小儿先天性心脏病体外循环术后毛细血管渗漏综合征的影响因素

目的探讨小儿先天性心脏病体外循环术后发生毛细血管渗漏综合征(capillary leak syndrome，CLS)的相关影响因素,为预防和控制CLS的发生提供依据。 方法收集2004 01—2005 12重庆医科大学附属儿童医院310例先天性心脏病体外循环(CPB)术后患儿的临床资料，对可能引起CLS发生的因素进行单因素分析和多元Logistic逐步回归分析，确定出与CLS发病相关的独立影响因素。 结果体外循环术后CLS的发生率为16.78%，病死率为19.23%。多元Logistic回归分析显示体外循环时间、心脏畸形的种类(单纯型/复杂型)、CPB术中最低温度、年龄是CLS发生的独立影响因素。 结论患儿的体外循环时间、心脏畸形的种类、术中最低温度、年龄是CLS发生的独立影响因素。     

七氟醚用于紫绀型心脏病患儿全麻诱导的临床观察

目的：研究探讨七氟醚用于紫绀型心脏病患儿全麻诱导的安全性及可行性。方法：对象选自先天性心脏病患儿紫绀型组（A组）20例,非紫绀型心脏病（B组）20例,面罩密闭自主吸入8%浓度的七氟醚。记录睫毛反射消失的时间,记录BIS达到45±10时间,以及诱导前（T1）,睫毛反射消失时（T2）,插管即刻（T3）和插管后5分钟（T4）时BP、HR和SPO2的变化。结果及结论：七氟烷能安全地应用于紫绀型的先天性心脏病患者,但是诱导时间明显长于非紫绀型心脏病组。     

妊娠合并心脏病并发心力衰竭的危险因素分析

目的探讨合并心脏病的孕产妇发生心力衰竭的危险因素。方法回顾分析于河南省新乡医学院第一附属医院接受治疗的344例合并心脏病的孕产妇的临床资料,发生心力衰竭的61例患者作为观察组,同期未发生心力衰竭的258例患者作为对照组。给予发生心力衰竭的孕产妇急救治疗,并分别采用单因素、多因素Logistic回归法分析合并心脏病孕产妇并发心力衰竭的危险因素。结果基础心率100次/min、先天性心脏病、围生期心肌病、风湿性心脏病、PAP50 mm Hg、年龄≥35岁、孕前发生心脏事件、早孕期心功能分级≥Ⅱ级是心脏病孕产妇发生心力衰竭的独立危险因素(P0.05),而孕前咨询和产前检查≥6次是其保护性因素(P0.05)。结论合并心脏病孕产妇并发心力衰竭受多种因素影响,在临床中应对危险因素干预或规避,并帮助患者积极实现保护性因素,从而降低心力衰竭的发生率。     

儿童重症腺病毒肺炎危险因素分析

目的 探讨儿童重症腺病毒肺炎的危险因素。方法 收集229例腺病毒肺炎患儿的临床资料并分为重症腺病毒肺炎组及非重症腺病毒肺炎组,对资料进行Logistic回归分析。结果 重症腺病毒肺炎患儿79例,占34.5％,非重症腺病毒肺炎150例,占65.5％;其中春季患病率最高,占38.4％;秋季患病率最低,占12.2％。多因素Logistic回归模型分析显示,营养性贫血（OR=30.565）和免疫功能低下（OR=24.495）增加儿童患重症腺病毒肺炎的风险。结论 营养性贫血和免疫功能低下是儿童重症腺病毒肺炎的危险因素,及时添加辅食,加强儿童营养的调理,增强其免疫力,可减少重症腺病毒肺炎的发生。     

神经管缺陷相关危险因素的病例对照研究

目的:探讨神经管缺陷(NTDs)发生的危险因素,为进一步采取干预措施提供科学依据.方法:采用1∶1配比的病例对照研究,对157例NTDs患儿的母亲和157例非患儿的母亲进行回顾性调查,并将结果进行Logistic回归分析.结果:多因素Logistic回归分析显示,孕产妇年龄(OR=2.850)、流产史(OR=1.453)、接触职业危险因素(OR =3.120)、流感(OR=2.272)及丈夫吸烟(OR=2.072)可能是NTDs发病的危险因素;孕前及孕早期服用叶酸(OR =0.237)为NTDs的保护因素.结论:孕产妇年龄、流产史、接触职业危险因素、流感和丈夫吸烟可能使NTDs发生的危险性增加.     

