米力农对小儿心脏直视术后血液动力学的效应

目的探讨静脉米力农制剂对先心病术后患儿血液动力学的效应。方法22例患儿随机分为用药组15例,对照组7例。观察(1)体、肺动脉压(sAP/mAP、sPAP/mPAP)、右房压(mRAP)、体、肺血管阻力(SVRI)、心排指数(CI)、HR、率压指数(RPI)的变化;(2)不同静脉维持量的疗效。结果(1)用药前,负荷后肺血管阻力指数(PVRI)、mPAP降低21.9％、13.3％;SVRI、mRAP、mAP降低21.4％、14.7％、8.1％;CI和HR上升16.1％和5.8％(P＜0.01,P＜0.05),而RPI无明显变化。(2)对照B组,3种维持量均降低PVRI、SVRI,提高CI(P＜0.01),高剂量下PVRI、mPAP维持最低而CI、SI保持最佳,且中、高剂量对mAP无影响。(3)心律失常和血小板下降发生率9.1％。结论米力农是治疗术后肺高压和低心排有效,且相对安全的强心扩血管药物。     

儿童气道梗阻

儿童气道梗阻的病因包括外来压迫和腔内梗阻。其临床表现多非特异性,部分与哮喘和慢性支气管炎重叠,尤其合并先天性心脏病时,伴发的呼吸道症状常掩盖了气道自身病变,故较难识别。因此,对反复或持续呼吸道感染、肺不张、粗糙咳嗽、严重喘鸣、吸入性胸骨凹陷、活动耐量降低、呼吸困难、窒息或有长期插管史且不能用其他原因解释的患儿应高度怀疑气道梗阻。纤维支气管镜检是诊断气道梗阻的一线筛查方法,三维CT和MRI血管造影适用于腔外梗阻,尤其是血管来源气道受压者的评估。有明显呼吸道症状、中等或严重程度的气道梗阻者一经诊断应尽早手术治疗,以降低并发症和病死率。术后持续的气道梗阻与残余压迫、继发性气道管壁软化或气管自身缺损有关。支架植入仅适用于全身状况较差、不能耐受手术或心血管畸形纠治术后长期插管的气道梗阻者。     

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目的分析法洛四联症(TOF)根治术后急性肺损伤(ALI)的原因,总结治疗体会。方法2003年7月至2004年6月,上海第二医科大学附属新华医院上海儿童医学中心心胸外科共行TOF根治术161例,发生ALI5例。记录5例ALI患儿术前经皮氧饱和度(SpO2)、红细胞压积比(HCT)、McGoon比值、肺动脉指数(PAI)和手术、体外循环(CPB)资料,以及ALI发生时间、ALI发生后各项治疗措施、各治疗阶段肺功能指标、计算其肺损伤分数。结果5例ALI患儿,年龄7～24(13.8±3.1)个月,体重7.0～9.5(8.2±0.5)kg,均在静吸复合麻醉CPB下进行,术毕给予改良超滤,平均CPB时间(67.2±5.9)min,主动脉阻断时间(43.6±2.4)min,ALI发生率为3.1%,发生时间为术后8～60h,死亡2例。5例均施行腹膜透析术(PD),2例给予一氧化氮吸入,1例给予肺表面活性物质替代治疗。各治疗阶段肺功能指标逐步改善,至治疗后期,肺功能指标在统计学上有显著性差异(P<0.05)。结论TOF术后ALI治疗困难,合理机械通气、尽早维持体液平衡、改善肺通气和氧合功能有利于及时阻断低氧酸中毒导致的恶性循环。     

