先心合并急性充血性心力衰竭是PICU常见的危重症之一。具有严重心力衰竭以及循环性低氧血症的患儿应给予持续吸氧治疗。传统观点认为经鼻持续气道正压(nasal continuous positive airway pressure NCPAP)可使肺内压力增高,加重右心负荷,对心功能有负面影响。但是近年来越来越多的研究证实NCPAP具有心肺支持作用,可通过降低左室后负荷及改善心肌氧合、减少呼吸功对衰竭心脏具有直接及间接的治疗作用。国外已有研究发现NCPAP应用于充血性心力衰竭的院前急救可显著降低插管率。本研究探讨在先心合并急性充血性心力衰竭中早期应用NCPAP呼吸支持对于急性期症状改善的有效性及预后的影响,同时探索影响NCPAP治疗效果的因素。
随着重症医学的飞速发展,在临床抢救、呼吸支持治疗等领域,机械通气作为重要的生命支持系统应用日益广泛。对于机械通气的危重患儿,在机械通气过程中常因为体位不适、气管内插管、气管内吸痰、气管导管以及各种床边的治疗操作等刺激,引起患儿疼痛及烦躁不安,出现自主呼吸与呼吸机对抗,增加呼吸功和耗氧量,加重病情；而人-机对抗又加重患儿不适,形成恶性循环,影响治疗效果。当患儿出现自主呼吸与呼吸机对抗时,可选用镇静、镇痛药物保持患儿自主呼吸与呼吸机同步。目前国内儿童重症监护病房中镇痛镇静的研究相对滞后。对于镇痛镇静药物合理剂量、使用的安全性、联合用药的方案、机械通气过程中的最佳给药方案等方面仍缺乏数据支持。
本研究通过前瞻性收集2010.10-2012.10山东省立医院PICU住院先天性心脏病合并急性充血性心力衰竭患儿75例病例资料,入院后随机鼻导管吸氧或NCPAP无创呼吸支持,评估早期应用NCPAP治疗对于先心合并急性充血性心力衰竭的有效性及影响NCPAP治疗效果的因素。若入院时或治疗过程中出现进行性呼吸窘迫、血气分析提示Ⅱ型呼吸衰竭或重度Ⅰ型呼吸衰竭、无创呼吸支持无效者,均及时气管插管施予有创机械通气治疗,给予咪达唑仑或咪达唑仑联合芬太尼镇痛镇静。探索先心合并心力衰竭机械通气中应用镇痛镇静的有效性及安全性。
研究方法：
采用描述性资料研究方法,对所有病例进行个案前瞻性资料收集,患儿入院日为起点,出院或死亡为终点。研究因素包括：年龄、性别、先心类型；生命体征：呼吸、心率、收缩压；血气分析指标：PH、动脉氧分压(Pa02)、二氧化碳分压(PaCO2)、乳酸值(Lac),计算氧合指数(PaO2/FiO2);血清学指标：血清氨基末端B型脑钠肽前体(NT-pro BNP)水平；心功能指标：左室射血分数(LVEF)；需要机械通气的比例、机械通气时间、入住PICU的时间和病死率；药物镇静前、用药后30分钟、用药后6小时、停药后30分钟等各个时间点SpO2、PaCO2、PaO2、呼吸、心率、收缩压的水平,达Ramsay3～4分时间(分钟)、停药后苏醒时间(分钟)、咪达唑仑平均用量(ug/kg.h)、机械通气时间、PICU住院天数,最后录入EXCEL建立数据库进行分析。
第一部分：筛选2010.10-2012.10在我院PICU住院的先天性心脏病合并急性充血性心力衰竭患儿75例,排除入院时即发生Ⅱ型呼吸衰竭或重度Ⅰ型呼吸衰竭需机械通气及治疗1d内死亡／放弃、转科的患儿,共60例纳入研究,根据年龄、CHD类型等按照简单随机化分组原则,随机分为早期NCPAP组(n=32)和早期异导管吸氧组(n=28)；从入院开始连续5天使用NCPAP治疗的患儿纳入连续NCPAP组(n=23),连续5天使用鼻导管吸氧的患儿纳入连续鼻导管吸氧组(n=19)；早期组患儿在入院时(Od)、治疗1d时,连续组分别在入院时(Od)、治疗5d时分别取动脉血0.5ml在GEM Premier3000血气分析仪上进行动脉血气分析,测定PH、动脉氧分压(Pa02)、二氧化碳分压(PaCO2)、乳酸值(Lac),计算氧合指数(PaO2/FiO2);取外周血2ml,采用电化学发光免疫分析法,Elecsys(r)2012-电化学发光系统测定血清氨基末端B型脑钠肽前体(NT-pro BNP)水平；同时采用美国Agilent Sonos5500型心脏超声诊断仪,直接测量左室射血分数(L VEF);分别比较患儿治疗前后及治疗后生命体征、动脉血气、血清NT-pro BNP水平及心功能改善情况,以及需要机械通气的比例、机械通气时间、入住PICU的时间和病死率的差异。
第二部分：筛选2010.10-2012.10我院小儿重症医学科(PICU)收治的先天性心脏病合并急性充血性心力衰竭、入院时即发生Ⅱ型呼吸衰竭或重度Ⅰ型呼吸衰竭或经鼻导管吸氧、NCPAP治疗失败存在气管插管有创机械通气指征的患儿共39例,随机分为咪达哗仑组(n=14),咪达唑仑联合芬太尼组(n=15)；所有患儿使用呼吸机通气模式为SIMV (PC)+PS, PRVC、A/C等,并根据患儿病情随时调整。两组患儿均在药物镇静前、用药后30分钟、用药后6小时、停药后30分钟等各个时间点分别取动脉血0.5ml在GEM Premier3000血气分析仪上进行动脉血气分析,测定动脉氧分压(Pa02)、二氧化碳分压(PaCO2);多功能心电监护仪持续监测并记录研究各时点两组患儿的Sp02、呼吸、心率、测定收缩压并记录在EXCEL表格中。镇静效果根据Ramsay镇静深度评分评估,镇静开始后每30分钟评估一次,记录两组患儿达Ramsay3～4分时间(分钟)、停药后苏醒时间(分钟)、咪达唑仑平均用量(ug/kg.h)、机械通气时间、PICU住院天数。
研究结果：
1.一般情况选择2010.10-2012.10我院小儿重症医学科(PICU)收治的、潜在青紫型或青紫型CHD发生急性CHF的患儿60例纳入研究,男：女比例为2.9：1,最大年龄11m,最小年龄1d,入院时无创超声心动图(UCG)确诊室间隔缺损(VSD)10例,动脉导管未闭(PDA)7例,PDA+房间隔缺损(ASD)5例,VSD+ASD4例,VSD+ASD+PDA4例,VSD+右室双出口4例,PDA+二.尖瓣脱垂并中重度反流3例,三房心+无顶冠状静脉窦+ASD2例,完全性大动脉转位(CTGA)+VSD4例,CTGA+PDA3例,完全性肺静脉异位引流(TAPVD)+ASD2例、TAPVD+PDA2例、TAPVD(心上型)+卵圆孔未闭(PFO)1例,心下型右肺静脉异位引流(弯刀综合征)+PDA1例,完全性房室间隔缺损2例,部分型房室间隔缺损2例,主动脉弓离断+VSD+ASD1例,主动脉缩+ASD+VSD+PDA+永存左位上腔静脉1例,三尖瓣下移畸形+VSD1例,左心发育不良综合征1例。
先天性心脏病合并急性充血性心力衰竭行机械通气的患儿39例,其中咪达唑仑组14例,咪达唑仑联合芬太尼组15例；男22例,女17例,最大年龄11月25天,最小年龄21天；入院时无创超声心动图(UCG)确诊室间隔缺损(VSD)9例,动脉导管未闭(PDA)3例,PDA+房间隔缺损(ASD)7例,VSD+ASD5例,VSD+ASD+PDA2例,VSD+右室双出口2例,PDA+二尖瓣脱垂并中重度反流4例,完全性大动脉转位(CTGA)+VSD3例,CTGA+PDA2例,完全性肺静脉异位引流(TAPVD)+ASD1例,主动脉弓离断+VSD+ASD1例。
2.早期NCPAP组与早期鼻导管吸氧组治疗前后及治疗后的比较。