腹主动脉球囊阻断在不同植入程度凶险性前置胎盘剖宫产中的应用效果

目的:研究腹主动脉球囊阻断术在不同植入程度凶险性前置胎盘(PPP)剖宫产中的应用效果。方法:选取2014年3月至2016年3月在山东省立医院产科行手术治疗的PPP伴植入患者115例。其中伴穿透性植入者60例(深植入组),非穿透性植入者55例(浅植入组)。根据是否行腹主动脉球囊阻断术,将两组再各分为阻断组和非阻断组。回顾分析患者的术中出血量、输血量、手术时间、子宫切除、膀胱损伤及新生儿窒息情况,以及腹主动脉球囊阻断的术中和术后并发症。结果:深植入阻断组的术中出血量中位数为1000ml,较非阻断组(2000ml)明显减少(P0.05);浅植入患者阻断组与非阻断组的术中出血量比较,差异无统计学意义(400ml vs 350ml,P0.05)。深植入阻断组的子宫切除率[7%(3/41)]低于非阻断组[37%(7/19)],差异有统计学意义(P0.05);浅植入组均无切除子宫者。深浅植入患者中,阻断组和非阻断组的膀胱损伤率、手术时间、新生儿窒息情况比较,差异均无统计学意义。64例腹主动脉球囊阻断术中发生导管打折1例,股动脉血栓20例,下肢深静脉血栓2例,术后穿刺点渗血2例,股动脉-股静脉瘘1例。结论:腹主动脉球囊阻断术可明显减少PPP伴穿透性植入患者的术中出血、降低子宫切除率,但对非穿透性植入的应用效果不佳。腹主动脉球囊阻断术后可发生较严重的并发症,应严格掌握其适应证。     

舒适护理在小儿先天性心脏病手术中的应用

目的：探讨先天性心脏病患儿进行舒适护理的价值。方法将48例先天性心脏病封堵手术的患儿随机分为观察组和对照组各24例。对照组只进行普通常规护理,观察组在常规护理的基础上进行舒适护理,比较两组患儿术后并发症和平均住院时间。结果经过舒适护理干预后,观察组发生术后并发症人数比对照组少,差异有统计学意义（P＜0．05）。观察组住院时间为（5．38±1．77）d,低于对照组（6．94±2．04）d,差异有统计学意义（P＜0．05）。结论对小儿先天性心脏病手术患者采取舒适护理,患儿能实现舒适治疗的效果,降低并发症,缩短住院时间。     

儿童高热惊厥的危险因素及预后分析

目的分析儿童高热惊厥的危险因素与预后的关系。方法选择2013年8月至2015年8月湖南省儿童医院儿科收治住院的高热惊厥患儿120例为研究对象,分析其首发年龄、初发体温、家族史、病史等危险因素与预后的关系。结果随访时间3～6年,平均(4.8±1.1)年。120例高热惊厥患儿中,预后较差者达14例,占11.7%;经脑电图证实,10例转为癫痫,4例测定智商显示智力障碍。高热惊厥患儿的危险因素包括首发年龄、初发体温、家族史和病史等,各组间的差异比较具有统计学意义(P0.05);Logistic回归分析提示影响高热惊厥患儿预后的独立危险因素为首发年龄1岁、初发体温40℃、病史、有家族疾病史。结论高热惊厥患儿的首发年龄、初发体温、家族史、病史等危险因素与疾病预后关系密切。     

小儿肺炎继发腹泻相关因素分析及微生态制剂的预防作用

目的探讨小儿肺炎继发腹泻的危险因素及应用微生态制剂(培菲康)预防的效果。 方法调查2002年1月至2004年5月在福建医科大学附属第一医院住院治疗的小儿肺炎314例，以住院期间抗生素治疗同时应用微生态制剂(培菲康)的患儿为病例组，仅使用抗生素治疗或住院72h后因出现继发腹泻才开始应用微生态制剂(培菲康)的患儿为对照组，对肺炎患儿的临床特征、微生态制剂的应用情况与继发腹泻的关系进行单因素卡方分析和非条件Logistic回归模型多因素分析。 结果病例组114例，住院治疗期间继发腹泻病21例，发生率为184%；对照组200例，继发腹泻79例，发生率395%。单因素卡方分析显示：患儿发病年龄、住院天数、住院后有无侵入性操作、微生态制剂的应用、居住地、病情严重程度、血中性粒细胞、血红蛋白数量、激素应用与小儿肺炎继发腹泻有关联。非条件Logistic多因素回归分析筛选出3个危险因素，即患儿年龄(χ2=14120,P=0000)、住院天数(χ2=11532,P=0001)、入院后接受侵入性操作(χ2=6827,P=0009)和1个保护因素：微生态制剂应用(χ2=12943,P=0000)。 结论肺炎患儿年龄越小、住院时间越长或进行侵入性操作可增加继发腹泻的发生率；微生态制剂能够降低小儿肺炎继发腹泻的发生率，提示具有预防作用。     