法洛四联症根治术后急性肺损伤的治疗

目的 分析法洛四联症(TOF)根治术后急性肺损伤(ALI)的原因，总结治疗体会。 方法 2003年7月至2004年6月，上海第二医科大学附属新华医院上海儿童医学中心心胸外科共行TOF根治术161例，发生ALI 5例。记录5例ALI患儿术前经皮氧饱和度(SpO2)、红细胞压积比(HCT)、McGoon比值、肺动脉指数(PAI)和手术、体外循环(CPB)资料，以及ALI发生时间、ALI发生后各项治疗措施、各治疗阶段肺功能指标、计算其肺损伤分数。 结果 5例ALI患儿，年龄7~24(13.8±3.1)个月，体重7.0~9.5(8.2±0.5)kg，均在静吸复合麻醉CPB下进行，术毕给予改良超滤，平均CPB时间(67.2±5.9)min，主动脉阻断时间(43.6±2.4)min，ALI发生率为3.1%，发生时间为术后8~60h，死亡2例。5例均施行腹膜透析术(PD)，2例给予一氧化氮吸入，1例给予肺表面活性物质替代治疗。各治疗阶段肺功能指标逐步改善，至治疗后期，肺功能指标在统计学上有显著性差异(P<0.05)。 结论 TOF术后ALI治疗困难，合理机械通气、尽早维持体液平衡、改善肺通气和氧合功能有利于及时阻断低氧酸中毒导致的恶性循环。 Abstract Objective To analyse the reasons of acute lung injury (ALI) after the surgical correction of tetralogy of Fallot (TOF) and summarize the postoperative treatment skill.Methods There were 161 cases of patients with TOF who underwent corrective repair operation in the Department of Cardiovascular Surgery of Xinhua Hospital/ Shanghai Children’s Medical Center from Jul.2003 to Jun.2004,in which there were 5 patients who developed ALI after the surgical correction of TOF.The mean age was 13.8±3.06 months (7~24 months) and the mean body weight was (8.20±0.46)kg (7~9.5kg).Before operation,their mean SpO2 was (72.8±2.2)% (67%~80%),mean HCT was (49.0±5.5)%,mean McGoon ratio was (1.27±0.05) and mean PAI was (136.0±16.8)mm2/m2.The total cardiopulmonary bypass (CPB) time and aortic clamp time were (67.2±3.9) min and (43.6±2.4) min,respectively.The modified ultrafiltration was used throughout the CPB.The treatment and the blood analysis were recorded when the ALI developed.The parameters of pulmonary function and lung injury score were calculated.Results ALI developed (30.0±9.7) hrs after the operation and the incidence of ALI after the surgical correction of TOF was 3.1%.Two cases died within 48 hrs.Peritoneal dialysis (PD) was performed on all the cases.Meanwhile,2 cases were given inhaled nitric oxide (NO) and 1 case was given pulmonary surfactant (PS).The parameters of pulmonary function were improved step by step and the differences were statistically significant at the latest stage of treatment (P<0.05).Conclusion The treatment of ALI after surgical correction of TOF includes reasonable mechanical ventilation and maintaining the balance of fluid.Inhaling NO and using PS will be benefitial to improve the pulmonary function and to stop the vicious circle which results in the hypoxemia and refractory acidosis. Key wordsTetralogy of Fallot;Acute lung injury;Cardiopulmonary bypass     

先天性心脏病术后肺动脉高压的一氧化氮吸入治疗

目的　探讨先天性心脏病(先心病)术后肺动脉高压(肺高压)病儿吸入一氧化氮(NO)的适应证、避免毒副作用等。方法　选择31例先心病术后传统治疗无效的、难治的反应性肺高压或肺高压危象病儿,给予NO吸入治疗。试验分NO吸入前、中、后3个阶段,各阶段均进行各项血液动力学指标的测定。结果　吸入不同浓度NO［10～80百万分之体积(ppm)］后,平均肺动脉压力和体肺循环压力之比分别降低了34.8%和45.0%(P＜0.01),有效率为87.1%;吸入NO后二氧化氮、高铁血红蛋白含量明显高于吸入前(P＜0.05),但仍在允许范围。结论　吸入NO可明显降低先心病术后难治的反应性肺高压或肺高压危象病儿的肺动脉压力和肺血管阻力,临床上未发现明显的毒副作用。因此,NO是一种有效、安全、理想的肺血管扩张剂。     

小婴儿先天性心脏病的术后管理体会

目的　探讨如何提高小婴儿先天性心脏病 (先心病 )术后并发症的治愈率及降低术后死亡率。方法　 1 996年 1 0月至 2 0 0 1年 3月期间心胸外科监护室 (CICU)≤ 6月龄病儿资料 2 4 3例 ,分成前 74例、后 1 69例两组 ,后组应用改进的监护常规和新医药、新技术。两组按例数、术后危及生命的严重并发症的治愈率、CICU死亡率、呼吸机使用时间、CICU滞留天数等进行比较。结果　后组较前组例数增加了1 2 8 4% ,CICU死亡率下降了 462 5 % (P <0 0 1 ) ;术后低心输出量综合征、心动过速、肾功能衰竭的治愈率分别提高了 2 7 4%、68 4%、66 7% (P <0 0 5) ;呼吸机使用时间下降了 33 7% ,CICU滞留天数下降了78 1 % (P <0 0 5)。结论　术后监护常规的日益规范和完善 ,新医药、新技术的推广应用 ,有助于提高小婴儿先心病术后的生存率     

