儿童心脏外科重症监护病房医院感染临床研究

目的:探讨先天性心脏病患儿术后PICU医院感染的发生情况.方法:回顾性分析行心脏手术的2 258例先天性心脏病患儿的临床资料,观察术后PICU医院感染发生率、发生部位、病原茵分布及耐药性,并进行统计分析.结果:198例惠儿术后发生PICU医院感染,发生率8.77%,其中呼吸机相关性肺炎181例(8.02%)、脓毒血症10例(0.44%)、血管相关性感染7例(0.31%).198例惠儿标本中共检出病原茵242株,包括革兰阴性杆菌174株(71.9%),革兰阳性球茵30株(12.4%),真茵38株(15.7%).复杂先天性心脏病与简单先天性心脏病患儿术后医院感染发生率比较差异有统计学意义(P＜0.01).不同住院时间患儿医院感染发生率比较差异有统计学意义(P＜0.01).随体外循环时间延长,医院感染发生率增高,差异有统计学意义(P＜0.01).常见的革兰阴性杆茵是肺炎克雷伯茵、铜绿假单胞茵、鲍曼不动杆茵、大肠埃希茵和嗜麦芽窄食单胞茵等;常见革兰阳性球菌是凝固酶阴性葡萄球菌、粪肠球菌、屎肠球菌和金黄色葡萄球茵等;真茵以白色假丝酵母茵为主.结论:先天性心脏病术后PICU医院感染发生率较高,不同感染部位病原茵分布有其自身特点.体外循环时间延长、住院时间延长可能会增加术后医院感染发生率.     

儿童心脏外科重症监护病房医院感染临床研究

目的:探讨先天性心脏病患儿术后PICU医院感染的发生情况。方法:回顾性分析行心脏手术的2 258例先天性心脏病患儿的临床资料,观察术后PICU医院感染发生率、发生部位、病原菌分布及耐药性,并进行统计分析。结果:198例患儿术后发生PICU医院感染,发生率8.77%,其中呼吸机相关性肺炎181例(8.02%)、脓毒血症10例(0.44%)、血管相关性感染7例(0.31%)。198例患儿标本中共检出病原菌242株,包括革兰阴性杆菌174株(71.9%),革兰阳性球菌30株(12.4%),真菌38株(15.7%)。复杂先天性心脏病与简单先天性心脏病患儿术后医院感染发生率比较差异有统计学意义(P<0.01)。不同住院时间患儿医院感染发生率比较差异有统计学意义(P<0.01)。随体外循环时间延长,医院感染发生率增高,差异有统计学意义(P<0.01)。常见的革兰阴性杆菌是肺炎克雷伯菌、铜绿假单胞菌、鲍曼不动杆菌、大肠埃希菌和嗜麦芽窄食单胞菌等;常见革兰阳性球菌是凝固酶阴性葡萄球菌、粪肠球菌、屎肠球菌和金黄色葡萄球菌等;真菌以白色假丝酵母菌为主。结论:先天性心脏病术后PICU医院感染发生率较高,不同感染部位病原菌分布有其自身特点。体外循环时间延长、住院时间延长可能会增加术后医院感染发生率。     

Candidemia in pediatric patients with congenital heart disease

Candidemia is an important problem in pediatrics. In our hospital, highest candidemia rates were documented among children with congenital heart disease (CHD). A series was conducted to describe the clinical and mortality features of candidemia in these patients. Fifty-two cases (1988-2000) included very young infants (median age, 2 months) who received long-term antibiotic treatment (median, 20.5 days). Candida parapsilosis predominated (54%). Endovascular infections occurred in 11.5%. In-hospital mortality was 39% and related mortality 14%. Maintenance of catheter (odds ratio [OR], 6.0; 95% confidence interval [CI], 1.0-37.2; P = .05) and severity of patients as measured with the Pediatric Risk Score of Mortality I (OR, 1.1, 95% CI, 1.0-1.3; P = .05) were independently associated with mortality. In summary, candidemia in children with CHD is diagnosed to very young infants with prolonged antibiotic therapy. Mortality is high but, in most cases, is not related to candidemia. Optimal management may include exclusion of endocarditis, early antifungal treatment, and catheter removal.     