(1)两组患儿治疗前生命体征(呼吸、心率)、动脉血气(PH、PaO2、PaC O2、PaO2/FiO2、Lac)、血清学(NT-pro BNP)及UCG心功能指标(LVEF)差异无明显统计学意义(P>0.05)。
(2)治疗1d后早期NCPAP治疗组呼吸、心率、PaO2、PaO2/FiO2、Lac、N T-pro BNP水平较早期鼻导管吸氧组均有显著性差异(P<0.05)。早期NCPAP治疗组治疗1d后PH、PaCO2、LVEF较早期鼻导管吸氧组无显著性差异(P>0.05)。
(3)早期NCPAP治疗组患儿呼吸、心率、PaO2、PaCO2、PaO2/FiO2、La c、NT-pro BNP在入院后1d较入院时水平差异有统计学意义(P<0.05), PH、L VEF水平较入院时差异无统计学意义(P>0.05)。
(4)早期鼻导管吸氧组患儿呼吸、心率、Pa02在入院后1d较入院时水平差异有统计学意义(P<0.05),PH、PaCO2、PaO2/FiO2、Lac、NT-pro BNP、LVEF较入院时水平差异无统计学意义(P>0.05)。
(5)两组患儿需行气管插管机械通气的比例、机械通气的时间、入住PICU的时间、病死率均存在显著性差异(P<0.05)。
3.持续NCPAP组与持续鼻导管吸氧组治疗前后及治疗后的比较。
(1)两组患儿治疗前生命体征(呼吸、心率)、动脉血气(PH、PaO2、PaC O2、PaO2/FiO2、Lac)、血清学指标(NT-pro BNP)及UCG心功能指标(LVEF)差异无明显统计学意义。
(2)治疗5d后持续NCPAP治疗组呼吸、心率、PH、PaO2、PaO2/FiO2、L ac、NT-pro BNP、LVEF水平较持续鼻导管吸氧组均有显著性差异(P<0.05)。治疗5d后持续NCPAP治疗组PaCO2较持续鼻导管吸氧组无显著性差异(P>0.05)。
(3)治疗5d后持续NCPAP治疗组呼吸、心率、PaO2、PaCO2、PaO2/FiO2、 Lac、NT-pro BNP、LVEF较入院时差异均有统计学意义(P<0.05)；治疗5d时PH差异比较无统计学意义(P>0.05)。
(4)治疗5d后持续鼻导管吸氧组呼吸、心率、PaO2、PaO2/FiO2、Lac较入院时差异有统计学意义(P<0.05)；治疗5d时PH、PaCO2、NT-pro BNP、LV EF差异比较无统计学意义(P>0.05)。
4. NCPAP治疗成功组及失败组患儿生命体征、动脉血气、血清学及UCG心功能的比较
通过对影响NCPAP治疗效果、避免气管插管的多个因素进行单因素分析发现,NCPAP治疗成功组及治疗失败组在入院时呼吸次数、PH、PaCO2、LVEF及治疗6h后PaCO2、PaO2/FiO2水平均存在统计学差异(P<0.05)。
5.咪达唑仑组及咪达唑仑联合芬太尼组患儿镇静前后及镇静后不同时间SpO2、 PaCO2、PaO2、呼吸、心率、收缩压的比较。
(1)两组患儿用药后30分钟、6小时、停药后30min的SpO2、PaCO2、 P aO2与镇静前基础值比较,差异均有统计学意义(P<0.05)；而对应各时点组间指标比较差异无统计学意义(P>0.05)。
(2)两组患儿呼吸、心率在镇静后30分钟、镇静后6h、停药后30分钟均明显低于镇静前,差异有统计学意义(P<0.05)；组间呼吸次数相应各时点比较无统计学差异(P<0.05)；咪达唑仑联合芬太尼组心率在镇静后30分钟、镇静后6h明显低于单用咪达唑仑组,差异有统计学意义(P<0.05)。组内收缩压在镇静后各时间点与镇静前比较以及两组患儿在相应各时间点的组间比较差异均无统计学意义(P>0.05)。
6.两组镇静效果及临床预后情况比较比较
从两组用药后镇静效果中看出,咪达唑仑联合芬太尼组达到满意镇静效果,停药后苏醒时间、咪达唑仑平均用量、PICU住院时间均明显低于单用咪达唑仑组,差异有统计学意义(P<0.05)；而机械通气时间差异无统计学意义(P>0.05)
研究结论：
1.CHD患儿发生急性CHF时,无创NCPAP通气支持可迅速改善急性期症状,减少机械通气时间,降低病死率。
2.血清NT-pro BNP水平较床旁UCG对心功能检测更为敏感。
3.本研究发现影响NCPAP治疗因效果的因素有呼吸次数、PH、PaCO2、 LVEF及治疗6h后、PaCO2、PaO2/FiO2水平。
4.单用咪达唑仑及咪达唑仑联合芬太尼均能起到满意的镇静效果,而联合用量组作用迅速、停药后苏醒时间短,可减少咪达唑仑的用量及PICU的住院时间,并不延长机械通气的时间,对呼吸、心率、血压等无明显影响,是机械通气镇痛镇静的良好组合
Background and objective:
At present, congenital malformation has climbed to the top in the cause of death in domestic infant. However, congenital heart disease (CHD) accounted f or the main component. It will seriously affect the normal growth and develop ment of children. If not promptly treated surgically, it eventually died of recurr ent respiratory tract infections, pulmonary hypertension, or heart failure and los e the best time for treatment. Acute congestive heart failure associated with co ngenital heart disease is one of the most common critically ill in PICU. Childr en associated with congenital heart disease who has serious right heart failure or cyclical hypoxemia should be given continuous oxygen therapy. The traditio nal view is that nasal continuous positive airway pressure (NCPAP) increase ri ght hear load due to increased pulmonary pressure, so NCPAP has a negative i mpact on cardiac function. But in recent years, a growing number of studies h ave confirmed that NCPAP has the cardiopulmonary support function. NCPAP on left ventricular function of the failing heart has a direct and indirect treatm ent.
