Nursing care of children developing diaphragmatic paralysis after correction surgeries for congenital heart diseases

目的 总结先天性心脏病术后膈肌麻痹患儿的护理要点.方法 对51例先天性心脏病术后并发膈肌麻痹患儿加强呼吸道管理,防治肺部感染；拔除气管插管后积极应对喉头水肿、支气管痉挛等并发症.结果 29例患儿呼吸困难症状轻,术后顺利撤离呼吸机；22例反复撤机失败行膈肌折叠术,其中19例膈肌折叠后顺利撤机痊愈出院,3例死亡.结论 先天性心脏病术后撤离呼吸机过程中应密切观察病情变化,及时评估膈肌功能反采取有效的护理措施,对于并发膈肌麻痹患儿的康复至关重要.     

先天性心脏病矫治术后膈肌麻痹的诊断与治疗

目的总结先天性心脏病矫治手术后膈肌麻痹的原因、临床表现和外科治疗经验,以提高对该类患者的诊治水平。方法2000年1月至2007年6月,36例患者在先天性心脏病矫治手术后出现膈肌麻痹,其中13例因手术后撤呼吸机困难,无法脱离呼吸机;6例术后出现呼吸矛盾运动,二氧化碳潴留（动脉血二氧化碳分压〉50mm Hg）和低氧血症（动脉血氧饱和度〈90％）;4例反复发生肺部感染无法治愈,均施行了膈肌折叠术,平均年龄为13个月;另外13例膈肌麻痹患者能顺利撤离呼吸机,未行手术治疗。结果术后因败血症和弥漫性血管内凝血死亡1例。膈肌折叠手术后胸部X线片示：所有患者膈肌位置正常或抬高小于1个肋间,肺部体征明显改善,呼吸矛盾运动消失,能正常撤离呼吸机。随访13例,失访22例,随访时间1～6年,其中行膈肌折叠的10例患者膈肌位置保持正常;未行膈肌折叠的3例患者膈肌仍然抬高1～2个肋间,但呼吸运动正常,未发生反复呼吸道感染。结论先天性心脏病手术后并发膈肌麻痹的原因大多与术中损伤膈神经有关;对低龄儿童和婴儿,早期施行膈肌折叠术可获得较好的临床治疗效果。     

膈肌折叠术治疗婴幼儿先天性心脏病矫治术后膈肌麻痹的临床疗效分析

目的 分析并评估膈肌折叠术治疗婴幼儿先天性心脏病矫治术后膈肌麻痹的临床效果。 方法 回顾性分析2009年12月至2012年12月13例先天性心脏病婴幼儿行矫治手术后发生膈肌麻痹的临床资料,其中男5例、女8例;年龄35 d 至 11个月［（6.6±3.2）个月］;体重3.5～9.6 （6.2±1.8） kg。膈肌折叠术在心脏直视手术后（19.08±4.29） d施行。所有患者均无法顺利脱离呼吸机,或脱机后因严重呼吸困难反复行气管内插管,13例患儿均行单侧或双侧膈肌折叠术。 结果 发生呼吸机相关性肺炎2例,发生率15.4%,其中1例痰培养为复合鲍曼不动杆菌阳性、血细菌培养阴性;另1例为法洛四联症合并肺动脉闭锁患儿,双侧膈肌麻痹,行双侧膈肌折叠术后第11 d痰培养和血培养均为铜绿假单胞菌阳性,并因多脏器功能衰竭死亡。所有患儿膈肌折叠术后胸部X线片提示膈肌下降至正常位置。膈肌折叠术后患儿脱离呼吸机时间为 （5.38±3.09） d。膈肌折叠术后患儿动脉血氧分压（PaO2）较术前明显增高 ［（90.22±8.47） mm Hg vs. （80.69±6.72） mm Hg ;P＜0.05］,动脉血二氧化碳分压（PaCO2）较术前明显降低 ［（39.87±6.31） mm Hg vs. （56.38±7.19） mm Hg ;P＜0.05］ 。随访12例,随访时间24个月,１例患儿行双侧膈肌折叠术,出院后6个月内反复2次出现肺部感染,其余患儿呼吸功能正常。所有随访患儿心功能Ⅰ～Ⅱ级（NYHA）。 结论 先天性心脏病婴幼儿行心脏直视手术后发生膈肌麻痹时,难以顺利脱离呼吸机,行膈肌折叠术是较安全、简便、有效的治疗手段,能提高患者的生存率,降低院内感染几率。     