Mid-term follow-up in patients with diaphragmatic plication after surgery for congenital heart disease

Objective Diaphragmatic palsy (DP) is a rare but severe complication after surgery for congenital heart disease. Transthoracic diaphragmatic plication is an effective means of treatment for those with respiratory impairment due to DP, but little is known about the mid-term effects of diaphragmatic plication. Design We performed a study in 24 patients with history of DP. Diaphragm movement was assessed using ultrasound. Patients with DP who were old enough were additionally followed-up with lung function and exercise testing. A group of patients with similar age, diagnoses and operations served as controls. Results Ultrasound showed that in the majority of cases with history of DP the paralysed diaphragm was static, independently of whether it was plicated or not. Patients with DP had a more restrictive lung function pattern (VC: 54.3 vs. 76.4% predicted, p < 0.001; FEV₁: 58.4 vs. 86.2% predicted, p < 0.001) and a lower exercise capacity compared with the control group (peak VO₂: 24.5 vs. 31.3 ml/kg/min, p = 0.03). Comparing patients with and without plication for DP, only a tendency towards lower lung function values in patients after diaphragmatic plication, but no differences regarding exercise capacity, could be found. Conclusions Our results provide evidence that DP is a serious surgical complication with a reduction in lung function and exercise capacity, even at mid-term follow-up; however, diaphragmatic plication, a useful tool in treating post-surgical DP in children with respiratory impairment, seems to be without mid-term risk in terms of recovery of phrenic nerve function, lung function values, and exercise capacity.     

Right ventricular function declines after cardiac surgery in adult patients with congenital heart disease

Right ventricular function (RVF) is often selectively declined after coronary artery bypass graft surgery. In adult patients with congenital heart disease (CHD) the incidence and persistence of declined RVF after cardiac surgery is unknown. The current study aimed to describe RVF after cardiac surgery in these patients. Adult CHD patients operated between January 2008 and December 2009 in the Academic Medical Centre in Amsterdam were studied. Clinical characteristics, laboratory tests, surgical data and intensive care unit outcome were obtained from medical records. RVF was measured by trans-thoracic echocardiography (TTE) and expressed by tricuspid annular plane systolic excursion (TAPSE), tissue Doppler imaging (RV S’) and myocardial performance index (MPI) pre-operatively and direct, at intermediate and late follow up. Of a total of 185 operated, 86 patients (mean age 39?±?13?years, 54% male) had echo data available. There was a significant fall in RVF after cardiac surgery. TAPSE and RV S’ were significantly higher and MPI was significantly lower pre-operatively compared to direct post-operative values (TAPSE 22?±?5 versus 13?±?3?mm (P?<?0.01), RV S’ 11?±?4 versus 8?±?2?cm/s (P?<?0.01) and MPI 0.36?±?0.14 vs 0.62?±?0.25; P?<?0.01). There were no significant differences in left ventricular function pre-operatively compared to post-operative values. Right-sided surgery was performed in 33, left-sided surgery in 37 and both sided surgery in 16 patients. Decline in RVF was equal for those groups. Patients with severe decline in RVF, were patients who underwent tricuspid valve surgery. Decline in RVF was associated with post-operative myocardial creatine kinase level and maximal troponin T level. There was no association between decline in RVF and clinical outcome on the intensive care unit. 18?months post-operatively, most RVF parameters had recovered to pre-operative values, but TAPSE which remained still lower (P?<?0.01). CHD patients have a decline in RVF directly after cardiac surgery, regardless the side of surgery. Although a gradual improvement was observed, complete recovery was not seen 18?months post-operatively.     

先天性心脏病术后患儿的呼吸道管理

小儿先天性心脏病(先心病)的发生率占出生活婴儿的7%～10%[1]。我国每年新生儿中约有10～15万患有先心病[2]。对先心病的手术治疗,其手术成功率,除与手术技巧、体外循环转流水平的提高与改进有关外,术后监护技术不容     

儿童先天性心脏病术后膈肌麻痹的临床研究

目的 探讨儿童先天性心脏病术后膈肌麻痹的临床表现、诊断及治疗.方法 回顾性分析10 200例先天性心脏病手术后发生膈肌麻痹35例患儿的临床资料,对膈肌麻痹的典型临床表现及确诊方法进行总结,对膈肌折叠术的疗效进行评价.结果 膈肌麻痹的发病率为0.34％ ;35例中左侧膈肌麻痹17例,右侧膈肌麻痹14例,双侧膈肌麻痹4例;脱离呼吸机通气困难35例,再次气管插管32例,呼吸机相关性肺炎29例,气管切开10例;32例行膈肌折叠术,术后均顺利脱离呼吸机辅助通气,膈肌折叠术后呼吸机使用时间较术前明显缩短(P＜0.05);无死亡病例.结论 先天性心脏病术后膈肌麻痹的发生率较低,膈肌折叠是膈肌麻痹有效的治疗手段.     

