体外循环对心内直视术患儿S100蛋白的影响

脑损伤仍然是心脏手术病人术后的主要死亡原因。目前的脑损伤诊断主要借助临床神经系统检查、CT、MRI等,但由于心内直视术后病人可能存在意识障碍,或使用人工呼吸机、服用镇静剂以及血压不稳等原因,上述方法并不适合于心脏手术后病人早期检查。S100蛋白对判断体外循环(CPB)术后脑损伤的时间和程度有很大帮助。本研究拟观察先天性心脏病(CHD)患儿心内直视术后S100蛋白的变化。     

含乌司他丁肺保护液在心肺转流术中的肺保护作用

Objective To evaluate protective effects of hypothermic pulmonary protective solution with uli-nastatin on lung function during cardiopulmouary bypass (CPB) in the patients with congenital heart disease(CHD) and pulmonary hypertenion. Method Fifty-four children,who had CHD of left-to-fight shunts with moderate-se-rious pulmonary hypertension, were enrolled. They had been performed with the radical operation under CPB from September 2005 to December 2006 in the Department of Cardiovascular Surgery, Children' s Hospital of Zhejiang University. Moderate-serious pulmonary hypertension was defined as pulmonary-to-systolic pressure ratio > 0.45(Pp/Ps > 0.45). Fifty-four children were randomly divided into three groups. Patients in group A (n = 18)didn't receive pulmonary protective solution, and scrved as control; patients in group B (n = 18) were adminis-tered with pulmonary protective solution without ulinastatin;patients in group C (n = 18) were administered with pulmonary protective solution with ulinastatin. The serum concentrations of MDA and MPO were measured at five different time points:pre-operation, 0 h, 3 h, 6 h and 24 h in the intensive care unit (ICU) (T1～5). Patients'lung functions were monitored at T1 - T4. The time of mechanical ventilation was recorded. Results No one died in this study. The mean time of mechanical ventilation was shorter in the group B and group C than that in the group A. The MDA and MPO levels were lower in group B compared with group A at T4. The MDA level at T3-T5 and the MPO level at T4 was lower in group C than those in group A. There were no significant in MDA and MPO levels between group B and group C at five time point.A-aDO2 was lower in groups B and C than those in group A at T3 and T4, whereas at T4, A-aDO2 was lower in group C than that in group B. Cdyn was higher in group B at T3and group C at T3 - T4 than those in group A. Cdyn was lower in groups C than that in group B at T4.Condusions Lung perfusion with hypothermic protective solution during CPB can all lung injury and promote recovery after operation, especialy with ulinastatin.     

婴幼儿体外循环术后毛细血管渗漏的危险因素

目的 探讨婴幼儿先天性心脏病(简称先心)患儿经历体外循环手术后发生毛细血管渗漏综合征(capillary leak syndrome,CIS)的相关危险因素,为预防和控制CIS的发生提供依据.方法 回顾性研究浙江大学医学院附属儿童院2003年6月至2007年7月38例行体外循环手术后发生CIS的婴幼儿先心患儿的临床资料,对照组为随机抽取同期150例行体外循环手术后未发生CLS的婴幼儿先心患儿,对可能引起CLS的因素采用二分类进行单因素和多因素非条件Logistic逐步回归分析,以确定与CLS发病相关的独立危险因素;并对两组患儿术后治疗转归进行总结.结果 ①Logistic回归分析显示发生CIS的独立危险因素按OR值排序分别是:体外循环时间≥120 min(OR=10.353)、紫绀型心脏病(OR=6.912)、年龄≤1岁(OR=6.254)、体外循环温度≤25 ℃(OR=4.151).②CLS组行腹膜透析10例,死亡4例;对照组无腹膜透析病例及死亡病例.结论 体外循环时间、心脏病类型、年龄、体外循环温度是婴幼儿体外循环术后发生CLS的独立危险因素.     

肺保护液对肺动脉高压患儿体外循环后炎性反应的影响

肺损伤是先天性心脏病患儿体外循环后常见的并发症,在合并肺血管病变如肺动脉高压时肺损伤较为严重,导致动脉氧合不足、肺间质水肿和肺顺应性下降等[1].研究表明,经肺动脉灌注低温肺保护液可明显改善肺动脉高压患儿体外循环后的肺功能[2].本研究拟评价肺保护液对肺动脉高压息儿体外循环后炎性反应的影响,探讨其肺保护作用的可能机制.     

Nuss手术治疗小儿漏斗胸50例分析

先天性漏斗胸是一种常见的胸廓畸形。患儿常因胸廓畸形,心肺受压,肺功能降低,表现为活动耐力差,肺活量低,易发生心悸及呼吸道感染,严重影响小儿生长发育。微创漏斗胸矫正术(Nuss手术)由于其具有创伤小、不切骨、手术时间短、疤痕小等优点而得到推广应用,但其需要使用特制的价格昂贵钢板,并且容易发生术中胸膜损伤造成气胸、胸腔积液、肺不张以及术后钢板滑动和旋转等并发症[1],故术后监护尤为关键。本院2004年8月至2006年2月行Nuss手术治疗漏斗胸患儿50例,术后入ICU监护,效果满意,报道如下。1临床资料1.1一般资料本组50名患者中男性30例,…     

小儿低温体外循环围术期甲状腺功能的变化

探讨先天性心脏病患儿在围体外循环期甲状腺激素的动态变化与临床意义。方法：用放射免疫法测定３１例先心病ＣＰＢ手术（Ⅰ组）围术期的血清 腺素水平,并与９例普通胸科手术者（Ⅱ组）作对照。结果：Ⅰ组术后即刻出现低Ｔ３、Ｔ４,并逐渐加重,持续３－５ｄ后,恢复至术前水平;Ⅱ组手术前后甲状腺素水平对比差异无显著意义。     

