体外循环下心脏瓣膜病换瓣术后ICU延迟脱离呼吸机病例对照研究

目的探讨心脏瓣膜病换瓣术后住ICU延迟脱离呼吸机的危险因素,为制订心脏瓣膜病换瓣术后住ICU延迟脱离呼吸机的防治措施提供依据。方法采用回顾性病例对照研究和非条件logistic多元回归分析方法,收集宜昌市第一人民医院重症医学科2008年1月至2012年1月心脏瓣膜病换瓣术后的71例患者资料,33例住ICU延迟脱离呼吸机患者与脱呼吸机时间无延迟的38例患者进行对照研究。结果心脏瓣膜病换瓣术后住ICU脱呼吸机时间延迟发生率为46．47％。心脏瓣膜病换瓣术后住ICU延迟脱离呼吸机的危险因素有术后低心排、术后。肾功能衰竭、年龄≥50岁、ST—T改变、住ICU〉5d等。心脏瓣膜病换瓣术后住ICU延迟脱离呼吸机的独立危险因素有：术后低心排（OR=5．329,95％CI1．682-16．881）、术后肾功能衰竭（OR=3．163,95％CI1．007-9．931）。结论心脏瓣膜病换瓣术后住ICU延迟脱离呼吸机的独立危险因素是术后低心排和肾功能衰竭。明确心脏瓣膜病换瓣术后住ICU延迟脱离呼吸机的危险因素,以缩短心脏瓣膜病换瓣术后呼吸机机械通气时间。     

早期经皮扩张气管切开对长期机械通气患者预后的影响

目的探讨早期气管切开对长期机械通气患者预后的影响。方法回顾分析衡水市哈励逊临床医学院重症医学科2009年6月至2012年11月经皮扩张气管切开的患者178例,按气管切开时间分为早期气管切开组（机械通气≤10d）及晚期气管切开组（机械通气〉10d）,比较两组患者呼吸机相关性肺炎（VAP）的发生率、机械通气时间、住ICU时间和28d病死率。结果早期气管切开组VAP的发生率低于晚期气管切开组,机械通气时间及住ICU时间均明显缩短,28d病死率差异无统计学意义。结论对于需要长时间机械通气患者,早期气管切开可以降低VAP的发生率,缩短患者机械通气时间及住ICU时间,但对患者28d病死率无影响。     

Preoperative predictors of prolonged postoperative mechanical ventilation in children following scoliosis repair

Scoliosis is associated with progressive restrictive lung disease and an increased risk of pulmonary complications following surgical correction. Identification of higher risks for prolonged postoperative mechanical ventilation (MV) improves postoperative care. Our objective was to determine if preoperative pulmonary function tests (PFT) predict prolonged postoperative MV (defined as MV >or=3 days). We correlated preoperative PFT (forced expired volume in 1 sec, FEV1; vital capacity, VC; inspiratory capacity, IC; maximal inspiratory pressure, MIP; total lung capacity, TLC; and residual volume, RV) and postoperative MV days in 125 patients who had scoliosis surgery (aged 13.7 +/- 3.0 (SD) years) from January 1990-July 2001. We had 71 male and 54 female patients. Scoliosis types were 13 congenital, 27 idiopathic, 57 neuromuscular, 23 syndrome/tumor, and 5 kyphoscoliosis. Forty patients (32%) had postoperative MV >or=3 days. Independent factors likely requiring postoperative MV >or=3 days were neuromuscular scoliosis (P < 0.001) and FEV1 <40% predicted. Independent factors most likely were: neuromuscular scoliosis with preoperative FEV1 <40% predicted (P < 0.01). Independent factors most unlikely were: idiopathic scoliosis (P < 0.002). VC <60% predicted, IC <30 ml/kg, TLC <60% predicted, and MIP <60 cm H2O correlated with postoperative MV >or=3 days (P < 0.05). We found no association between RV and postoperative MV. FEV1 <40% predicted, VC <60% predicted, IC <30 ml/kg, TLC <60% predicted, MIP <60 cm H2O, and neuromuscular disease each correlated with prolonged postoperative MV. Neuromuscular disease or a preoperative FEV(1) <40% predicted were more likely, and older children with neuromuscular disease and FEV1 <40% predicted were most likely to require prolonged postoperative MV (P < 0.01). Clearly FEV1, and possibly VC, IC, TLC, and MIP, may increase accuracy in predicting the need for prolonged postoperative MV.     