膈肌折叠术治疗婴幼儿心内直视术后膈肌麻痹的护理

目的探讨膈肌折叠术在婴幼儿心内直视术后膈肌麻痹中的应用及护理。方法对9例心内直视术后膈肌麻痹患儿实施膈肌折叠术治疗,术后密切监测患儿生命体征变化,定时复查动脉血气,纠正水、电解质酸碱平衡紊乱,加强循环系统的观察及处理,常规进行气道管理、胃肠道的护理、营养支持等。结果术中无并发症。9例患儿中除1例二次插管外,其余8例一次性顺利脱离呼吸机,胸片显示膈肌均恢复到正常位置,康复出院。结论密切的病情观察、积极有效的护理对于膈肌折叠术后先心病患儿康复十分有利。     

婴儿先天性心脏病术后膈肌麻痹的外科治疗

目的探讨膈肌折叠术适应证及其使患儿脱离呼吸机的益处。方法回顾性分析北京儿童医院2008年10月至2014年6月完成婴儿(1岁)心内直视手术2 692例中同期经B超及胸部X线检查诊断膈肌麻痹31例患者的临床资料,其中男22例、女9例,年龄1~12(4.5±4.2)个月,体重2.9~8.5(5.6±2.2)kg。双侧膈肌麻痹6例,左侧膈肌麻痹10例,右侧膈肌麻痹15例。患儿均呼吸机辅助呼吸,脱离呼吸机困难,31例在全身麻醉气管插管下行膈肌折叠手术。结果 31例患儿均行膈肌折叠术,膈肌折叠术前机械通气时间123~832(420±223)h,折叠后机械通气时间15~212(75±58)h,差异有统计学意义(P0.05)。术后所有患儿均顺利脱离呼吸机辅助,治愈出院。结论婴儿先天性心脏病术后发生膈肌麻痹时,常常难以顺利脱离呼吸机。膈肌折叠是非常安全、简便的治疗手段,有利于脱离呼吸机或改善呼吸状态。     

心脏手术后膈肌功能障碍致困难撤机患者的康复护理

目的 对7例心脏手术后膈肌功能障碍致困难撤机的患者,给予咳嗽能力评估及实施气道廓清方案,加强呼吸肌肌力及耐力训练,强化心功能监测、目标导向式肢体功能锻炼、吞咽训练、谵妄预防及心理康复.经精心护理,7例患者均成功撤离呼吸机,顺利出院.提出心脏手术后膈肌功能障碍导致的困难撤机会严重影响患者术后恢复,呼吸肌的肌力及耐力训练是...     

肺泡表面活性物质在婴幼儿先心病术后撤机中的应用

对7例心脏直视术后反复撤离呼吸机失败的患儿应用肺泡表面活性物质(PS)按4种体位进行气道内滴注治疗.结果患儿氧合指数、动脉血氧饱和度、动脉血二氧化碳分压均有所改善,其中6例经一次用药后顺利撤机.提示外源性PS有助于改善先天性心脏病术后患儿肺功能,减少呼吸机应用时间.     

呼吸机通气下超声诊断先天性心脏病术后膈肌麻痹的自身交叉对照研究

目的探索先天性心脏病术后患者在呼吸机通气情况下超声诊断膈肌麻痹的可行性。方法 2013年1月1日至2016年4月30日我院542例先天性心脏病外科手术后,难以脱离呼吸机或者怀疑存在膈肌麻痹的患者,分别在呼吸机持续气道正压通气(CPAP)模式下和完全自主呼吸状态下,以超声检查膈肌功能诊断是否存在膈肌麻痹。其中男327例、女215例,年龄(14±32)个月。对比在呼吸机CPAP模式下与在完全自主呼吸状态下超声诊断的结果。结果完全自主呼吸状态下,82例患者诊断为膈肌麻痹,其中右侧39例,左侧25例,双侧18例,其他均为正常;CPAP模式下,82例患者诊断膈肌麻痹,其中右侧38例,左侧25例,双侧19例,其他均为正常。超声在CPAP模式下诊断先天性心脏病术后膈肌麻痹的结果,与在完全自主呼吸状态下对比,敏感性为100.0%,特异性为99.9%。结论在呼吸机通气状态下用超声检查诊断先天性心脏病术后患者是否存在膈肌麻痹结果准确可行。     

小儿膈肌膨出症33例诊断和治疗

目的总结小儿膈肌膨出症的诊断及治疗特点。方法对1990～2004年收治的33例小儿膈肌膨出症患者进行回顾性分析。结果本组33例，均行膈肌折叠手术，1例新生儿术后呼吸功能衰竭死亡，1例术后并发膈疝，32例均治愈出院，随访6个月～10年，手术治疗效果良好，无症状复发等现象。结论反复呼吸道感染是小儿膈肌膨出症的主要临床症状，早期诊断和适时手术治疗能获得良好疗效。     