血管阻断联合经子宫后路子宫修补术治疗穿透性胎盘植入的疗效观察

目的:比较并分析血管阻断联合经子宫后路子宫修补术治疗与低位腹主动脉球囊阻断术联合子宫修补术治疗穿透性胎盘植入的临床疗效。方法:选择2014年3月至2018年3月在本院住院分娩的穿透性胎盘植入孕妇67例临床资料进行回顾性分析。根据手术方式不同分为子宫后路组和球囊阻断组。子宫后路组31例采用血管阻断联合经子宫后路子宫修补术治疗,球囊阻断组36例采用低位腹主动脉球囊阻断术联合子宫修补术治疗。比较两组剖宫产围手术相关指标、剖宫产术后并发症、非产科因素并发症、胎儿透视时间、新生儿结局。结果:子宫后路组和球囊阻断组在剖宫产手术时间、术中出血量、血浆输入量及术后住院时间方面比较,差异均无统计学意义(P>0.05);子宫后路组和球囊阻断组产后24小时出血量、弥散性血管内凝血(DIC)发生率、下肢血栓发生率及产褥期感染发生率比较,差异无统计学意义(P>0.05);子宫后路组非产科相关并发症总发生率(3.23%)低于球囊阻断组(27.78%),差异有统计学意义(P<0.05),子宫后路组胎儿无X线辐射暴露,球囊阻断组胎儿透视平均时间8.28±2.54秒;两组产妇术后子宫恢复及月经复潮情况比较,差异无统计学意义(P>0.05);子宫后路组和球囊阻断组新生儿体质量、新生儿Apgar评分、新生儿窒息发生率及远期随访结果比较,差异无统计学意义(P>0.05)。结论:血管阻断联合经子宫后路子宫修补术治疗与低位腹主动脉球囊阻断术联合子宫修补治疗穿透性胎盘植入临床疗效相似,但血管阻断联合经子宫后路子宫修补术治疗非产科因素并发症较少,且不接受X线辐射,安全性更高。     

Spontaneous abortions in sibship of children with congenital malformation or malignant disease.

Parents of 751 children affected by cancer/leukemia, congenital heart disease, strawberry nevus or mental retardation have been investigated with respect to their reproductive history and their exposure to risk factors for spontaneous abortion. Differences between the four groups were established for the number of children in the sibship, the proportion of multigravidae and the spontaneous abortion rate among these women. The greatest differences were observed in the two groups of malformed children compared with the other two groups, being as marked in those with a severe malformation (heart defect) as in those with a benign one (strawberry nevus). Taking known risk factors for spontaneous abortion into account did not explain the observed differences. An etiological hypothesis is put forward which takes account of the high proportion of quantitative abnormalities of the karyotype associated with congenital heart disease and spontaneous abortion.     

ECMO and congenital heart disease

Although initially designed for respiratory failure, venoarterial extracorporeal membrane oxygenation (VA ECMO) has become a mainstay of therapy in the treatment of patients with congenital heart disease, providing preoperative and postoperative support for infants with temporary impairment of myocardial function. Postoperative support for pulmonary hypertension has allowed dramatic improvements in lesions such as total anomalous pulmonary venous connection. VA ECMO has also proven to be an acceptable bridge to cardiac transplantation in patients too small for currently available ventricular assist devices. Intraoperative elective use of ECMO has also provided a surgical environment with some specific advantages over conventional cardiopulmonary bypass for lesions such as long segment tracheal stenosis. The results of "rescue ECMO" or extracorporeal cardiopulmonary resuscitation (ECPR) has shown that many children with congenital heart disease are very salvageable despite sudden decompensation and arrest. These techniques of VA ECMO have evolved and improved over the last two decades, allowing expanded application of this life saving support.     

Open heart surgery in geriatric patients.