无创机械通气在心外科术后患者中的应用

目的探讨无创性经面罩机械通气在心外科手术后患者中应用的经验。方法回顾性分析2001年9月至2001年12月在本院心外科手术后患者拔除气管插管后需再次机械通气的资料。结果共有22例患者进入本组分析,占同期心外科手术患者的5.7%。其中12例患者首选无创机械通气(NIMV),10例患者首选气管插管。两组患者年龄、体外循环时间、主动脉阻断时间、首次拔管时间、再次机械通气时间、ICU停留时间差异均无显著意义,但NIMV组患者APACHEII评分显著低于气管插管组。12例NIMV患者中,8例患者经NIMV过渡后痊愈;4例患者中途改行气管插管,原因分别为神志异常不能配合咳痰(2例)、人机对抗(2例)。全部12例患者均成功转出ICU,无一例患者死亡。12例NIMV患者中除1例患者腹胀外无其它并发症,无感染病例。10例首选气管插管机械通气患者中6例痊愈,4例患者死亡。结论无创性经面罩机械通气是改善肺泡通气的一种有效方法,在选择性心外科手术后患者中可能会降低术后再插管的需要。     

无创机械通气在心外科术后患者中的应用

目的探讨无创性经面罩机械通气在心外科手术后患者中应用的经验。方法回顾性分析2001年9月至2001年12月在本院心外科手术后患者拔除气管插管后需再次机械通气的资料。结果共有22例患者进入本组分析，占同期心外科手术患者的5．7％。其中12例患者首选无创机械通气（NIMV）．10例患者首选气管插管。两组患者年龄、体外循环时间、主动脉阻断时间、首次拔管时间、再次机械通气时间、ICU停留时间差异均无显著意义，但NIMV组患者APACHEⅡ评分显著低于气管插管组。12例NIMV患者中，8例患者经NIMV过渡后痊愈；4例患者中途改行气管插管，原因分别为神志异常不能配合咳痰（2例）、人机对抗（2例）。全部12例患者均成功转出ICU，无一例患者死亡。12例NIMV患者中除1例患者腹胀外无其它并发症．无感染病例。10例首选气管插管机械通气患者中6例痊愈，4例患者死亡。结论无创性经面罩机械通气是改善肺泡通气的一种有效方法，在选择性心外科手术后患者中可能会降低术后再插管的需要。     

Prediction of Pulmonary Arterial Pressure Level after Repair of Congenital Cardiac Communications and Discharge from the Hospital: Role of Down Syndrome and Early Postoperative Hemodynamics

Background: Postoperative pulmonary hypertension limits the success of surgical treatment in some patients with unrestrictive congenital cardiac communications. Identifying patients at risk of developing postoperative pulmonary hypertension is important to individualize follow-up strategies. Methods: We analyzed a prospective cohort of 52 pediatric patients (age 3 to 35 months) looking for perioperative predictors of mildly elevated pulmonary arterial pressure 6 months after surgery, defined as a systolic pressure greater than 30 mmHg by transthoracic echocardiography. This corresponds to a mean pulmonary arterial pressure of >20 mmHg. Clinical, echocardiographic and hemodynamic parameters were investigated. Perioperative hemodynamics was assessed by directly measuring pulmonary and systemic arterial pressures using indwelling catheters. Early postoperative pulmonary hemodynamics was defined as the mean pulmonary/systemic mean arterial pressure ratio (PAP/SAP) obtained per patient during the first 6 h of postoperative care. Results: Among the factors that were investigated as possible predictors, perioperative hemodynamics and the presence of Down syndrome were initially selected using univariate analysis (p < 0.030). Early postoperative PAP/SAP was correlated with PAP/SAP obtained in the operating room just after cardiopulmonary bypass (r = 0.70, p < 0.001), and it was higher in subjects with Down syndrome than in nonsyndromic individuals (p = 0.003). Early postoperative PAP/SAP was the only predictor selected using multivariate analysis. It was characterized as an independent predictor after adjustments for possible confounders. An early postoperative PAP/SAP of >0.35 was 76% sensitive and 74% specific at predicting a systolic pulmonary arterial pressure of >30 mmHg 6 months after surgery (hazard ratio with 95% CI 8.972 [2.428–33.158], p = 0.002). Conclusion: The hypertensive early postoperative behavior of the pulmonary circulation was strongly but not exclusively associated with Down syndrome, and it was characterized as an independent predictor of altered pulmonary arterial pressure after discharge from the hospital.     