With the rapid development of critical care medicine, mechanical ventilation as an important life-support systems, has been widely used in the clinical resc ue, respiratory therapy and other aspects. For mechanical ventilation in criticall y ill children, the artificial airway cause pain and discomfort, prone to irritabili ty, restlessness, man-machine confrontation Etc., it is necessary to give appropri ate sedation. At present, the study of analgesia and sedation in the PICU is la gging behind. Dose of sedative and analgesic drugs/security/combination therapy program is still a lack of data.
In this study, we collect clinical data of75cases of acute congestive heart failure children associated with congenital heart disease. We evaluated the effe ctiveness of the early application of NCPAP treatment and factors affecting the NCPAP treatment effect. At the same time, we explored the efficacy and safet y of midazolam combined with fentanyl in the mechanical ventilation of acute congestive heart failure children associated with congenital heart disease.
Methods
The descriptive data study method was used in this clinical study, the data of all the case was collected prospectively. The starting point was that time on which children were admitted to the hospital and the end point death or disch arge. Factors examined included age, gender, type of congenital heart diseases; Vital signs:respiration, heart rate, systolic blood pressure; Blood gas analysis i ndex:PH, artery oxygen points pressure (PaO2), and carbon dioxide points pre ssure (PaCO2), and lactic acid value (Lac), at the same time, we calculate oxy gen collection index (PaO2/FiO2); Serological indexes:serum N-terminal pro-brain natriuretic peptide in type B (NT-pro BNP) level; Cardiac function index:left ventric ular ejection fraction (LVEF).The proportion requiring mechanical ventilation, d uration of mechanical ventilation, stay in PICU time and mortality; SpO2, PaC O2, PaO2, breathing, heart rate, systolic blood pressure level of each time poin t including before sedation,30minutes and6hours after administration, and3Omin after stopping; time of reach Ramsay3to4minutes (minutes), recovery time after stopping (minutes), the average amount of midazolam (ug/kg. h), d uration of mechanical ventilation, PICU length of stay. Eventually, the clinical materials were inputed into EXCEL to establish database for statistical analysis. Part Ⅰ—we collect clinical data of75cases of acute congestive heart failure c hildren associated with congenital heart disease. A total of60patients were inc luded in the study and randomly divided into the early NCPAP group (n=32) a nd early oxygen-Absorbing by Nasal Trachea group (n=28). Children with NCP AP treatment for Continuous5days after admission were grouped into continu ous NCPAP group (n=23); with nasal cannula oxygen for Continuous5days after admission were grouped into the continuous oxygen-Absorbing by Nasal Trachea group (n=19). Early group on admission (0d)/1d and Continuous gr oup on admission (0d)/5d take blood0.5ml to conduct Arterial blood gas analy sis by GEM Premier3000blood gas analyzer. We record pH, partial pressure of arterial oxygen (PaO2), carbon dioxide partial pressure (PaCO2), lactate (La c), calculate the oxygenation index (PaO2/FiO2); we take peripheral blood2ml to determination of serum amino-terminal B-type natriuretic peptide precurso r (NT-pro BNP)levels with Elecsys (r))2012-electrochemiluminescence immunoa ssay. While using the United States Agilent Sonos5500cardiac ultrasound diag nostic apparatus to direct measure of left ventricular ejection fraction (LVEF).W e compared arterial blood gases, serum NT-pro BNP level and improvement of cardiac function, as well as the proportion of requiring mechanical ventilation, duration of mechanical ventilation, stay in the PICU and mortality before and after treatment.
Part Ⅱ—we filter39cases of acute congestive heart failure children associat ed with congenital heart disease who on admission exist type Ⅱ respiratory fail ure or severe type I respiratory failure, has indications of tracheal intubation in vasive for mechanical ventilation. They were randomly divided into midazolam group (n=14), fentanyl and midazolam group (n=15). Ventilator mode were S IMV (PC)+PS, PRVC, A/C, and adjust mode according to condition of Ch ildren. On each time point including before sedation, after treatment for30mi nutes/6hours,30min after discontinuation,two groups of children were taken ar terial blood0.5ml to conduct arterial blood gas analysis by GEM On premier3000blood gas analyzer, determination of arterial oxygen (PaO2), carbon dioxid e partial pressure (PaC02);We continuous monitoring and record SpO2, respirati on, heart rate, systolic blood pressure using Multi-function ECG of two groups at each time point and recorded date in EXCEL form. Sedation effect was a ssessed using The Ramsay Sedation Scale (RSS). Form the start of the sedatio n, assessment was conducted every30minutes. We record the time of reach R amsay3to4(minutes), recovery time after stopping (minutes), the average amo unt of midazolam (ug/kg.h), duration of mechanical ventilation, length of hospit al stay in PICU. The United States Agilent Sonos5500cardiac ultrasound diag nostic equipment was used to measure directly the pulmonary artery pressure b efore treatment.
Results
1.60cases were included in the study, male:female:2.9:1; the maximum age:11m, minimum age:1d.With invasive echocardiography (UCG) on admission, t he number of ventricular septal defect (VSD) was10cases, Patent ductus arter iosus(PDA)7cases, PDA+atrial septal defect(ASD)5cases, VSD+ASD+PDA4cases, VSD+double outlet of right ventricular4cases, PDA+mitral valve prolapse and severe reflux3cases, Triatriatum+unroofed coronary sinus+AS D2cases, Complete transposition of great arteries(CTGA)+VSD4cases, C TGA+PDA3cases, total anomalous pulmonary venous drainage(TAPVD)+ASD2cases, TAPVD+the PDA2cases, TAPVD (supracardiac)+patent fora men ovale (PFO)1cases, scimitar syndrome+PDA1cases, complete atrioventric ular septal defect2cases, partial atrioventricular septal defect2cases, interrupt ed aortic arch+VSD+ASD lcases, aortic contraction+ASD+VSD+PD A+persistent left superior vena cava1cases, Ebstein+VSD lcases, hypopl astic left heart syndrome1cases. The number of analgesic-sedation39cases, i ncluding midazolam group14cases, and midazolam combined with fentanyl gr oup15cases. With invasive echocardiography (UCG) on admission, the number of ventricular septal defect (VSD) was9cases, Patent ductus arteriosus (PDA)3cases. PDA+atrial septal defect(ASD)7cases, VSD+ASD5cases, VSD+A SD+PDA2cases, VSD+double outlet of right ventricular2cases, PDA+mitr al valve prolapse and severe reflux4cases, CTGA+VSD3cases, CTGA+PD A2cases, TAPVD)+ASD1cases, interrupted aortic arch+VSD+ASD1cas es.
2. Comparison between early NCPAP group and early oxygen-Absorbing b y Nasal Trachea group
(1) before treated, the difference of vital signs (respiration, heart rate)/arterial blood gas (PH, PaO2, PaCO2, PaO2/FiO2,Lac)/serological (NT-proBNP) and UCG cardiac function indicators (LVEF) between early NCPAP group and oxygen-Absorbing by Nasal Trachea group had no statistically significant (P>0.05).
