小儿重症及复杂先天性心脏病术后急性呼吸窘迫综合征的危险因素分析

目的通过对比小儿重症及复杂先天性心脏病（CCHD）术后发生急性呼吸窘迫综合征（ARDS）与未发生ARDS的两组患儿的临床资料，探讨重症及复杂先心病术后发生ARDS的危险因素。方法依据2011年ARDS的柏林定义，选取我院2009年1月~2014年5月心外科收治的75例未发生ARDS的重症及复杂先心病患儿作为I组，同期发生ARDS的80例患儿作为Ⅱ组，对比分析两组的临床资料，选取年龄、性别、体质量、术前氧分压及二氧化碳分压、术前及术后血白蛋白、术前及术后血肌酐、术前左室EF等39 项指标进行单因素分析和多因素Logistic 回归分析。结果Ⅱ组死亡17 例，病死率21%。II 组中轻度ARDS 27例，中度ARDS 25例，重度ARDS 28例。单因素分析发现，体质量、术前PCO2、术前左室射血分数、术后早期血清球蛋白、术中主动脉阻断时间、体外循环时间、手术时间、术中出血量、术中输血总量、术后8 h胸液量、术后8 h输血量、术后血白蛋白、术后血肌酐、术后初始乳酸值、术后24 h最大乳酸增高率、术后24 h B型尿钠肽、术后24 h降钙素原、术后24 h C反应蛋白、术后24 h血清前白蛋白、年龄、术前肺动脉压、术前肺部感染、术前凝血功能异常等23项指标在两组间差别有统计学意义（P<0.05），Logistic回归分析表明，术中主动脉阻断时间、体外循环时间、术后24 h最大乳酸增高率、术后24 h降钙素原及术中出血量等5项指标是CCHD术后发生ARDS的独立危险因素。结论ARDS是重症及复杂先心病术后的一种严重并发症，大大增加患儿的病死率。根据其发生的主要危险因素：主动脉阻断时间、体外循环时间、术后24 h最大乳酸增高率、术后24 h降钙素原及术中出血量等可以预测ARDS的发生并早期采取必要的措施，以利于提高CCHD患儿术后ARDS救治的成功率。

Risk factors for acute respiratory distress syndrome following surgeries for pediatric critical and complex congenital heart disease

Objective To explore the risk factors for acute respiratory distress syndrome (ARDS) in children receiving surgeries for critical and complex congenital heart disease (CCHD).Methods According to the 2011's Berlin definition of ARDS,the clinical data were collected from 75 children without ARDS (group Ⅰ) and 80 children with ARDS (group Ⅱ) following surgeries for CCHD performed in the Department of Cardiac Surgery of our hospital from January,2009 to May,2014.Univariate analyses and logistic regression were used to analyze the risk factors contributing to the occurrence of ARDS following the surgeries.Results In the 80 patients who developed ARDS postoperatively in group Ⅱ,27 had mild ARDS,25 had moderate ARDS,and 28 had severe ARDS;death occurred in 17 (21％) cases.Univariate analyses showed that 23 parameters were significantly different between groups Ⅰ and Ⅱ (P＜0.05),including weight;preoperative PCO2,left ventricular ejection fraction,pulmonary artery pressure,pulmonary infection,and coagulation abnormalities;early postoperative serum globulin;intraoperative aortic cross clamp (ACC) time;cardiopulmonary bypass (CPB) time;operation time;blood loss and blood transfusion amount intraoperatively and during the first 8 h after operation;lactic add level immediately after the operation and its maximum increasing rate within 24 h postoperatively;postoperative serum levels of albumin and creatinine;serum levels of B-type natriuretic peptide,procalcitonin,C-reactive protein,and prealbumin 24 h after operation;and age.Logistic regression analyses showed that intraoperative ACC time,CPB time,the maximum increasing rate of lactic acid within 24 h after operation,serum procalcitonin 24 h after operation and intraoperative blood loss were independent risk factors for postoperative ARDS.Conclusion The risk factors of ARDS identified in these children can predict the occurrence of ARDS following the surgeries and timely interventions can improve the success rate in treatment of postoperative ARDS in children with CCHD.