Risk factors for and outcomes of prolonged mechanical ventilation in patients received DeBakey type I aortic dissection repairment

BackgroundThis study aimed to identify risk factors for prolonged mechanical ventilation (PMV) and its association with disease prognosis following acute DeBakey type I aortic dissection surgery.MethodsA total of 582 patients who received emergency surgery for acute DeBakey type I aortic dissection from 2014 to 2018 were enrolled in this study. Mechanical ventilation period after surgery longer than 48 hours was defined as postoperative PMV. Multiple logistic regression analysis was used to identify risk factors for PMV. This study also compared short- and long-term outcomes in patients who developed PMV with patients who did not develop this complication. To identify and compare long-term cumulative survival rate, Kaplan-Meier survival curve was plotted.ResultsAmong all enrolled patients, 259 (44.5%) received PMV treatment. Our data suggested that the length of intensive care unit and hospital stay were longer for patients who received PMV treatment. Thirty-day mortality was also higher in patients with PMV than in patients without PMV. Elevated leukocyte count and increased serum cystatin C level upon admission, lower preoperative platelet count and longer cardiopulmonary bypass (CPB) duration were identified as risk factors for PMV. Interestingly, our data suggested that there was no significant difference of survival rate between patients with or without PMV history.ConclusionsPMV after DeBakey type I aortic dissection repair surgery was a common complication and associated with increased short-term mortality rate but did not affect long-term mortality rate. Elevated preoperative leukocyte count, increased preoperative serum cystatin C level, lower preoperative platelet count and longer CPB duration were risk factors for PMV.     

Down综合征并发先天性心脏病的临床分析

目的：总结分析Down综合征（Down’s syndrome）并发的先天性心脏病畸形及血流动力学资料。方法：2008年7月-2012年10月,采用经胸二维超声心动图并彩色多普勒显像及右心导管／心血管造影检查方法,诊断36例并发先心病的Down综合征患者,本文通过36例临床资料分析,探讨Down综合征并发的先心病畸形及其血流动力学。结果：36例患者中室间隔缺损（VSD）10例,房室间隔缺损（AVSD）6例,动脉导管未闭（PDA）6例,房间隔缺损（ASD）2例,ASD＋PDA2例,ASD＋VSD1例,ASD＋PDA＋VSD1例,VSD＋PDA4例,PDA十二叶主动脉瓣（BAV）1例,法洛四联症（TOF）2例,TOF＋ASD1例,18例有肺动脉高压者,其中5例为阻力型肺动脉高压。结论：①Down综合征并发的心血管畸形中,以VSD、AVSD和PDA最为常见,并常并发ASD、TOF。②在无肺动脉狭窄的患者中,约50％并发有肺动脉高压。     