(2) After treatment of one day, compared with early oxygen-Absorbing by Nasa1Trachea group, breathing, heart rate, PaO2, PaO2/FiO2, Lac, NT-proBNP1evels of early NCPAP group had a significant difference (P<0.05); pH, Pa CO2, LVEF had no significant difference (P>0.05).
(3) Compared with admission, breathing, heart rate, PaO2, PaO2/FiO2, Lac, Pa CO2, NT-pro BNP of early NCPAP group after treatment of one day had a significant difference (P<0.05); The value of PH, LVEF had no significa nt difference (P>0.05).
(4) Compared with admission, breathing, heart rate, PaO2day of early oxygen-Absorbing by Nasal Trachea group after treatment of one day had a signif icant difference (P<0.05); PH, PaCO2, PaO2/FiO2, Lac, NT-pro BNP,LV EFhad no significant difference (P>0.05).
(5) The proportion of mechanical ventilation, duration of mechanical ventilation, stay at the PICU、mortality between early NCPAP group and early oxyge n-Absorbing by Nasal Trachea group had a significant difference (P<0.05).
3. Comparison between continuous NCPAP group and the continuous oxyge n-Absorbing by Nasal Trachea group
(1) Before treated, the difference of vital signs (respiration, heart rate)、arterial blood gas (PH, PaO2, PaCO2, PaO2/FiO2,Lac)、serological (NT-pro BNP) a nd UCG cardiac function indicators (LVEF) between continuous NCPAP gr oup and the continuous oxygen-Absorbing by Nasal Trachea group had no statistically significant (P>0.05).
(2) After treatment of one day, compared with the continuous oxygen-Absorbin g by Nasal Trachea group, breathing, heart rate, pH, PaO2, PaO2/FiO2, Lac, NT-pro BNP, LVEFof continuous NCPAP group had a significant diffe rence (P<0.05); PaCO2had no significant difference (P>0.05).
(3) Compared with admission, breathing, heart rate, PaO2, PaO2, PaCO2, PaO2/FiO2Lac, NT-pro BNP, LVEFof continuous NCPAP group after treatment o f5day had a significant difference (P<0.05); The value of PH had no si gnificant difference (P>0.05).
(4) Compared with admission, breathing, heart rate, PaO2, PaO2/FiO2, Lac of continuous oxygen-Absorbing by Nasal Trachea group after treatment of5day had a significant difference (P<0.05); pH, PaCO2, NT-pro BNP, LVE Fhad no significant difference (P>0.05).
4. Comparison between the NCPAP success group and failure group Univariate analysis was performed on a number of factors which may affect NCPAP treatment effect, we found that breathing, pH, PaCO2, LVEFon admissionand PaCO2, PaO2/FiO2after treatment for6h had a significant difference (P<0.05)
5. Comparison of SpO2PaCO2, PaO2, breathing, heart rate, systolic blood pressure between midazolam group and midazolam combined with fentanyl group at different time points.
Two groups of children can obtain a satisfactory sedative effect. Compared with pre-sedation, SpO2, PaCO2, PaO2of two groups of children after treatmen t for30minutes/6hours,30min after discontinuation had a significant differenc e.(P<0.05); However, each index between the two groups in the corresponding time point had no significant difference (P>0.05). Compared with pre-sedatio n, breathing, heart rate of two groups after treatment for30minutes/6hours,30mi n after discontinuation had a significant difference.(P<0.05); Breathing between the two groups in the corresponding time point had no significant difference (P >0.05). Compared with the midazolam group, heart rate after treatment for30minu tes/6hours of midazolam combined with fentanyl group was significantly lower, th e difference had a statistically significant (P<0.05).
6. Comparison of Clinical outcomes
Form sedative effect of the two group, we can see that compared with the midazolam group, the time of obtaining a satisfactory sedative effect, recovery time after stopping, the average dose of midazolam, PICU length of stay, pulmo nary artery pressure of midazolam combined with fentanyl group after treatment were lower, the difference had a statistically significant (P<0.05); the time of mechanical ventilation had no significant difference (P>0.05).
Conclusion
(1) The early use of noninvasive NCPAP for eligible patients with acute CHF complicated by CHD seems to improve their prognosis by reducing left ve ntricular and right ventricular afterload and improving the left ventricular f unction.
(2) The monitor and evaluation cardiac function, serum NT-pro BNP level is more sensitive than bedside UCG.
(3) Factors that may affect the success or failure of NCPAP treatment is breat hing frequency, pH, PaCO2, LVEF before treated and P aCO2, PaO2/Fi02after treated for6h.
(4) Two groups of children can obtain a satisfactory sedative effect, compared with the midazolam group, the time of obtaining a satisfactory sedative eff ect, recovery time after stopping, the average dose of midazolam, PICU le ngth of stay, pulmonary artery pressure of midazolam combined with fenta nyl group after treatment were lower, the difference had a statistically signi ficant (P<0.05); Both the two group had no significant effect on respiratio n, heart rate, blood pressure. Sedation with midazolam combined with fenta nyl is a good combination of mechanical ventilation in PICU.