Elevated plasma levels of adrenomedullin in congenital cyanotic heart disease.

Adrenomedullin is a novel hypotensive peptide originally isolated from human pheochromocytoma. Accumulating evidence suggests the possible involvement of adrenomedullin in the physiology of the pulmonary circulation and the pathophysiology of hypoxaemia. The aim of the present study was to investigate the pathophysiological significance of adrenomedullin in hypoxaemia caused by congenital cyanotic heart disease. Subjects were 16 patients with congenital cyanotic heart disease aged 0.8-10 years (Group C) and 12 age-matched control subjects (patients with coronary artery dilatation after Kawasaki disease; Group N). Plasma adrenomedullin concentrations were measured, using radioimmunoassay, in femoral venous, pulmonary arterial and pulmonary venous blood obtained during cardiac catheterization. Plasma adrenomedullin concentrations in Group C were significantly (3-fold) higher than those in Group N at all sampling sites. In Group C, plasma adrenomedullin concentrations in pulmonary venous blood were significantly lower than those in pulmonary arterial blood. Pulmonary uptake of adrenomedullin in Group C was significantly greater than that in Group N. Patients with congenital cyanotic heart disease showed elevated plasma adrenomedullin concentrations and an increased uptake of adrenomedullin in the pulmonary circulation, which may act to dilate pulmonary vessels and increase pulmonary blood flow to alleviate hypoxaemia. Intrinsically increased adrenomedullin levels may function as a compensatory mechanism for hypoxaemia in congenital cyanotic heart disease.     

脑钠素与先天性心脏病患儿术后心功能的关系研究

目的 探讨血浆脑钠素(BNP)对先天性心脏病(先心病)患儿术后心功能评价的临床价值.方法 选择153例先心病手术患儿.术后24 h用酶联免疫吸附法测定BNP,同时用超声心动图测量左室射血分数(LVEF),用胸阻抗法测量心排血指数(CI1),用脉搏指示连续心排血量(PiCCO)测量心排血指数(CI2),并分析各指标之问的相关性.同时比较BNP＜ 140 ng/L组(A组,108例)与BNP＞ 140 ng/L组(B组,45例)患儿的呼吸机使用时间、重症监护病房(ICU)停留时间、总住院时间、病死率的差异.结果 153例先心病患儿的平均BNP为(168.8±71.6) ng/L,LVEF为0.409±0.137,CI1、为(51.7±15.0) ml·s-1·m-2,CI2为(61.7±11.7) ml·s-1·m-2;BNP与CI1和CI2均呈显著负相关(r1=-0.79,r2=-0.79,均P＜0.01),LVEF与CI1和CI2均呈显著正相关(r1=0.68,r2=0.68,均P＜0.01),CI1与CI2呈显著正相关(r=0.88,P＜0.01).B组的呼吸机使用时间(h)、ICU停留时间(d)、总住院时间(d)均明显长于A组(呼吸机使用时间:39.7±11.6比26.4±13.5,ICU停留时间:4.9±1.3比2.5±0.9,总住院时间:15.9±5.1比11.2±3.7,均P＜0.01);两组均无死亡患儿.结论 BNP水平是评价先心病患儿术后心功能的有效指标,并对患儿预后的估测有一定的临床价值.     

Recombinant factor VIIa to control excessive bleeding following surgery for congenital heart disease in pediatric patients