瓣膜置换术后机械通气时间延长的危险因素分析

目的 分析瓣膜置换术后机械通气时间延长(≥48 h)的危险因素.方法 回顾我院2010年1月～2011年8月行心脏瓣膜置换术的518例患者的临床资料,并对术后机械通气辅助呼吸时间延长(≥48 h)的危险因素进行分析.结果 手术后机械通气时间超过48 h的患者72例,发生率13.9％.单因素分析结果表明,患者的年龄、心功能分级、术前血浆BNP水平、射血分数、肺动脉收缩压、同期行冠状动脉旁路移植手术、主动脉内球囊反搏支持、体外循环时间、主动脉阻断时间、置换瓣膜的数量、术后使用多巴胺≥10 μg/( kg·min)以及术后使用肾上腺素与患者术后机械通气时间延长相关(P＜0.05或P＜0.01),上述因素进入二元逐步Logistic回归分析,结果显示患者的心功能分级、肺动脉收缩压和术后使用多巴胺≥10μg/(kg·min)与术后机械通气时间延长独立相关(P＜0.05或P＜0.01).结论 瓣膜置换术后机械通气时间延长的影响因素较多,其中患者的心功能分级、肺动脉收缩压和术后使用多巴胺≥10μg/(kg·min)是患者术后机械通气时间延长的独立危险因素.     

冠状动脉旁路移植术后延迟拔管病例对照研究

目的 探讨冠状动脉旁路移植术(CABG)后延迟拔管的危险因素.方法 回顾性纳入2008年1月至2013年1月宜昌市第一人民医院重症医学科CABG术后全部患者,以延迟拔管术后机械通气(＞48 h)者作为观察组,以术后无延迟拔管的患者作为对照.对潜在危险因素进行对比分析,并采用非条件logistic多元回归分析.结果 共收治CABG术后患者92例,其中延迟拔管患者24例,发生率为35.29％.单因素分析结果显示,低心排、近期心梗、IABP、急诊手术、再次手术、CRRT、术后住ICU时间延长是CABG术后延迟拔管的高危因素.Logistic多因素回归分析显示,术后低心排[优势比(OR)=11.809,95％可信区间(95％CI)为(2.61353.364)]是CABG术后延迟拔管的独立危险因素(P＜0.05).结论 低心排是CABG术后延迟拨管的独立危险因素.     

舒芬太尼与芬太尼对小儿心脏手术乳酸水平影响的回顾性研究

目的:通过对非发绀先天性心脏病(先心病)小儿心脏手术中乳酸水平的大样本回顾分析,对比舒芬太尼与芬太尼复合麻醉乳酸水平以及高乳酸血症的发生率。方法:选择我院2006年10月至2008年11月期间实施的新生儿、婴幼儿心脏手术405例,年龄11～1095d平均(353.72±249.84)d,美国麻醉医师学会(ASA)Ⅰ～Ⅱ级。根据麻醉方法分成芬太尼组(F组,210例)和舒芬太尼组(S组,195例)。2组均为静吸复合麻醉,诱导麻醉F组芬太尼5～l0μg/kg,S组舒芬太尼0.5～1μg/kg;维持麻醉F组芬太尼总量(50.43±30.41)μg/kg,S组舒芬太尼(9.12±4.44)μg/kg,2组均间断吸入异氟烷(0.5%～1%),静脉注入咪达唑仑和哌库溴铵。收集切皮前(T1)、体外循环心脏复跳后10min(T2)、体外循环结束后15min(T3)、ICU1h(T4)、ICU8h(T5)、ICU24h(T6)6个时间点动脉血乳酸值,比较2组各个时间点高乳酸血症(乳酸值≥3mmol/L)的发生率和乳酸值变化趋势。结果:全组T2点乳酸值明显高于其它各点(P0.01),并且与年龄、体质量呈明显负相关性,与手术时间、体外循环时间、阻断主动脉时间、拔气管导管时间及ICU停留时间等呈明显正相关性(P0.01)。S组年龄、体质量、手术时间、体外循环时间及阻断主动脉时间、拔气管导管时间及ICU停留时间与F组比较差异无统计学意义(P0.05)。S组T1、T2、T3及T4点乳酸值均明显低于F组(P0.01);S组T2、T3点高乳酸血症发生率明显低于F组(P0.05)。结论:手术中,与芬太尼比较,舒芬太尼能够降低乳酸水平,明显降低高乳酸血症发生率,对改善非发绀先心病小儿心脏手术中的乳酸代谢有明显积极作用。     