先天性心脏病(congenital heart diseases, CHD)是指胎儿时期心脏血管发育异常而致的心血管畸形,是小儿最常见的心脏病。据报道国内的发病率约占活产婴儿的5‰-7‰,我国每年约有15万新生婴儿患有各种类型的先心病。先心病是引起小儿充血性心力衰竭(acute congestive heart failure CHF)最常见的原因。先心合并急性充血性心力衰竭是PICU常见的危重症之一。具有严重心力衰竭以及循环性低氧血症的患儿应给予持续吸氧治疗。传统观点认为经鼻持续气道正压(nasal continuous positive airway pressure NCPAP)可使肺内压力增高,加重右心负荷,对心功能有负面影响。但是近年来越来越多的研究证实NCPAP具有心肺支持作用,可通过降低左室后负荷及改善心肌氧合、减少呼吸功对衰竭心脏具有直接及间接的治疗作用。国外已有研究发现NCPAP应用于充血性心力衰竭的院前急救可显著降低插管率。本研究探讨在先心合并急性充血性心力衰竭中早期应用NCPAP呼吸支持对于急性期症状改善的有效性及预后的影响,同时探索影响NCPAP治疗效果的因素。
随着重症医学的飞速发展,在临床抢救、呼吸支持治疗等领域,机械通气作为重要的生命支持系统应用日益广泛。对于机械通气的危重患儿,在机械通气过程中常因为体位不适、气管内插管、气管内吸痰、气管导管以及各种床边的治疗操作等刺激,引起患儿疼痛及烦躁不安,出现自主呼吸与呼吸机对抗,增加呼吸功和耗氧量,加重病情；而人-机对抗又加重患儿不适,形成恶性循环,影响治疗效果。当患儿出现自主呼吸与呼吸机对抗时,可选用镇静、镇痛药物保持患儿自主呼吸与呼吸机同步。目前国内儿童重症监护病房中镇痛镇静的研究相对滞后。对于镇痛镇静药物合理剂量、使用的安全性、联合用药的方案、机械通气过程中的最佳给药方案等方面仍缺乏数据支持。
本研究通过前瞻性收集2010.10-2012.10山东省立医院PICU住院先天性心脏病合并急性充血性心力衰竭患儿75例病例资料,入院后随机鼻导管吸氧或NCPAP无创呼吸支持,评估早期应用NCPAP治疗对于先心合并急性充血性心力衰竭的有效性及影响NCPAP治疗效果的因素。若入院时或治疗过程中出现进行性呼吸窘迫、血气分析提示Ⅱ型呼吸衰竭或重度Ⅰ型呼吸衰竭、无创呼吸支持无效者,均及时气管插管施予有创机械通气治疗,给予咪达唑仑或咪达唑仑联合芬太尼镇痛镇静。探索先心合并心力衰竭机械通气中应用镇痛镇静的有效性及安全性。
研究方法：
采用描述性资料研究方法,对所有病例进行个案前瞻性资料收集,患儿入院日为起点,出院或死亡为终点。研究因素包括：年龄、性别、先心类型；生命体征：呼吸、心率、收缩压；血气分析指标：PH、动脉氧分压(Pa02)、二氧化碳分压(PaCO2)、乳酸值(Lac),计算氧合指数(PaO2/FiO2);血清学指标：血清氨基末端B型脑钠肽前体(NT-pro BNP)水平；心功能指标：左室射血分数(LVEF)；需要机械通气的比例、机械通气时间、入住PICU的时间和病死率；药物镇静前、用药后30分钟、用药后6小时、停药后30分钟等各个时间点SpO2、PaCO2、PaO2、呼吸、心率、收缩压的水平,达Ramsay3～4分时间(分钟)、停药后苏醒时间(分钟)、咪达唑仑平均用量(ug/kg.h)、机械通气时间、PICU住院天数,最后录入EXCEL建立数据库进行分析。
第一部分：筛选2010.10-2012.10在我院PICU住院的先天性心脏病合并急性充血性心力衰竭患儿75例,排除入院时即发生Ⅱ型呼吸衰竭或重度Ⅰ型呼吸衰竭需机械通气及治疗1d内死亡／放弃、转科的患儿,共60例纳入研究,根据年龄、CHD类型等按照简单随机化分组原则,随机分为早期NCPAP组(n=32)和早期异导管吸氧组(n=28)；从入院开始连续5天使用NCPAP治疗的患儿纳入连续NCPAP组(n=23),连续5天使用鼻导管吸氧的患儿纳入连续鼻导管吸氧组(n=19)；早期组患儿在入院时(Od)、治疗1d时,连续组分别在入院时(Od)、治疗5d时分别取动脉血0.5ml在GEM Premier3000血气分析仪上进行动脉血气分析,测定PH、动脉氧分压(Pa02)、二氧化碳分压(PaCO2)、乳酸值(Lac),计算氧合指数(PaO2/FiO2);取外周血2ml,采用电化学发光免疫分析法,Elecsys(r)2012-电化学发光系统测定血清氨基末端B型脑钠肽前体(NT-pro BNP)水平；同时采用美国Agilent Sonos5500型心脏超声诊断仪,直接测量左室射血分数(L VEF);分别比较患儿治疗前后及治疗后生命体征、动脉血气、血清NT-pro BNP水平及心功能改善情况,以及需要机械通气的比例、机械通气时间、入住PICU的时间和病死率的差异。
第二部分：筛选2010.10-2012.10我院小儿重症医学科(PICU)收治的先天性心脏病合并急性充血性心力衰竭、入院时即发生Ⅱ型呼吸衰竭或重度Ⅰ型呼吸衰竭或经鼻导管吸氧、NCPAP治疗失败存在气管插管有创机械通气指征的患儿共39例,随机分为咪达哗仑组(n=14),咪达唑仑联合芬太尼组(n=15)；所有患儿使用呼吸机通气模式为SIMV (PC)+PS, PRVC、A/C等,并根据患儿病情随时调整。两组患儿均在药物镇静前、用药后30分钟、用药后6小时、停药后30分钟等各个时间点分别取动脉血0.5ml在GEM Premier3000血气分析仪上进行动脉血气分析,测定动脉氧分压(Pa02)、二氧化碳分压(PaCO2);多功能心电监护仪持续监测并记录研究各时点两组患儿的Sp02、呼吸、心率、测定收缩压并记录在EXCEL表格中。镇静效果根据Ramsay镇静深度评分评估,镇静开始后每30分钟评估一次,记录两组患儿达Ramsay3～4分时间(分钟)、停药后苏醒时间(分钟)、咪达唑仑平均用量(ug/kg.h)、机械通气时间、PICU住院天数。
研究结果：
1.一般情况选择2010.10-2012.10我院小儿重症医学科(PICU)收治的、潜在青紫型或青紫型CHD发生急性CHF的患儿60例纳入研究,男：女比例为2.9：1,最大年龄11m,最小年龄1d,入院时无创超声心动图(UCG)确诊室间隔缺损(VSD)10例,动脉导管未闭(PDA)7例,PDA+房间隔缺损(ASD)5例,VSD+ASD4例,VSD+ASD+PDA4例,VSD+右室双出口4例,PDA+二.尖瓣脱垂并中重度反流3例,三房心+无顶冠状静脉窦+ASD2例,完全性大动脉转位(CTGA)+VSD4例,CTGA+PDA3例,完全性肺静脉异位引流(TAPVD)+ASD2例、TAPVD+PDA2例、TAPVD(心上型)+卵圆孔未闭(PFO)1例,心下型右肺静脉异位引流(弯刀综合征)+PDA1例,完全性房室间隔缺损2例,部分型房室间隔缺损2例,主动脉弓离断+VSD+ASD1例,主动脉缩+ASD+VSD+PDA+永存左位上腔静脉1例,三尖瓣下移畸形+VSD1例,左心发育不良综合征1例。
先天性心脏病合并急性充血性心力衰竭行机械通气的患儿39例,其中咪达唑仑组14例,咪达唑仑联合芬太尼组15例；男22例,女17例,最大年龄11月25天,最小年龄21天；入院时无创超声心动图(UCG)确诊室间隔缺损(VSD)9例,动脉导管未闭(PDA)3例,PDA+房间隔缺损(ASD)7例,VSD+ASD5例,VSD+ASD+PDA2例,VSD+右室双出口2例,PDA+二尖瓣脱垂并中重度反流4例,完全性大动脉转位(CTGA)+VSD3例,CTGA+PDA2例,完全性肺静脉异位引流(TAPVD)+ASD1例,主动脉弓离断+VSD+ASD1例。
2.早期NCPAP组与早期鼻导管吸氧组治疗前后及治疗后的比较。
(1)两组患儿治疗前生命体征(呼吸、心率)、动脉血气(PH、PaO2、PaC O2、PaO2/FiO2、Lac)、血清学(NT-pro BNP)及UCG心功能指标(LVEF)差异无明显统计学意义(P>0.05)。
(2)治疗1d后早期NCPAP治疗组呼吸、心率、PaO2、PaO2/FiO2、Lac、N T-pro BNP水平较早期鼻导管吸氧组均有显著性差异(P<0.05)。早期NCPAP治疗组治疗1d后PH、PaCO2、LVEF较早期鼻导管吸氧组无显著性差异(P>0.05)。
(3)早期NCPAP治疗组患儿呼吸、心率、PaO2、PaCO2、PaO2/FiO2、La c、NT-pro BNP在入院后1d较入院时水平差异有统计学意义(P<0.05), PH、L VEF水平较入院时差异无统计学意义(P>0.05)。
(4)早期鼻导管吸氧组患儿呼吸、心率、Pa02在入院后1d较入院时水平差异有统计学意义(P<0.05),PH、PaCO2、PaO2/FiO2、Lac、NT-pro BNP、LVEF较入院时水平差异无统计学意义(P>0.05)。