The purpose of this article is to evaluate the efficacy of recombinant factor VII (rFVIIa) in the treatment of bleeding following cardiac surgery in a pediatric population. The study included a case series of postcardiac surgical patients with chest tube output of = 4 mL/kg/h for the initial 3 postoperative hours who received rFVIIa. Chest tube output for the 3 hours before and the 3 hours after rFVIIa was compared using a paired t test. In addition, chest tube output for the initial 3 postoperative hours and the 3 hours following rFVIIa was compared to 8 control patients who did not require rFVIIa. Recombinant factor VIIa was administered to 9 children (age = 9 +/- 4 years) following repair of tetralogy of Fallot (6), closure of ventricular septal defect (1), closure of sinus venosus atrial septal defect (1), and mitral valve repair (1). Chest tube output for the initial 3 postoperative hours prior to the administration of rFVIIa was 5.8 +/- 2.8 mL/kg/h and decreased to 2.0 +/- 1.3 mL/kg/h for the 3 hours following the administration of rFVIIa (P =.002). In the patients that did not receive rFVIIa, chest tube output for the first 3 postoperative hours was 1.6 +/- 0.9 mL/kg/h and 1.2 +/- 0.6 mL/kg/h for the next 3 hours (P = nonsignificant when compared to chest tube output for the 3 hours following rFVIIa in patients who received rFVIIa). No adverse effects were noted. Recombinant factor VIIa decreased chest tubing bleeding following cardiac surgery in children. Given its potential therapeutic impact, rFVIIa warrants further investigation in the pediatric cardiac population.     

先天性心脏病患儿术后希氏束性心动过速治疗效果

目的探讨先天性心脏病患儿术后希氏束性心动过速的治疗效果。方法希氏束性心动过速患儿14例均及时给予抗心律失常治疗。结果14例经胺碘酮、普罗帕酮＋普萘洛尔、低温疗法等治疗后,12例恢复良好,2例死亡。结论小儿先天性心脏病术后尽早明确希氏束性心动过速诊断并给予有效治疗,可取得良好治疗效果。     

Junctional ectopic tachycardia after surgery for congenital heart disease in children

Objective To determine incidence, predictors and outcome [intensive care unit (ICU) mortality and length of stay (LOS)] after postoperative junctional ectopic tachycardia (JET) in an unselected paediatric population. Design Patients with JET (n = 89) were compared with non-JET controls (n = 178) in a nested case–control study. Setting Tertiary ICU at Skejby Sygehus, Aarhus University Hospital, Denmark. Patients The patient records of all children (n = 874) who underwent corrective cardiac surgery on cardio-pulmonary bypass (CPB) between 1998 and 2005 were reviewed for postoperative JET. Methods and results The association between JET and its potential predictors was examined with multivariate conditional regression analyses. The overall incidence of JET was 10.2%. CPB duration > 90 min [adjusted odds ratio (OR) 2.6; 95% confidence interval (CI) 1.1–6.5], high inotropic requirements (adjusted OR 2.6; CI 1.2–5.9) and high postoperative levels of creatine kinase (CK)-MB (adjusted OR 3.1; CI 1.3–7.1) were associated with an increased risk of JET. ICU mortality was higher for patients with JET (13.5%; CI 7.2–22.4%) than for controls (1.7%; CI 0.3–4.8%), and LOS in ICU was 3 times higher in JET patients (median 2 vs. 7 days, p < 0.001). Conclusions JET occurred in approximately 10% of children following cardiac surgery and was associated with higher mortality and longer ICU stay. Risk factors included high inotropic requirements after surgery and extensive myocardial injury in terms of high CK-MB values and longer CPB duration.     

Immune dysfunction in children after corrective surgery for congenital heart disease

OBJECTIVE: To study the effect of open- and closed-heart surgery on the immune status of infants and children. DESIGN: Prospective study. Data collected before anesthesia and surgery and 2 and 24 hrs after surgery. SETTING: Operating room and pediatric ICU in a children's hospital. PATIENTS: Children undergoing surgery for correction of congenital heart disease (age 3 months to 12 yrs). A total of 31 patients were studied (open-heart surgery, n = 25; closed-heart surgery, n = 6). MEASUREMENTS AND MAIN RESULTS: Increased neutrophil counts and lymphopenia were observed after both open- and closed-heart surgery. Serum levels of the complement components C3 and C4 were depressed after open-heart surgery, but not after closed procedures. The percentage of T3+ and T4+ lymphocytes, proliferative responses of the lymphocytes and serum immunoglobulin (Ig)G and IgM were decreased from preoperative levels after open-heart surgery. The percentage of T8+ lymphocytes and serum IgA levels did not change. Intraoperative variables and postoperative severity of illness (Pediatric Risk of Mortality score) did not correlate with immune suppression. CONCLUSIONS: The immune system is affected after pediatric cardiac surgery, particularly after open-heart surgery.     