Ultrasonography assessment of vocal cords mobility in children after cardiac surgery

ObjectivesUpper airway obstruction after pediatric cardiac surgery is not uncommon. In the cardiac surgical population, an important etiology is vocal cord paresis or paralysis following extubation. In this study, we aimed to evaluate the feasibility and accuracy of ultrasonography (US) assessment of the vocal cords mobility and compare it to fiber-optic laryngoscope (FL).Material and methodsA prospective pilot study has been conducted in Pediatric Cardiac ICU (PCICU) at King Abdulaziz Cardiac Center (KACC) from the 1st of June 2009 till the end of July 2010. Patients who had cardiac surgery manifested with significant signs of upper airway obstruction were included. Each procedure was performed by different operators who were blinded to each other report. Results of invasive (FL) and non-invasive ultrasonography (US) investigations were compared.ResultsTen patients developed persistent significant upper airway obstruction after cardiac surgery were included in the study. Their mean ± SEM of weight and age were 4.6 ± 0.4 kg and 126.4 ± 51.4 days, respectively. All patients were referred to bedside US screening for vocal cord mobility. The results of US were compared subsequently with FL findings. Results were identical in nine (90%) patients and partially different in one (10%). Six patients showed abnormal glottal movement while the other four patients demonstrated normal vocal cords mobility by FL. Sensitivity of US was 100% and specificity of 80%.ConclusionUS assessment of vocal cord is simple, non-invasive and reliable tool to assess vocal cords mobility in the critical care settings. This screening tool requires skills that can be easily obtained.     

A study of mechanical ventilation in the ICU after cardiac surgery: a bibliometric analysis

BackgroundAfter cardiac surgery, patients are often admitted to the intensive care unit (ICU) due to various preoperative factors and continue to receive mechanical ventilation. This study sought to conduct a bibliometric analysis to summarize studies on mechanical ventilation among postoperative ICU patients who had undergone cardiac surgery.MethodsWe searched the Science Citation Index Expanded (SCI-E) database using the following terms: “cardiac surgery (Topic)”, “intensive care (Topic)” and “ventilation (Topic)”. The search results were analyzed using R software. The analysis examined the number of publications of relevant articles and the annual change trend, the number of times an article was cited and the annual change trend, the distribution of countries conducting the research, the cooperation between countries and the citation frequency, the distribution of institutions conducting research, the cooperation between institutions, and the citation frequency, the number of published articles, the cooperation among researchers, and the citations frequency of researchers, the journals in which the articles were published, and the use of keywords.ResultsA total of 1,969 relevant research papers were included in this study. The main countries that conducted the relevant research included the United States (US), China, Germany, and Canada. The research institutions were mainly located in the US and Canada, and the main researchers were from research institutions in these countries. The most cited authors were Zappitelli, Hichey, and Wypij. According to Bradford''s law, 9 core journals in this field were identified. The results of the keyword analysis showed that in the past 10 years, research has focused on the mortality of patients, but only a few related random controlled trials have been conducted.ConclusionsMore randomized controlled trials need to be conducted in this field to provide higher evidence-based medical evidence.     

Noninvasive mechanical ventilation and corrective surgery for treatment of a child with severe kyphoscoliosis

We report on an 11-year-old boy with severe kyphoscoliosis and respiratory failure. Noninvasive mechanical ventilation by nasal mask and hospitalization resulted in improved pulmonary function, thus facilitating corrective surgery for kyphoscoliosis. Following surgery, the patient remained on mechanical ventilation at home. Clinical and pulmonary function stabilized after discharge, as noted on a 1-month follow-up visit.     