(5)两组患儿需行气管插管机械通气的比例、机械通气的时间、入住PICU的时间、病死率均存在显著性差异(P<0.05)。
3.持续NCPAP组与持续鼻导管吸氧组治疗前后及治疗后的比较。
(1)两组患儿治疗前生命体征(呼吸、心率)、动脉血气(PH、PaO2、PaC O2、PaO2/FiO2、Lac)、血清学指标(NT-pro BNP)及UCG心功能指标(LVEF)差异无明显统计学意义。
(2)治疗5d后持续NCPAP治疗组呼吸、心率、PH、PaO2、PaO2/FiO2、L ac、NT-pro BNP、LVEF水平较持续鼻导管吸氧组均有显著性差异(P<0.05)。治疗5d后持续NCPAP治疗组PaCO2较持续鼻导管吸氧组无显著性差异(P>0.05)。
(3)治疗5d后持续NCPAP治疗组呼吸、心率、PaO2、PaCO2、PaO2/FiO2、 Lac、NT-pro BNP、LVEF较入院时差异均有统计学意义(P<0.05)；治疗5d时PH差异比较无统计学意义(P>0.05)。
(4)治疗5d后持续鼻导管吸氧组呼吸、心率、PaO2、PaO2/FiO2、Lac较入院时差异有统计学意义(P<0.05)；治疗5d时PH、PaCO2、NT-pro BNP、LV EF差异比较无统计学意义(P>0.05)。
4. NCPAP治疗成功组及失败组患儿生命体征、动脉血气、血清学及UCG心功能的比较
通过对影响NCPAP治疗效果、避免气管插管的多个因素进行单因素分析发现,NCPAP治疗成功组及治疗失败组在入院时呼吸次数、PH、PaCO2、LVEF及治疗6h后PaCO2、PaO2/FiO2水平均存在统计学差异(P<0.05)。
5.咪达唑仑组及咪达唑仑联合芬太尼组患儿镇静前后及镇静后不同时间SpO2、 PaCO2、PaO2、呼吸、心率、收缩压的比较。
(1)两组患儿用药后30分钟、6小时、停药后30min的SpO2、PaCO2、 P aO2与镇静前基础值比较,差异均有统计学意义(P<0.05)；而对应各时点组间指标比较差异无统计学意义(P>0.05)。
(2)两组患儿呼吸、心率在镇静后30分钟、镇静后6h、停药后30分钟均明显低于镇静前,差异有统计学意义(P<0.05)；组间呼吸次数相应各时点比较无统计学差异(P<0.05)；咪达唑仑联合芬太尼组心率在镇静后30分钟、镇静后6h明显低于单用咪达唑仑组,差异有统计学意义(P<0.05)。组内收缩压在镇静后各时间点与镇静前比较以及两组患儿在相应各时间点的组间比较差异均无统计学意义(P>0.05)。
6.两组镇静效果及临床预后情况比较比较
从两组用药后镇静效果中看出,咪达唑仑联合芬太尼组达到满意镇静效果,停药后苏醒时间、咪达唑仑平均用量、PICU住院时间均明显低于单用咪达唑仑组,差异有统计学意义(P<0.05)；而机械通气时间差异无统计学意义(P>0.05)
研究结论：
1.CHD患儿发生急性CHF时,无创NCPAP通气支持可迅速改善急性期症状,减少机械通气时间,降低病死率。
2.血清NT-pro BNP水平较床旁UCG对心功能检测更为敏感。
3.本研究发现影响NCPAP治疗因效果的因素有呼吸次数、PH、PaCO2、 LVEF及治疗6h后、PaCO2、PaO2/FiO2水平。
4.单用咪达唑仑及咪达唑仑联合芬太尼均能起到满意的镇静效果,而联合用量组作用迅速、停药后苏醒时间短,可减少咪达唑仑的用量及PICU的住院时间,并不延长机械通气的时间,对呼吸、心率、血压等无明显影响,是机械通气镇痛镇静的良好组合
Background and objective:
At present, congenital malformation has climbed to the top in the cause of death in domestic infant. However, congenital heart disease (CHD) accounted f or the main component. It will seriously affect the normal growth and develop ment of children. If not promptly treated surgically, it eventually died of recurr ent respiratory tract infections, pulmonary hypertension, or heart failure and los e the best time for treatment. Acute congestive heart failure associated with co ngenital heart disease is one of the most common critically ill in PICU. Childr en associated with congenital heart disease who has serious right heart failure or cyclical hypoxemia should be given continuous oxygen therapy. The traditio nal view is that nasal continuous positive airway pressure (NCPAP) increase ri ght hear load due to increased pulmonary pressure, so NCPAP has a negative i mpact on cardiac function. But in recent years, a growing number of studies h ave confirmed that NCPAP has the cardiopulmonary support function. NCPAP on left ventricular function of the failing heart has a direct and indirect treatm ent.
With the rapid development of critical care medicine, mechanical ventilation as an important life-support systems, has been widely used in the clinical resc ue, respiratory therapy and other aspects. For mechanical ventilation in criticall y ill children, the artificial airway cause pain and discomfort, prone to irritabili ty, restlessness, man-machine confrontation Etc., it is necessary to give appropri ate sedation. At present, the study of analgesia and sedation in the PICU is la gging behind. Dose of sedative and analgesic drugs/security/combination therapy program is still a lack of data.
In this study, we collect clinical data of75cases of acute congestive heart failure children associated with congenital heart disease. We evaluated the effe ctiveness of the early application of NCPAP treatment and factors affecting the NCPAP treatment effect. At the same time, we explored the efficacy and safet y of midazolam combined with fentanyl in the mechanical ventilation of acute congestive heart failure children associated with congenital heart disease.