一氧化氮和米力农联合应用改善Fontan术后肺循环阻力的疗效

Objective Inhaled nitric oxide(iNO) has been successful used for patients with increased pulmonary vascular re- slstance (PVR) shortly after Fontan operation, but its withdrawal rebound remains a major concem. We hypothesized that iNO associ- ated with milrinone could provide additive benefits for pulmonary hemodynamics and reduce the occurrence of iNO withdrawal rebound. Methods Thirty-one patieats with high transpulmonary pressure gradient(TPG, >10mmHg) and arterial oxygen saturation(SatO2, 0.85) after modified fenestrated Fontan operation were prospectively randomized into two groups, I.e. , group iNO (iNO at 10 ppm, dynamics, arterial blood oxygenation and occurrence of withdrawal rebound were compared between the two groups.Results Com- bined application achieved following improvenents including (1) decrement of CVP [(19.6±3.5)% vs. (15.2±4.6)% in group iNO, P<0.05] and TPG [(18.2±4.8)% vs. (15.3±2.6)% in group iNO, P<0.05); and increment of systemic aterial pres- sure [(8.7±2.7)% vs. (5.2±3.1)% in group iNO, P<0.05].(2)improvement of arterial oxygen saturation[(9.3±3.2)% vs. (6.8±2.8)% in group iNO, P<0.05)]. (3)occurrence of withdrawal rebound were significantly lower in group iNO+ Mil (1 patient vs. 6 patients in group iNO, P<0.05). Conclusion Combined uae of iNO and milrinone provided additional benefits as compared with exclusive use d iNO for patients with elevated PVR after Fontan procdure.     

一氧化氮和米力农联合应用改善Fontan术后肺循环阻力的疗效

Objective Inhaled nitric oxide(iNO) has been successful used for patients with increased pulmonary vascular re- slstance (PVR) shortly after Fontan operation, but its withdrawal rebound remains a major concem. We hypothesized that iNO associ- ated with milrinone could provide additive benefits for pulmonary hemodynamics and reduce the occurrence of iNO withdrawal rebound. Methods Thirty-one patieats with high transpulmonary pressure gradient(TPG, >10mmHg) and arterial oxygen saturation(SatO2, 0.85) after modified fenestrated Fontan operation were prospectively randomized into two groups, I.e. , group iNO (iNO at 10 ppm, dynamics, arterial blood oxygenation and occurrence of withdrawal rebound were compared between the two groups.Results Com- bined application achieved following improvenents including (1) decrement of CVP [(19.6±3.5)% vs. (15.2±4.6)% in group iNO, P<0.05] and TPG [(18.2±4.8)% vs. (15.3±2.6)% in group iNO, P<0.05); and increment of systemic aterial pres- sure [(8.7±2.7)% vs. (5.2±3.1)% in group iNO, P<0.05].(2)improvement of arterial oxygen saturation[(9.3±3.2)% vs. (6.8±2.8)% in group iNO, P<0.05)]. (3)occurrence of withdrawal rebound were significantly lower in group iNO+ Mil (1 patient vs. 6 patients in group iNO, P<0.05). Conclusion Combined uae of iNO and milrinone provided additional benefits as compared with exclusive use d iNO for patients with elevated PVR after Fontan procdure.     

腺苷用于肺高压治疗的进展

腺苷(Adenosine,AD)为内皮源性血管舒张剂,通过作用于肺血管平滑肌上特异性A2受体兴奋腺苷酸环化酶,并由之后增高的血管平滑肌细胞内cAMP浓度参与介导肺血管的舒张。中心静脉途径给药时,由于该药具有被肺循环大量摄取、快速经肺代谢和极短T1/2的特性,决定其对肺血管有相对高的选择扩张作用,因而避免了传统药物在肺高压治疗中低血压的发生。对心脏术后、原发性以及顽固性肺高压均获良好疗效。     

皮肤粘合剂"爱必肤"应用于小儿先天性心脏病手术切口的研究

“爱必肤”(EPIGLU)是一种以 2 乙基氰丙烯酸酯为主要成分的组织粘合剂 ,作为对传统针线缝合技术的一次革新 ,“爱必肤”替代缝线缝合已被成功地用于皮肤切割伤、撕裂伤和皮肤肿瘤切除术后的伤口粘合 ,并积累了一定的经验[1,2 ] 。目前尚未见其应用于小儿心脏直视术后胸部皮肤切口粘合的相关报道。本研究对小儿先天性心脏病术后“爱必肤”粘合伤口及传统缝线缝合技术进行比较 ,旨在评价“爱必肤”对近远期皮肤伤口愈合的影响 ,为其进一步推广提供可行性依据。一、临床资料1.一般资料 :我院于 2 0 0 2年 1～ 4月收治因先天性心脏病而行心…