With the progress of medical science, the scope of open heart surgery has expanded. From 1975 through 1987, we operated on 114 consecutive patients aged 65 years and over with the aid of a cardiopulmonary bypass in the Department of Surgery, National Taiwan University Hospital. The annual number of these elderly patients has increased gradually, reaching 6.4% of the annual open heart cases in 1987. Eighty-six of our 114 patients were males and 28 were females. Their ages ranged from 65 to 88 years with an average of 68.5 years. Overall, 65 patients (57%) were operated on for coronary artery disease and/or its associated lesions; 41 (36%), for valvular heart disease; six, for aortic dissection; two, for cardiac tumor; and one, for congenital pulmonary stenosis. One patient had combined coronary artery disease and aortic dissection. The mortality for isolated coronary artery bypass surgery was 12%; for single valvular surgery it was 11%. The complexity of the surgical procedure increased the operative mortality. The overall mortality was 23.6% (27/114), with subsequent death in 5.7% during an average of 25 months of follow-up. Because of the degeneration of organ-systems in elderly patients, and its frequent association with poor cardiac reserve and other medical problems, these elderly cardiac patients should be checked thoroughly before they are considered for open heart surgery. Our experience suggests that open heart surgery can be done in selected patients aged 65 years or older with acceptable risks. Age alone should not be an absolute contraindication to surgery, and clinical improvement is to be expected after surgery.     

Risk factors for mortality in primary isolated coronary artery bypass grafting surgery.

BACKGROUND AND PURPOSE: Identifying the risk factors for mortality in coronary artery bypass grafting (CABG) surgery is important to improve surgical results. The purpose of this study was to identify the risk factors for mortality in primary isolated CABG in a series of Taiwanese patients. METHODS: Medical records of 914 patients who underwent primary isolated CABG surgery in Veterans General Hospital-Taipei during the period from January 1, 1991, to December 31, 1995, were reviewed. Eighteen clinical and seven operative variables were included in the univariate and multivariate analyses to identify the determinants of mortality in CABG surgery. RESULTS: Thirty-one patients (3.4%) died within 30 days after surgery; 41 (4.5%) died during hospitalization for the procedure. After univariate and multivariate analyses, emergency surgery, history of myocardial infarction, concomitant peripheral artery occlusive disease (PAOD), and prolonged cardiopulmonary bypass (CPB) were found to be significant determinants of mortality in primary isolated CABG. Other variables, including age, sex, angina class, NYHA class, diabetes mellitus, the number of anastomoses, aortic cross-clamp time, stenosis of the left main coronary artery, the number of stenotic coronary arteries, history of congestive heart failure, and a left ventricular ejection fraction less than 35%, were not significant determinants of mortality. Patients undergoing emergency surgery were found to be at highest risk of mortality. CONCLUSIONS: Patients undergoing emergency surgery who had a history of myocardial infarction, concomitant PAOD, or prolonged CPB were at higher risk of mortality in CABG surgery. More comprehensive techniques in myocardial protection, surgical procedures, and postoperative care should be used in the treatment of high-risk patients to reduce mortality.     

Psychological distress in parents of children with severe congenital heart disease: the impact of prenatal versus postnatal diagnosis.

OBJECTIVE: The purpose of the study was to evaluate coping and psychological functioning of parents of children prenatally or postnatally diagnosed with congenital heart disease. STUDY DESIGN: Parents of 10 infants prenatally diagnosed by fetal echocardiogram and 7 infants postnatally diagnosed with severe congenital heart disease completed the Brief Symptom Inventory (BSI) at the time of diagnosis, at the time of birth and 6 months after birth. Prenatal and postnatal groups were compared to each other and to BSI norms. RESULT: Although both groups scored higher than test norms at the time of diagnosis, they did not differ significantly from each other. Six months after birth, the postnatal group scores did not differ from test norms, but the prenatal group scores were still significantly higher than test norms. The severity of the child's heart lesion at diagnosis was related to parental distress levels; parents with children with more severe lesions had higher BSI scores. CONCLUSION: Results suggest the need to provide parents with psychological support, regardless of the timing of diagnosis. Parents of children with more severe lesions may be at risk for higher levels of psychological distress, particularly over time.     