Methods
The descriptive data study method was used in this clinical study, the data of all the case was collected prospectively. The starting point was that time on which children were admitted to the hospital and the end point death or disch arge. Factors examined included age, gender, type of congenital heart diseases; Vital signs:respiration, heart rate, systolic blood pressure; Blood gas analysis i ndex:PH, artery oxygen points pressure (PaO2), and carbon dioxide points pre ssure (PaCO2), and lactic acid value (Lac), at the same time, we calculate oxy gen collection index (PaO2/FiO2); Serological indexes:serum N-terminal pro-brain natriuretic peptide in type B (NT-pro BNP) level; Cardiac function index:left ventric ular ejection fraction (LVEF).The proportion requiring mechanical ventilation, d uration of mechanical ventilation, stay in PICU time and mortality; SpO2, PaC O2, PaO2, breathing, heart rate, systolic blood pressure level of each time poin t including before sedation,30minutes and6hours after administration, and3Omin after stopping; time of reach Ramsay3to4minutes (minutes), recovery time after stopping (minutes), the average amount of midazolam (ug/kg. h), d uration of mechanical ventilation, PICU length of stay. Eventually, the clinical materials were inputed into EXCEL to establish database for statistical analysis. Part Ⅰ—we collect clinical data of75cases of acute congestive heart failure c hildren associated with congenital heart disease. A total of60patients were inc luded in the study and randomly divided into the early NCPAP group (n=32) a nd early oxygen-Absorbing by Nasal Trachea group (n=28). Children with NCP AP treatment for Continuous5days after admission were grouped into continu ous NCPAP group (n=23); with nasal cannula oxygen for Continuous5days after admission were grouped into the continuous oxygen-Absorbing by Nasal Trachea group (n=19). Early group on admission (0d)/1d and Continuous gr oup on admission (0d)/5d take blood0.5ml to conduct Arterial blood gas analy sis by GEM Premier3000blood gas analyzer. We record pH, partial pressure of arterial oxygen (PaO2), carbon dioxide partial pressure (PaCO2), lactate (La c), calculate the oxygenation index (PaO2/FiO2); we take peripheral blood2ml to determination of serum amino-terminal B-type natriuretic peptide precurso r (NT-pro BNP)levels with Elecsys (r))2012-electrochemiluminescence immunoa ssay. While using the United States Agilent Sonos5500cardiac ultrasound diag nostic apparatus to direct measure of left ventricular ejection fraction (LVEF).W e compared arterial blood gases, serum NT-pro BNP level and improvement of cardiac function, as well as the proportion of requiring mechanical ventilation, duration of mechanical ventilation, stay in the PICU and mortality before and after treatment.
Part Ⅱ—we filter39cases of acute congestive heart failure children associat ed with congenital heart disease who on admission exist type Ⅱ respiratory fail ure or severe type I respiratory failure, has indications of tracheal intubation in vasive for mechanical ventilation. They were randomly divided into midazolam group (n=14), fentanyl and midazolam group (n=15). Ventilator mode were S IMV (PC)+PS, PRVC, A/C, and adjust mode according to condition of Ch ildren. On each time point including before sedation, after treatment for30mi nutes/6hours,30min after discontinuation,two groups of children were taken ar terial blood0.5ml to conduct arterial blood gas analysis by GEM On premier3000blood gas analyzer, determination of arterial oxygen (PaO2), carbon dioxid e partial pressure (PaC02);We continuous monitoring and record SpO2, respirati on, heart rate, systolic blood pressure using Multi-function ECG of two groups at each time point and recorded date in EXCEL form. Sedation effect was a ssessed using The Ramsay Sedation Scale (RSS). Form the start of the sedatio n, assessment was conducted every30minutes. We record the time of reach R amsay3to4(minutes), recovery time after stopping (minutes), the average amo unt of midazolam (ug/kg.h), duration of mechanical ventilation, length of hospit al stay in PICU. The United States Agilent Sonos5500cardiac ultrasound diag nostic equipment was used to measure directly the pulmonary artery pressure b efore treatment.
Results
1.60cases were included in the study, male:female:2.9:1; the maximum age:11m, minimum age:1d.With invasive echocardiography (UCG) on admission, t he number of ventricular septal defect (VSD) was10cases, Patent ductus arter iosus(PDA)7cases, PDA+atrial septal defect(ASD)5cases, VSD+ASD+PDA4cases, VSD+double outlet of right ventricular4cases, PDA+mitral valve prolapse and severe reflux3cases, Triatriatum+unroofed coronary sinus+AS D2cases, Complete transposition of great arteries(CTGA)+VSD4cases, C TGA+PDA3cases, total anomalous pulmonary venous drainage(TAPVD)+ASD2cases, TAPVD+the PDA2cases, TAPVD (supracardiac)+patent fora men ovale (PFO)1cases, scimitar syndrome+PDA1cases, complete atrioventric ular septal defect2cases, partial atrioventricular septal defect2cases, interrupt ed aortic arch+VSD+ASD lcases, aortic contraction+ASD+VSD+PD A+persistent left superior vena cava1cases, Ebstein+VSD lcases, hypopl astic left heart syndrome1cases. The number of analgesic-sedation39cases, i ncluding midazolam group14cases, and midazolam combined with fentanyl gr oup15cases. With invasive echocardiography (UCG) on admission, the number of ventricular septal defect (VSD) was9cases, Patent ductus arteriosus (PDA)3cases. PDA+atrial septal defect(ASD)7cases, VSD+ASD5cases, VSD+A SD+PDA2cases, VSD+double outlet of right ventricular2cases, PDA+mitr al valve prolapse and severe reflux4cases, CTGA+VSD3cases, CTGA+PD A2cases, TAPVD)+ASD1cases, interrupted aortic arch+VSD+ASD1cas es.
2. Comparison between early NCPAP group and early oxygen-Absorbing b y Nasal Trachea group
(1) before treated, the difference of vital signs (respiration, heart rate)/arterial blood gas (PH, PaO2, PaCO2, PaO2/FiO2,Lac)/serological (NT-proBNP) and UCG cardiac function indicators (LVEF) between early NCPAP group and oxygen-Absorbing by Nasal Trachea group had no statistically significant (P>0.05).
(2) After treatment of one day, compared with early oxygen-Absorbing by Nasa1Trachea group, breathing, heart rate, PaO2, PaO2/FiO2, Lac, NT-proBNP1evels of early NCPAP group had a significant difference (P<0.05); pH, Pa CO2, LVEF had no significant difference (P>0.05).
(3) Compared with admission, breathing, heart rate, PaO2, PaO2/FiO2, Lac, Pa CO2, NT-pro BNP of early NCPAP group after treatment of one day had a significant difference (P<0.05); The value of PH, LVEF had no significa nt difference (P>0.05).
(4) Compared with admission, breathing, heart rate, PaO2day of early oxygen-Absorbing by Nasal Trachea group after treatment of one day had a signif icant difference (P<0.05); PH, PaCO2, PaO2/FiO2, Lac, NT-pro BNP,LV EFhad no significant difference (P>0.05).
(5) The proportion of mechanical ventilation, duration of mechanical ventilation, stay at the PICU、mortality between early NCPAP group and early oxyge n-Absorbing by Nasal Trachea group had a significant difference (P<0.05).
3. Comparison between continuous NCPAP group and the continuous oxyge n-Absorbing by Nasal Trachea group
(1) Before treated, the difference of vital signs (respiration, heart rate)、arterial blood gas (PH, PaO2, PaCO2, PaO2/FiO2,Lac)、serological (NT-pro BNP) a nd UCG cardiac function indicators (LVEF) between continuous NCPAP gr oup and the continuous oxygen-Absorbing by Nasal Trachea group had no statistically significant (P>0.05).
(2) After treatment of one day, compared with the continuous oxygen-Absorbin g by Nasal Trachea group, breathing, heart rate, pH, PaO2, PaO2/FiO2, Lac, NT-pro BNP, LVEFof continuous NCPAP group had a significant diffe rence (P<0.05); PaCO2had no significant difference (P>0.05).