先天性心脏病患者手术前后生存质量及其影响因素的研究

先天性心脏病(congenital heart disease,CHD)简称先心病,是小儿时期最常见的心血管疾病,是由于胎儿心脏在母体内发育有缺陷或部分发育停顿所造成的畸形.近年来随着治疗技术的不断提高,先心病的病死率大幅度下降[1],但诊断手段的提高,特别是心脏超声的广泛使用,使许多先心病患者得以及时确诊,因此,先心病的患病率增加[2].据统计[3],美国约有100万人受到先心病的侵袭,估计我国每年新出生的先心病患儿达12～15万,是严重危害儿童生命及健康的慢性病之一.     

Procalcitonin kinetics in pediatric patients with systemic inflammatory response after open heart surgery

Objective To evaluate procalcitonin and C-reactive protein as markers of inflammation severity and their value in predicting development of organ failure after pediatric open heart surgery.Design Prospective, observational, clinical study.Setting Single university hospital.Patients Thirty-three pediatric patients with systemic inflammatory response syndrome (SIRS; n = 19) and SIRS+organ failure (SIRS+OF; n = 14) following open heart surgery were included.Measurements and results Plasma procalcitonin and C-reactive protein levels were measured before and after the operation, and 1, 2, 3, and 4 days after surgery. Patients were evaluated daily to assess organ failure. Postoperative procalcitonin levels in the SIRS+OF group were significantly higher than in the SIRS group. C-reactive protein levels were similar between the groups throughout the study period. Peak procalcitonin levels were found to be positively correlated with aortic cross-clamp and cardiopulmonary bypass times, duration of mechanical ventilation, intensive care unit and hospital stay, mortality and organ failure development. Peak procalcitonin was found to be a good predictor of postoperative organ failure development and mortality. However, the predictive value of peak C-reactive protein for organ failure and mortality was found to be weak. Double-peak procalcitonin curves were observed in SIRS+OF patients with infection during the intensive care unit stay.Conclusion In the SIRS+OF group peak procalcitonin levels were found to be highly predictive for mortality and organ failure development, whereas C-reactive protein levels were not. Daily procalcitonin measurements in SIRS+OF patients may help identify the postoperative infection during the follow-up period.     

婴幼儿先天性心脏病快通道手术后喂养时机的研究

目的 探讨婴幼儿先天性心脏病实施快通道手术后喂养时机及其安全性。 方法 纳入 124 例先天性心脏病快通道手术后的患儿,随机分为两组。 实验组采用按需喂养方法,患儿拔除气管插管后,每 30 min 采用 Steward 苏醒评分对其进行评估,当评分 ≥4 分时,开始喂养。 对照组采用常规喂养方法,拔除气管插管后 4 h ,由责任护士采用Steward 苏醒评分对其进行评估,当评分 ≥4 分时开始喂养。 两组患儿的喂养内容及喂养量均一致。 记录两组喂养后不良事件的发生情况,并评估两组患儿拔管后 1 h 、 3 h 、 6 h 、 12 h 的舒适度。 结果 实验组喂养时间为拔除气管插管后（ 2.41±1.04 ） h ,显著早于对照组的 4 h （ P<0.05 ）,两组均未发生恶心、呕吐等胃肠道不良反应。 两组舒适度比较,差异无统计学意义（ P>0.05 ）。 结论 先天性心脏病快通道手术后,可以根据患儿的清醒程度尽早开始喂养,不会增加患儿术后与麻醉相关的胃肠道不适的发生。     

小儿先天性心脏病术后实施强化气道护理策略的价值分析

目的分析小儿先天性心脏病术后实施强化气道护理的应用价值。方法选取本科室2014年7月~2015年5月先天性心脏病行手术的患儿56例,将其随机分为对照组26例和强化组30例,对照组患儿在手术后予常规护理干预,强化组患儿在术后实施强化气道护理干预,观察两组患儿并发症发生率,比较其护理效果。结果对照组患儿并发症的发生率为35%,其中呼吸机相关性肺炎5例、肺不张3例、气胸1例,而强化组患儿并发症的发生率为7%,其中呼吸机相关性肺炎2例、肺不张1例。对照组患儿的并发症发生率高于强化组,差异有统计学意义(P0.05)。结论小儿先天性心脏病术后实施强化气道护理干预能有效降低呼吸机相关性肺炎、气胸以及肺不张等并发症的发生率,实施强化气道护理策略有助于患儿的早日康复。