本文關(guān)鍵詞： 室間隔缺損 危重病 外科手術(shù) 治療 預(yù)后　出處：《安徽醫(yī)科大學(xué)》2014年碩士論文　論文類型：學(xué)位論文

【摘要】：目的 1.探討影響6月齡以下危重嬰兒室間隔缺損手術(shù)治療近期預(yù)后的相關(guān)危險(xiǎn)因素； 2.針對(duì)性地強(qiáng)化術(shù)前病情評(píng)估、外科操作技術(shù)、體外循環(huán)和心肌保護(hù)、術(shù)后監(jiān)護(hù)等措施； 3.減少術(shù)后并發(fā)癥的發(fā)生和提高手術(shù)的效果； 方法 回顧性分析2009.1-2011.12間161例小嬰兒（≤6月）室間隔缺損急或亞急診手術(shù)治療近期預(yù)后的情況，其中，男83例，女78例，年齡（4.1±1.3）月，體重（5.5±1.1）kg，有中度及以上肺動(dòng)脈高壓148例。部分患兒合并ASD或功能性單心房、PDA、COA、中度以上的二尖瓣返流、無(wú)頂冠狀靜脈竇等。術(shù)前均有持續(xù)或反復(fù)肺炎、心功能不全史，經(jīng)兒內(nèi)科、PICU等反復(fù)治療63例，部分術(shù)前需呼吸機(jī)輔助，治療好轉(zhuǎn)或無(wú)效時(shí)直接轉(zhuǎn)入心外科手術(shù)，其中1例持續(xù)到外科手術(shù)時(shí)。均采用氣管插管靜脈復(fù)合麻醉、膜式氧合器和改良超濾、淺或中低溫轉(zhuǎn)流，其中4例聯(lián)合深低溫/停循環(huán)。室間隔缺損用心包補(bǔ)片間斷（或連續(xù)）修補(bǔ)，同時(shí)處理合并的其它畸形，如結(jié)扎PDA、修補(bǔ)ASD、二或三尖瓣整形、糾治CoA、擴(kuò)大肺動(dòng)脈等；酌情放置左或右房和肺動(dòng)脈測(cè)壓管、臨時(shí)起博導(dǎo)線。術(shù)后呼吸機(jī)支持，常規(guī)應(yīng)用多巴胺、米力農(nóng)，必要時(shí)加異丙腎上腺素、硝酸甘油等。術(shù)后存活156例。其中出現(xiàn)嚴(yán)重并發(fā)癥27例，包括持續(xù)低心排3例、惡性室性早博、心跳驟停、再次氣管插管、敗血癥等各1例,再開(kāi)胸探查止血2例、大量氣胸4例、呼吸道感染（同時(shí)痰培養(yǎng)有致病菌生長(zhǎng)）16例，均經(jīng)及時(shí)處理治愈。死亡5例，直接原因是嚴(yán)重低心排、肺出血、多器官功能衰竭等。根據(jù)治療過(guò)程和結(jié)果，將患兒分為預(yù)后好和預(yù)后差二組。后者包括術(shù)后死亡和嚴(yán)重并發(fā)癥者，如低心排、惡性心律失常、心臟停搏、再次氣管插管、需清創(chuàng)的切口或縱隔感染，胸腔引流量多和時(shí)間長(zhǎng)（≥5天）、正性肌力藥物評(píng)分（inotrope score;IS）＞20、血液和或痰培養(yǎng)有致病菌生長(zhǎng)、急性腎功能不全需腹膜或血透析、再次開(kāi)胸探查、ALT和或AST500U／L、CICU監(jiān)護(hù)時(shí)間＞4天、中等量以上氣胸、胸腔積液和乳糜胸等。根據(jù)上述描述，進(jìn)入預(yù)后好組97例、預(yù)后差組60例。將手術(shù)時(shí)的年齡、體重、有無(wú)心內(nèi)合并畸形和氣管狹窄、術(shù)前感染情況、肺動(dòng)脈高壓程度、轉(zhuǎn)流和主動(dòng)脈阻斷時(shí)間、室間隔缺損直徑、呼吸機(jī)支持時(shí)間、胸引量、正性肌力藥物評(píng)分（inotropescore;IS）、監(jiān)護(hù)時(shí)間等因素進(jìn)行統(tǒng)計(jì)學(xué)分析，再把分布不同的可能因素納入多因素非條件Logistic回歸模型中進(jìn)行分析，最后篩選出影響預(yù)后的危險(xiǎn)因素。 結(jié)果 本組研究的161例人數(shù)中，死亡5例，死亡率3.1%。單因素分析結(jié)果顯示：體重、呼吸機(jī)支持時(shí)間、胸引量、心內(nèi)合并的其他畸形、肺動(dòng)脈高壓程度、有無(wú)氣管狹窄只在單因素分析中有差異。多因素Logistic逐步回歸分析而轉(zhuǎn)流和主動(dòng)脈阻斷時(shí)間、IS、監(jiān)護(hù)時(shí)間在單、多因素分析中均有不同，P值分別是0.000-0.001、0.000-0.042，差異有統(tǒng)計(jì)學(xué)意義。 結(jié)論 轉(zhuǎn)流時(shí)間長(zhǎng)、主動(dòng)脈阻斷時(shí)間長(zhǎng)、IS高、監(jiān)護(hù)時(shí)間長(zhǎng)是影響手術(shù)治療近期預(yù)后的主要危險(xiǎn)因素。監(jiān)護(hù)時(shí)間是一個(gè)間接的危險(xiǎn)因素，是患兒病情的綜合體現(xiàn)。影響小嬰兒室間隔缺損急或亞急診手術(shù)治療近期預(yù)后的可能危險(xiǎn)因素很多，，術(shù)前完備的評(píng)估病情、術(shù)中滿意的矯治畸形、術(shù)后有力的生命支持、并發(fā)癥的及時(shí)發(fā)現(xiàn)和處理都是十分必要的。
[Abstract]:objective
1. to investigate the risk factors related to the short-term prognosis of critical infant ventricular septal defect under the influence of 6 month old.
2. to strengthen the preoperative assessment, surgical technique, cardiopulmonary bypass and myocardial protection, and postoperative monitoring.
3. to reduce the incidence of postoperative complications and to improve the effect of the operation.
Method
A retrospective analysis of 161 cases of infant 2009.1-2011.12 (up to June) of ventricular septal defect or sub acute emergency surgical treatment prognosis, among them, male 83 cases, female 78 cases, age (4.1 + 1.3), weight (5.5 + 1.1) kg, moderate and above of 148 patients with pulmonary hypertension. Patients with ASD or functional single atrium, PDA, COA, moderate mitral regurgitation, unroofed coronary sinus. All patients have persistent or recurrent pneumonia, heart failure history, the Department of Pediatrics, PICU repeated treatment in 63 cases, partial preoperative ventilator treatment required, or invalid directly into the heart surgery, including 1 cases of surgery. To adopt tracheal intubation intravenous anesthesia, membrane oxygenator and modified ultrafiltration in low temperature, shallow or bypass, among which 4 