(3) Compared with admission, breathing, heart rate, PaO2, PaO2, PaCO2, PaO2/FiO2Lac, NT-pro BNP, LVEFof continuous NCPAP group after treatment o f5day had a significant difference (P<0.05); The value of PH had no si gnificant difference (P>0.05).
(4) Compared with admission, breathing, heart rate, PaO2, PaO2/FiO2, Lac of continuous oxygen-Absorbing by Nasal Trachea group after treatment of5day had a significant difference (P<0.05); pH, PaCO2, NT-pro BNP, LVE Fhad no significant difference (P>0.05).
4. Comparison between the NCPAP success group and failure group Univariate analysis was performed on a number of factors which may affect NCPAP treatment effect, we found that breathing, pH, PaCO2, LVEFon admissionand PaCO2, PaO2/FiO2after treatment for6h had a significant difference (P<0.05)
5. Comparison of SpO2PaCO2, PaO2, breathing, heart rate, systolic blood pressure between midazolam group and midazolam combined with fentanyl group at different time points.
Two groups of children can obtain a satisfactory sedative effect. Compared with pre-sedation, SpO2, PaCO2, PaO2of two groups of children after treatmen t for30minutes/6hours,30min after discontinuation had a significant differenc e.(P<0.05); However, each index between the two groups in the corresponding time point had no significant difference (P>0.05). Compared with pre-sedatio n, breathing, heart rate of two groups after treatment for30minutes/6hours,30mi n after discontinuation had a significant difference.(P<0.05); Breathing between the two groups in the corresponding time point had no significant difference (P >0.05). Compared with the midazolam group, heart rate after treatment for30minu tes/6hours of midazolam combined with fentanyl group was significantly lower, th e difference had a statistically significant (P<0.05).
6. Comparison of Clinical outcomes
Form sedative effect of the two group, we can see that compared with the midazolam group, the time of obtaining a satisfactory sedative effect, recovery time after stopping, the average dose of midazolam, PICU length of stay, pulmo nary artery pressure of midazolam combined with fentanyl group after treatment were lower, the difference had a statistically significant (P<0.05); the time of mechanical ventilation had no significant difference (P>0.05).
Conclusion
(1) The early use of noninvasive NCPAP for eligible patients with acute CHF complicated by CHD seems to improve their prognosis by reducing left ve ntricular and right ventricular afterload and improving the left ventricular f unction.
(2) The monitor and evaluation cardiac function, serum NT-pro BNP level is more sensitive than bedside UCG.
(3) Factors that may affect the success or failure of NCPAP treatment is breat hing frequency, pH, PaCO2, LVEF before treated and P aCO2, PaO2/Fi02after treated for6h.
(4) Two groups of children can obtain a satisfactory sedative effect, compared with the midazolam group, the time of obtaining a satisfactory sedative eff ect, recovery time after stopping, the average dose of midazolam, PICU le ngth of stay, pulmonary artery pressure of midazolam combined with fenta nyl group after treatment were lower, the difference had a statistically signi ficant (P<0.05); Both the two group had no significant effect on respiratio n, heart rate, blood pressure. Sedation with midazolam combined with fenta nyl is a good combination of mechanical ventilation in PICU.
引文
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[4]Dib J E, Matin S A, Luckert A. Prehospital use of continuous positive airway pressure for acute severe congestive heart failure [J]. The Journal of emergency medicine,2012,42(5):553-558.
[5]Executive summary of the guidelines on the diagnosis and treatment of acute heart failure. (2005) The task force on acute heart failure of the European society of cardiology. Eur Heart J26:384-416
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[7]诸福棠.实用儿科学.人民卫生出版社,2005：1510-1524.
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[2]Task Force for Diagnosis and Treatment of Acute and Chronic Heart Failure 2008 of European Society of Cardiology, Dick stein K, Cohen-Solal A, Filippatos G, McMurray JJ, Ponikowski P, Poole-Wilson PA, Stromberg A, van Veldhuisen DJ, Atar D,Hoes AW, Keren A, Mebazaa A, Nieminen M, Priori SG, et al. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2008:the Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2008 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association of the ESC (HFA) and endorsed by the European Society of Intensive Care Medicine (ESICM). Eur Heart J 2008; 29:2388-442.
[3]郭小玲,付四毛,冯华俊.经鼻持续气道正压治疗婴儿左向右分流先天性心脏病并心力衰竭的前瞻性研究[J].中国临床实用医学,2010(002)：21-22.
[4]Dib J E, Matin S A, Luckert A. Prehospital use of continuous positive airway pressure for acute severe congestive heart failure [J]. The Journal of emergency medicine,2012,42(5):553-558.
[5]Executive summary of the guidelines on the diagnosis and treatment of acute heart failure. (2005) The task force on acute heart failure of the European society of cardiology. Eur Heart J26:384-416
[6]Pieters T H, Amy J J, Burrini D, et al. Normal pregnancy in primary alveolar hypoventilation treated with nocturnal nasal intermittent positive pressure ventilation [J]. European Respiratory Journal,1995,8(8):1424-1427.
[7]诸福棠.实用儿科学.人民卫生出版社,2005：1510-1524.
[8]J. Masip, A.J. Betbese, J. Paez et al.Non-invasive pressure support ventilation versus conventional oxygen therapy in acute cardiogenic pulmonary oedema:a randomized trial Lancet,356 (2000), pp.2126-2132
[9]P.K. Plant, J.L. Owen, M.W. Elliott Early use of non-invasive ventilation for acute exacerbations of chronic obstructive pulmonary disease on general respiratory wards:a multi-centre randomized controlled trial Lancet,355 (2000), pp.1931-1935
[10]Wang C. Early use of non-invasive positive pressure ventilation for acute exacerbations of chronic obstructive pulmonary disease:A multicentre randomized controlled trial [J]. Chin Med J (Engl),2005,118(24):2034-40.
[11]J. Masip, A.J. Betbese, J. Paez et al.Non-invasive pressure support ventilation versus conventional oxygen therapy in acute cardiogenic pulmonary oedema:a randomized trial Lancet,356 (2000), pp.2126-2132
[12]郭小玲,付四毛,冯华俊.经鼻持续气道正压治疗婴儿左向右分流先天性心脏病并心力衰竭的前瞻性研究[J].中国临床实用医学,2010(002)：21-22.
[13]Winck J C, Azevedo L F, Costa-Pereira A, et al. Efficacy and safety of non-invasive ventilation in the treatment of acute cardiogenic pulmonary edema—a systematic review and meta-analysis [J]. Crit Care,2006,10(2):R69.
[14]Collins SP, Mielniczuk LM, Whittingham HA, Boseley ME, Schramm DR, Storrow AB (2006) The use of noninvasive ventilation in emergency department patients with acute cardiogenic pulmonary edema:a systematic review. Ann Emerg Med 48:260-269
[15]Guarracino F, Ambrosino N. Non invasive ventilation in cardio-surgical patients [J]. Minerva Anestesiol,2011,77(7):734-741.
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