先天性膈肌发育缺陷疾病的修复问题

先天性膈肌发育缺陷疾病包括①食管裂孔疝;②先天性膈疝;③膈膨升。报道51例患儿的诊治经验,介绍不同的膈肌发育缺陷疾病,各自不同的病理解剖特点。强调在手术修复中按照其病理解剖及病理生理特点,选用正确术式以提高疗效。     

Diaphragm plication following phrenic nerve injury: a comparison of paediatric and adult patients

BACKGROUND: A study was undertaken to evaluate whether adults differ from children in the indications and outcome of diaphragmatic plication following phrenic nerve injury. METHODS: A retrospective study was performed of 21 patients, 10 below the age of 5 and 11 older than 37 years. The indication for surgery for all the children was failure to wean from ventilatory support. The indications for surgery in the adult group were ventilator dependency (n=4) and symptomatic dyspnoea (n=7). All patients had at least one imaging study confirming diaphragmatic paralysis. The American Thoracic Society (ATS) dyspnoea scale, pulmonary function tests, and quantitative pulmonary perfusion scans were used as evaluation parameters. At surgery the diaphragm was centrally plicated. RESULTS: One child died immediately after surgery due to irreversible heart failure and two children died within 2 months of surgery from ongoing complications of their original condition. These three patients were considered as selection failures. Seven children were weaned from ventilatory support within a median of 4 days (range 2-140). Only one of four ventilated adults was successfully weaned. Seven adults who underwent surgery for chronic symptoms had a marked subjective improvement of 2-3 levels in the ATS dyspnoea scale. Pulmonary function studies in the seven symptomatic adults showed a 40% improvement above baseline. Severely asymmetrical perfusion scans reverted to a normal pattern after plication. CONCLUSIONS: Diaphragmatic plication offers a significant benefit to children with diaphragmatic paralysis and should be performed early to facilitate weaning from mechanical ventilation. While plication is of limited benefit in weaning ventilated adults, it results in significant subjective and objective lifetime improvement in non-ventilated symptomatic adults.     

Paralysed diaphragm after cardiac surgery in children: value of plication

Over a 2-year period (1987-1988), 31 children (3% of 960 operations) were found to have a paralysed diaphragm following cardiac surgery. The median age was 5 months with 65% less than 1 year of age. In the 31 patients, 38 paralysed diaphragms were identified. The phrenic nerve injury was on the right in 8 cases, the left in 16, bilateral in 7 and 40% were related to modified Blalock Taussig shunts. The time to extubation was analysed for each patient in two separate groups: Group A: (greater than 1 year): 11 children of whom 5 were extubated without difficulty, 4 had non-respiratory reasons for prolonged ventilation and only 2 were plicated--both were extubated within 4 days. Group B: (less than 1 year): 20 infants of whom 16 were plicated and 4 were not. Three of the children who were plicated died from cardiac causes. Of the 13 survivors, there were 3 who had other reasons for prolonged ventilation. Thus 10 infants required prolonged ventilation (mean 11 days) because of respiratory difficulties. All underwent plication and were extubated at a mean of 2.4 days postoperatively. The 4 who were not plicated were extubated at a mean of 11 days postoperatively. In infants in whom there is no cardiac cause for failure to wean from ventilation, diaphragmatic paralysis should be suspected and plication performed if not extubated 2 weeks after operation.     

Diaphragmatic plication in adult patients with diaphragm paralysis after cardiac surgery.

OBJECTIVE: We investigated the benefit of diaphragmatic plication for weaning from mechanical ventilation in these adult patients. PATIENTS AND METHODS: Four patients underwent diaphragmatic plication for difficulty of weaning from mechanical ventilation due to diaphragmatic paralysis. They were all men with an average age of 70.5 +/- 6.3 years. Three of the patients had undergone cardiac surgeries for coronary artery bypass grafting and one patient ascending aortic replacement for pseudoaneurysm after coronary revascularization. Right diaphragmatic plication (muscle sparing procedure) was performed between 30 to 61 days after cardiac surgery. RESULTS: The mean forced tidal volume improved dramatically from 216 to 415 ml after plication in all patients, and it was possible to discontinue mechanical ventilation from 2 to 12 days after plication. One patient with obstructive respiratory dysfunction died from aspiration pneumonia 15 days after plication. However, postoperative tidal volume in this patient improved to 420 ml and he was able to be weaned from ventilatory support five days after plication. The other three patients were discharged between 26 to 58 days after plication and continue to do well without symptoms. CONCLUSION: Diaphragmatic plication is a useful procedure for treatment of diaphragmatic paralysis in adults as well in children.     