机械通气在儿科重症毛细支气管炎中的应用

目的 研究机械通气在儿科重症毛细支气管炎中的应用.方法 选取我院收治的重症毛细支管炎患儿80例,随机分为治疗组和对照组中.对照组采用常规治疗,治疗组在常规治疗基础上再予以机械通气治疗,比较两组患者治疗临床效果.结果 治疗组治疗后的临床症状改善情况明显优于对照组.治疗组呼吸频率和心率较对照组下降更明显,其血PCO2下降、血PO2升高程度亦比对照组显著,两组差异有统计学意义（P〈0.05）.结论 机械通气可以代替患者自主呼吸,缓解了患儿的乏氧状况,对重症毛细血管炎的有很好的治疗效果.     

慢性阻塞性肺疾病患者长期人工通气撤机指标的临床研究

目的评价床边综合肺功能作为长期人工通气的慢性阻塞性肺疾病（COPD）患者脱机指标的指导意义。方法监测58例（成功组：43例,失败组：15例）通气时间＞72h的COPD呼衰患者达到临床脱机标准后的血气分析、肺功能及呼吸力学的改变情况。结果两组患者的血气分析、急性生理、慢性健康评分（APACHEⅡ）、氧合指数、动态顺应性及气道阻力均无显著差异（P均＞0．05）;成功组患者的肺活量／潮气量（VC／V_T）、最大吸气负压（Pi_(max)）和浅快呼吸指数（f／V_T）分别为：2．10±0．20、（－21±4）cmH_2O及（74±30）次·min~(-1)·L~(-1);失败组患者则依次为1．30±0．20、（－13±3）cmH_2O及（115±20）次·min~(-1)·L~(-1),两组结果比较差异有显著性,P均＜0．05。以VC／V_T＞1．8、Pi_(max)＜－18cmH_2O和f／V_T＜105次·min~(-1)·L~(-1)作为临界值预测此类患者脱机成功与否,具有较高的敏感性（84％）和特异性（90％）。结论　综合肺功能指标（VC／V_T、Pi_(max)及f／V_T）可用于指导长期通气的COPD患者选择脱机时机,适宜在我国目前条件下推广普及。     

Distinctive hematological abnormalities in East Asian neonates and children with Down syndrome

Introduction: Neonates with Down syndrome (DS) are predisposed to developing transient abnormal myelopoiesis (TAM) and acute myeloid leukemia (AML) associated with DS. However, there is a paucity of data on hematological aberrations and GATA1 mutations in neonates with DS in East Asian populations. Methods: Total 109 patients with DS who had one or more CBCs obtained were enrolled. The molecular analysis of the GATA1 gene performed in 10 patients (three TAM, three AML associated with DS at diagnosis, one remission case of AML associated with DS and three DS without TAM or AML). Results: East Asian DS neonates showed low frequency of thrombocytopenia, uncommon neutrophilia and higher prevalence rate of TAM compared to previous reports from western countries. GATA1 mutations were identified in almost all TAM and AML associated with DS samples, but were not detected in the samples from DS without TAM or AML associated with DS. Conclusion: East Asian DS neonates and children showed distinctive spectrum of hematological abnormalities.     

Airway anomalies in children with Down syndrome: endoscopic findings

Down syndrome (DS) is the most common chromosomal anomaly in humans. Numerous congenital malformations associated with DS have been described. However, there are insufficient data available about airway anomalies. Our objective was to characterize the clinical presentation, frequency, and type of airway anomalies in a population of patients with DS. A retrospective evaluation of flexible bronchoscopies performed in 24 DS patients due to significant respiratory morbidity was compared to the findings in 324 non-DS patients during the same time period. The procedure was carried out under sedation, using an Olympus BF3C20 bronchoscope. The main indications for the procedure were atelectasis of the right upper lobe (12/24) and stridor (7/24). The most common associated conditions were congenital heart disease (12/24) and reactive airways disease (12/24). The most important endoscopic findings were: laryngomalacia (12/24), tracheomalacia (8/24), tracheal bronchus (5/24), and bronchomalacia (5/24). Only six patients had a normal examination. Multiple airway anomalies (>/=2) were a common finding in this series. We conclude that patients with DS and respiratory symptoms have a high incidence of airway anomalies compared to non-DS patients. The clinician should have a high index of suspicion for airway anomalies in DS patients with respiratory symptoms.