cases were combined with deep hypothermic circulatory arrest. Heart / VSD patch (intermittent or continuous) repair, at the same time to deal with the It is such as deformity, ligation of PDA, repair ASD, two or three tricuspid valve surgery, correction of CoA, expansion of pulmonary artery; appropriate placement of left or right atrial and pulmonary artery catheter, temporary pacemaker wire. Ventilator support after operation, the routine application of dopamine, milrinone, if necessary with isoproterenol, nitroglycerin. Postoperative survival in 156 cases. Among them 27 cases had severe complications, including persistent low cardiac output in 3 cases, malignant ventricular premature beat, cardiac arrest, re intubation, sepsis and other 1 cases, 2 cases of open thoracotomy bleeding, 4 cases of massive pneumothorax, respiratory tract infection (and sputum culture of pathogenic bacteria) 16 patients were cured after timely treatment. 5 cases of death, is the direct cause of severe low cardiac, pulmonary hemorrhage, multiple organ failure. According to the treatment process and results, the patients were divided into two groups of good prognosis and poor prognosis. The latter include postoperative death and serious complications, such as low cardiac output, malignant arrhythmia Often, cardiac arrest, re intubation, need debridement or incision infection of mediastinum, chest drainage and long time (5 days), inotrope score (inotrope score; IS, 20), and the blood or sputum culture of pathogenic bacteria, acute renal insufficiency to peritoneal or blood dialysis, re thoracotomy, and ALT or AST500U / L, CICU monitoring time more than 4 days, moderate pneumothorax, pleural effusion and chylothorax. According to the above description, into the good prognosis group of 97 cases, 60 cases of poor prognosis group. The age at the time of surgery, weight, heart malformation and tracheal stenosis, preoperative infection, pulmonary hypertension, bypass and aortic clamping time, diameter of VSD, ventilator time, chest drainage volume, inotrope score (inotropescore; IS), monitoring time and other factors were analyzed, then the distribution of different factors in multiple factors The conditional Logistic regression model was analyzed and the risk factors affecting the prognosis were selected.
Result
The number of this group of 161 cases, 5 cases died, the mortality rate of 3.1%. single factor analysis results showed that: weight, duration of mechanical ventilation, chest, heart and other associated malformations, the degree of pulmonary hypertension, with tracheal stenosis only in univariate analysis there are differences. Multivariate Logistic regression analysis and flow and aortic clamp time, IS, monitoring time in single and multi factor analysis were different, the P value is 0.000-0.001,0.000-0.042 respectively, the difference was statistically significant.
conclusion
Bypass time, aortic clamping time, high IS, long time monitoring is a major risk of surgical treatment prognosis factors. The monitoring time is an indirect risk factor, is a comprehensive reflection of children with the disease. Many risk factors that might influence the infant acute ventricular septal defect or subemergency surgical treatment prognosis complete, preoperative assessment of the disease, patients with deformity, strong life support after operation, complications timely detection and treatment are necessary.

【學(xué)位授予單位】：安徽醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2014
【分類號(hào)】：R726.5

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