Antenatal predictors of the neurologic sequelae at 3 years of age: a multivariate analysis

OBJECTIVE: To study the association between fetal blood flow abnormalities and the occurrence of long-term neurologic sequelae. STUDY DESIGN: Umbilical, aortic and middle cerebral artery blood flow parameters were obtained by Doppler examination and retrospectively analyzed in 128 high-risk singleton pregnancies, followed by neurologic examination of the surviving children at 3 years of age. Traditional parameters of neurologic outcome (Apgar scores, intrauterine growth retardation (IUGR), umbilical artery pH and base deficit, gestational age, birth weight, newborn encephalopathy, mode of delivery, fetal heart rate, neurosonographic examination) were included as possible confounding factors. Mann-Whitney U-test, Student's t-test, analysis of variance or Fisher's exact test, where applicable, were used for the univariate analysis. A stepwise logistic regression procedure was conducted to test the independent association of selected perinatal risk factors on neurological outcome. Statistical significance was assumed at P<0.05. RESULTS: Eighteen out of 114 surviving children suffered neurologic illness at 3 years of age. Four children had major neurologic dysfunction and the remaining 14 suffered minor or mild form of the disease. Although blood flow parameters and various perinatal parameters did not differ significantly between the group of children with major neurologic dysfunction and healthy children, aortic resistance index showed an independent association with occurrence of minor or mild neurologic disabilities. CONCLUSION: Antenatal evaluation of the aortic blood flow might be an important predictive variable for permanent neurologic disturbances.     

高危妊娠中孕11～16周应用超声筛查胎儿心脏畸形的价值

目的：探讨高危妊娠中孕11~16周应用超声筛查胎儿心脏畸形的意义。方法：回顾性分析天津市中心妇产科医院与美国费城儿童医院胎儿心脏中心就诊的高危妊娠孕妇668例,于孕11～16周胎儿心脏超声筛查,其中404例采用四腔心切面筛查法,264例采用心脏节段性扫查法。结果：在所有高危妊娠孕妇中,应用四腔心切面筛查法,严重复杂性先心病的检出率为5.7%（23/404）,应用心脏节段性扫查法严重复杂性先心病检出率为9.5%（25/264）,两者比较差异无统计学意义（P＞0.05）。胎儿颈部透明层（nuchal translucency,NT）增高与淋巴水囊瘤患者中,应用四腔心切面筛查法,严重复杂性先心病的检出率为2.5%（9/362）,心脏节段性扫查法检出率为10.0%（7/70）,两者比较差异有统计学意义（P＜0.05）。同一孕期（孕12~14周前）比较,四腔心切面筛查法与心脏节段性扫查法对于严重复杂性先心病的检出率分别为5.9%（21/358）、10.4%（8/77）,两者比较差异无统计学意义（P＞0.05）。结论：随着心脏畸形的高危因素如NT值增高、淋巴水囊瘤、胎儿心外畸形等在早期得以越来越多地检出,在同一时间段内应用超声筛查胎儿心脏畸形尤为必要。四腔心切面作为胎儿超声心动图中最重要、最易获得的切面,尤其在早期胎儿心脏体积较小的情况下,对于严重复杂性先心病的检出具有较高的临床应用价值。先心病的早期检出能最大限度减轻对孕妇本身的损害。     

Impact of perinatal management on neurodevelopmental outcomes in congenital heart disease

With advancements in cardiopulmonary bypass technique and perioperative care, there has been a progressive decline in mortality associated with neonatal surgical correction of congenital heart disease (CHD). Thus, there is now increased focus on improving neurodevelopmental outcomes in CHD survivors. While the cause of these neurodevelopmental impairments is multifactorial, there is increasing evidence that structural and functional cerebral abnormalities are present before cardiac corrective repair. This suggests that in addition to patient specific risk factors, underlying cardiac physiology and clinical hemodynamics are critical to brain health and development. Prenatal diagnosis of CHD and subsequent optimization of perinatal care may therefore be important modifiable factors for long-term neurodevelopmental outcome.This article reviews the impact that prenatal diagnosis of CHD has on perinatal care and the preoperative clinical status of a neonate, as well as the potential influence this may have on lessening the degree of cerebral injury and long-term neurodevelopmental impairments.     

妊娠合并先天性心脏病的围产期管理

过去几十年,随着诊断和治疗手段的发展,先天性心脏病（先心病）患者生存率显著提高。越来越多先心病女性患者可以存活到生育年龄,并考虑生育问题。与普通孕妇相比,先心病患者妊娠其母体风险和新生儿并发症,如早产、胎儿生长受限、胎儿死亡或新生儿死亡率增加。如何降低孕产妇病死率和改善围产结局?文章回顾妊娠合并先天性心脏病的相关文献,对围产期管理进行阐述。