小儿动脉导管未闭结扎手术中硝普钠降压效果探讨

目的 :比较小儿动脉导管未闭 (PDA)手术不同麻醉方法对硝普钠 (SNP)降压效果的作用。方法 :选择 6 0例 3～ 12岁施行手术患儿 ,随机分成两组 ;观察两组达到理想控制降压所需SNP的平均最大剂量 ,以及降压过程伴随的心率 (HR)、心率收缩压乘积 (RPP)变化。结果 :与Ⅱ组对比Ⅰ组SNP用量显著降低 (为 2 47± 2 2 0 μg·kg 1·min 1) ;降压期间Ⅱ组HR明显增快 (P <0 0 5 ) ,RPP显著增高 (P <0 0 5 ) ;麻醉期间Ⅰ组Isof吸入浓度显著低于Ⅱ组 (P <0 0 5 )。结论 :采用全麻加硬膜外或骶管阻滞可增强SNP的降压效果 ,减少其用量和副作用 ,提高了SNP的使用安全性。     

5 kg以下低体重婴儿室间隔缺损的外科治疗

目的:探讨5 kg以下低体重婴儿室间隔缺损(VSD)的外科治疗适应证、手术时机、手术技术及围术期处理。方法:回顾性分析2001年1月至2005年12月期间,5kg以下VSD婴儿134例,年龄(3.9±1.9)月。患儿均于体外循环下行室间隔缺损修补术及同期合并畸形矫治术。结果:全组术后早期死亡1例,死亡率0.7%,死亡原因心律失常,心功能衰竭。术后并发肺炎14例,肺高压危象6例,肺不张4例,心律失常4例,低心排4例,胸腔积液1例。133例随访6个月~6年,生长发育良好;VSD残余分流2例,1年后超声心动图证实已自动愈合。结论:低体重婴儿VSD的外科治疗效果良好,正确选择手术适应证和时机、正确合理的体外循环和手术方法、加强围术期处理是提高治疗效果的关键。     

含乌司他丁肺保护液在心肺转流术中的肺保护作用

Objective To evaluate protective effects of hypothermic pulmonary protective solution with uli-nastatin on lung function during cardiopulmouary bypass (CPB) in the patients with congenital heart disease(CHD) and pulmonary hypertenion. Method Fifty-four children,who had CHD of left-to-fight shunts with moderate-se-rious pulmonary hypertension, were enrolled. They had been performed with the radical operation under CPB from September 2005 to December 2006 in the Department of Cardiovascular Surgery, Children' s Hospital of Zhejiang University. Moderate-serious pulmonary hypertension was defined as pulmonary-to-systolic pressure ratio > 0.45(Pp/Ps > 0.45). Fifty-four children were randomly divided into three groups. Patients in group A (n = 18)didn't receive pulmonary protective solution, and scrved as control; patients in group B (n = 18) were adminis-tered with pulmonary protective solution without ulinastatin;patients in group C (n = 18) were administered with pulmonary protective solution with ulinastatin. The serum concentrations of MDA and MPO were measured at five different time points:pre-operation, 0 h, 3 h, 6 h and 24 h in the intensive care unit (ICU) (T1～5). Patients'lung functions were monitored at T1 - T4. The time of mechanical ventilation was recorded. Results No one died in this study. The mean time of mechanical ventilation was shorter in the group B and group C than that in the group A. The MDA and MPO levels were lower in group B compared with group A at T4. The MDA level at T3-T5 and the MPO level at T4 was lower in group C than those in group A. There were no significant in MDA and MPO levels between group B and group C at five time point.A-aDO2 was lower in groups B and C than those in group A at T3 and T4, whereas at T4, A-aDO2 was lower in group C than that in group B. Cdyn was higher in group B at T3and group C at T3 - T4 than those in group A. Cdyn was lower in groups C than that in group B at T4.Condusions Lung perfusion with hypothermic protective solution during CPB can all lung injury and promote recovery after operation, especialy with ulinastatin.     

无创正压通气减少儿童心内直视术后再次插管

目的 探讨鼻(面)罩双水平无创正压通气(bilevel positive airway pressure,BiPAP)应用于儿童心内直视术后呼吸功能不全的呼吸支持,减少再次插管的疗效.方法 将2007年1月至2007年12月在浙江大学医学院附属儿章医院行先天性心脏病(先心病)体外循环心内直视术后在拔除气管插管后表现呼吸费力、呼吸功能不全经常规治疗无效,已符合二次插管机械通气指征的25例患者进行前瞻性研究,记录无创BiPAP通气应用前后临床和动脉血气等指标的变化并进行单因素方差分析,同时分析患者的转1月.结果 (1)25例患者共30例次接受无创鼻(面)罩BiPAP.其中25例次患者(25/30,83.3%)在应用无创BiPAP通气后成功地避免了再次插管.4例患者共5例次接受无创鼻(面)罩BiPAP呼吸衰竭无法改善予气管捕管.(2)该组患者平均在撤离有创通气后9.4 h(0-72)h应用无创BiPAP治疗,BiPAP应用时间1.96 d(0.03-12)d,并发症少而轻微.(3)应用无创BiPAP治疗1 h后患者心率、呼吸频率及心率收缩压乘积显著降低(P<0.05);同时血气pH,SaO2 PaO2/FiO2显著升高(P<0.05),A-aDO2显著下降(P<0.05);4 h后PaCO2显著下降(P<0.05).结论 无创鼻(面)罩BiPAP正压通气可显著改善体外循环心内直视术后呼吸功能不全患儿的氧合,降低氧耗量,减少再次插管,是一种安全有效的无创的呼吸支持手段.