Incidence and treatment of diaphragmatic paralysis after cardiac surgery in children.

OBJECTIVE: Diaphragmatic paralysis (DP) caused by phrenic nerve injury is potentially life-threatening in infants. Phrenic nerve injury due to thoracic surgery is the most common cause of DP in children. We retrospectively analyzed incidence, surgical details, management and follow-up of our patients with DP after cardiac surgery to develop an algorithm for the management and follow-up. METHODS: Retrospective analysis of 43 patients with DP after cardiac surgery performed between 1996 and 2000. RESULTS: Median age at cardiac surgery was 1 month (range 3 days to 9 years). Incidence of DP was 5.4%. A trend towards higher incidences of DP were observed after arterial switch operation (10.8%, P=0.18), Fontan procedure (17.6%, P=0.056) and Blalock-Taussig Shunt (12.8%, P=0.10). Median time from cardiac surgery to surgical plication was 21 days (range 7-210 days). Transthoracic diaphragmatic plication was performed in 29/43 patients, no plication was done in 14/43 patients. Patients in whom diaphragmatic plication was required were younger (median age 2 months, range 21 days to 53 months versus 17.5 months, range 4 days to 110 months; P<0.001). Indications for plication were failure to wean from ventilator (n=22), respiratory distress (n=4), cavopulmonary anastomosis (n=2), and failure to thrive (n=1). All these symptoms resolved after diaphragmatic plication, however, 8/29 patients with plication and 2/14 without plication died. Cause of death was not related to diaphragmatic plication in any patient. Position of plicated diaphragm was normal in 18/21 surviving patients 1 month after plication. In 2/12 surviving patients without plication hemidiaphragm showed a normal position 1 year after surgery. The rate of pulmonary infections was not significantly different during 12-60 months follow-up. CONCLUSIONS: DP is an occasional complication of cardiac surgery. High incidences of DP were seen after arterial switch operation, Fontan procedure and Blalock-Taussig shunt (BT). Respiratory insufficiency requires diaphragmatic plication in most infants with DP whereas older children may tolerate DP. Transthoracic diaphragmatic plication is an effective treatment of DP and achieves relief of respiratory insufficiency in most patients. Spontaneous recovery from postsurgical DP is rare.     

Outcome analysis of a conservative approach to diaphragmatic paralysis following congenital cardiac surgery in neonates and infants: a bicentric retrospective study

Open in a separate window OBJECTIVESDiaphragmatic paralysis following congenital cardiac surgery is associated with significant morbidity and mortality. Spontaneous recovery of diaphragmatic function has been described, contrasting with centres providing early diaphragmatic plication. We aimed to describe the outcomes of a conservative approach, as well as to identify factors associated with a failure of the strategy.METHODSThis is a retrospective study of patients admitted after cardiac surgery and suffering unilateral diaphragmatic paralysis within 2 French Paediatric Cardiac Surgery Centers. The conservative approach, defined by the prolonged use of ventilation until successful weaning from respiratory support, was the primary strategy adopted in both centres. In case of unsuccessful evolution, a diaphragmatic plication was scheduled. Total ventilation time included invasive and non-invasive ventilation. Diaphragm asymmetry was defined by the number of posterior rib segments counted between the 2 hemi-diaphragms on the chest X-ray after cardiac surgery.RESULTSFifty-one neonates and infants were included in the analysis. Patients’ median age was 12.0 days at cardiac surgery (5.0–82.0), and median weight was 3.5 kg (2.8–4.9). The conservative approach was successful for 32/51 patients (63%), whereas 19/51 patients (37%) needed diaphragm plication. There was no difference in patients’ characteristics between groups. Respiratory support prolonged for 21 days or more and diaphragm asymmetry more than 2 rib segments were independently associated with the failure of the conservative strategy [odds ratio (OR) 6.9 (1.29–37.3); P = 0.024 and OR 6.0 (1.4–24.7); P = 0.013, respectively].CONCLUSIONSThe conservative approach was successful for 63% of the patients. We identified risk factors associated with the strategy’s failure.     

