婴儿期体外循环术后床边紧急再开胸手术11例

目的总结婴儿期体外循环术后床边紧急再开胸手术经验及教训,以减少心脏术后2次开胸的发生率。方法回顾性分析婴儿心内直视手术365例,其中行监护病房床边紧急再次开胸手术11例,发生率3.12%。室间隔缺损并重度肺动脉高压2例,法洛四联症2例,完全性肺静脉异位引流(心上型)3例,完全性房室管畸形1例,重度肺动脉狭窄1例,右心室双出口1例,大动脉转位1例。体外循环时间53～240min,主动脉阻断时间30～130min。两次手术间隔3～60h,平均16h。结果再开胸的原因:活动性出血2例;广泛性渗血5例;心脏压塞2例;心包填塞1例;心肌收缩无力1例。床边紧急再开胸手术后,死亡1例,继发脑损害1例,败血症1例。结论采取缩短体外循环时间;术中有效的止血及必要地扩大纵隔容积;术后引流管的负压吸引;术后早期充分镇静条件下的气道护理等措施,可减少2次开胸的发生率。遇到:①怀疑心脏填塞;②出血不止,引流量多;③心搏骤停等严重情况或经药物治疗无效时,应紧急开胸手术抢救,任何犹豫与延误,将失去对患者的抢救机会。虽然是紧急手术,仍必须注意无菌操作。

11 case report of emergent re-operation after cardiopulmonary bypass in infants

Objectives To review the experience of emergent re-operation after cardiopulmonary bypass(CPB)in infants, with respect to lessen the occurrence rate of reoperation. Methods 365 cases of CPB in infants during the period of January 1999 to December 2005 were retrospectively analyzed. Among them,there were 11 cases of secondary bedside open-chest emergent surgery after CPB in ICU. Occurrence rate being 3.12%. The species of patients includes: 2 cases of VSD with severe pulmonary hypertension; 2 cases of T0F; 3 cases of TAPVC (Supracardic type); 1 case of CAVC; 1 case of PA; 1 case of DORV; 1 case of TGA. Time of extracorporal circulation was 53 to 240 min; Aortic crass clamping was 30 to 130 min. Time to secondary surgery was 3 h to 60 h, with mean time being 16h. Results The causes of reoperation were:2 cases of hemostasis; 5 cases of coagulopathy; 2 cases of cardiac tamponade; 1 case of pericardial tamponade; 1 case of low output. After re-operation, 1 case died; 1 case with brain damage;1 case with sapraemia. Conclusions The following measures could be taken to lessen the re-operation:Shortening CPB time; effective hemostasis and enlarging of interpleural space during open heart surgery; postoperative suction of drainage tube; early postoperative airway nursing with sufficient sedation. While coming across severe situations like cardiac tamponade suspicious, bleeding unstoppable and excessive drainage, and cadiac arrest etc, should open-chest emergent exploration, any hesitation and delay will lost the chance of salvation. The conception of asepsis should still be regarded anytime.