Diaphragmatic paralysis: pathology at the reach of the pediatric surgeon

The phrenic nerve is the only motor nerve in the diaphragm. The injury will lead to a diaphragmatic paralysis or eventration with paradoxical movements during breathing. The aim of this review is to analyze the diagnostic criteria, surgical indications, and the patients that are not treated by surgery. We review 53 cases with diaphragmatic pathology in the last 5 years; 19 females and 20 males. One was a diaphragmatic rupture, 13 were diaphragmatic hernias, and 39 had diaphragmatic paralysis. Diaphragmatic paralysis was diagnosed by fluoroscopy in 97%, electromiography 5.1% or ultrasounds. The ethiology was 64% after cardiac surgery and 10% after thoracic oncologic surgery. The age at diagnosis was less than 1 month in 41% cases. In 29 patients the paralysis was well tolerated and were extubated between 24 h and 4 days after the diagnosis, frequently was in the first 48 h. 4 patients need a traqueostomy and 2 went to another hospital. In 5 we performed a diaphragmatic plication because the inability to be extubated or the persistence of respiratory distress. The paralysis was demonstrated by fluoroscopy. 2 patients are asymptomatic, 2 are in mechanical ventilation and 1 died (sepsis). The most frequent cause of diaphragmatic paralysis was related to cardiac or thoracic surgery. In general, is well tolerated, almost asymptomatic, the patients were extubated between 24 or 48 h. In pediatric population they are few cases that need surgical treatment. The patients that we operated on were less than 2 months old, because is at that age were the repercussion is more important. We must follow strict criteria, without precipìtation for the surgical indications.     

Phrenic nerve paralysis after pediatric cardiac surgery. Retrospective study of 125 cases

Phrenic nerve paralysis was diagnosed in 125 children (1.6%) from a series of 7,670 cardiac surgical procedures in infants and children during a 12 year period. The incidence was 1.9% for open heart and 1.3% for closed heart operations. In order of decreasing incidence, the open heart procedures included Mustard procedure (6.7%), right ventricular outflow tract reconstruction (5.6%), and repair of tetralogy of Fallot (2.7%). The closed heart procedures included Glenn anastomosis (6.2%), Blalock-Hanlon atrial septectomy (5.9%), and right Blalock-Taussig shunt (5.1%). Procedures following previous operations or thoracotomies had almost twice the incidence of phrenic nerve paralysis: Mustard procedure 9.9%, right ventricular outflow tract reconstruction 10.8%, and tetralogy repair 5.5%. Seven patients (5.6%) with phrenic nerve paralysis died. Patients less than 2 years old with phrenic nerve paralysis were intubated for 0 to 57 (average 15.7) days after their cardiac operations and those over 2 years old for 13 to 35 (average 7.2) days (p less than 0.001). Twelve patients had diaphragmatic plication without mortality and were extubated 0 to 6 (average 2.3) days after plication. We have made the following conclusions: (1) Phrenic nerve paralysis may occur after both open and closed cardiac procedures and is more common in children requiring reoperation; (2) it is associated with considerable morbidity; (3) eventual recovery of phrenic nerve function occurs in 84% of children; and (4) diaphragmatic plication is safe, reliable, and of most value in patients who are under 2 years of age and require mechanical ventilation for more than 2 weeks.     

Eventration of the diaphragm

OBJECTIVE: Eventration of the diaphragm (ED) is defined as the abnormal elevation of the diaphragm. Although asymptomatic ED may be amenable to conservative treatment, symptomatic ED in children, either congenital or acquired, may require surgical treatment. This study evaluated the results of diaphragmatic plication in children with unilateral ED. METHODS: Fifteen patients who had undergone diaphragmatic plication for ED between 1997 and 2003 were evaluated retrospectively. The diagnosis of ED was established by routine chest radiographs and fluoroscopy. Patients who failed to respond to nonoperative treatment were referred for surgery. Nine patients underwent diaphragmatic fluoroscopy 1-5 years following plication to assess function. RESULTS: Indications for diaphragmatic plication were respiratory symptoms such as tachypnoea, dyspnoea, recurrent pneumonia and failure to thrive. In 14 patients, the position of the diaphragm was normal after plication, but the diaphragm was elevated without symptoms in one patient during postoperative follow-up. The motion of the diaphragm was investigated in nine patients. Fluoroscopic studies showed that the operated hemidiaphragm was immobile and there was no paradoxical motion. No return of symptoms was found during follow-up. CONCLUSION: ED is the abnormal elevation of the diaphragm as a result of paralysis or aplasia of the muscular fibres. The abnormally elevated diaphragm may compress the ipsilateral lung, and with respiratory effort the mediastinum may shift towards the normal side. Therefore, diaphragmatic plication is performed to restore normal pulmonary parenchymal volume by replacing the diaphragm in its normal location. After plication, there was immediate remission of symptoms in most patients and decreasing symptoms were observed for a year in others. During follow-up, the location of the diaphragm was normal and no paradoxical movement was observed. Relapse of symptoms was not noted in patients with immobile diaphragms.