本文選題：先天性心臟病　切入點(diǎn)：營(yíng)養(yǎng)狀況　出處：《北京協(xié)和醫(yī)學(xué)院》2017年博士論文

【摘要】：目的:通過(guò)對(duì)阜外醫(yī)院PICU先天性心臟病患兒營(yíng)養(yǎng)狀況的評(píng)估以及分析其與術(shù)后臨床預(yù)后的關(guān)系,探討先天心臟病患兒營(yíng)養(yǎng)不良發(fā)生率與臨床結(jié)局的關(guān)系,為先天性心臟病規(guī)范化營(yíng)養(yǎng)風(fēng)險(xiǎn)評(píng)估及營(yíng)養(yǎng)支持治療提供理論依據(jù)。方法:選取2015年1月-2016年1月于阜外醫(yī)院小兒外科中心先天性心臟病2歲以下手術(shù)患兒,選取患兒均給予先天性心臟病手術(shù)風(fēng)險(xiǎn)分級(jí)(RACHS-1分級(jí))。研究設(shè)定了入選標(biāo)準(zhǔn)及排除標(biāo)準(zhǔn),收集患兒術(shù)前、術(shù)中及術(shù)后臨床資料,對(duì)術(shù)前營(yíng)養(yǎng)狀況進(jìn)行評(píng)估,了解先天性心臟病患兒營(yíng)養(yǎng)狀況,對(duì)比營(yíng)養(yǎng)不良患兒與非營(yíng)養(yǎng)不良患兒在臨床指標(biāo)上的差異,分析影響或加重先天性心臟病營(yíng)養(yǎng)不良患兒的危險(xiǎn)因素,明確先天性心臟病營(yíng)養(yǎng)不良與臨床預(yù)后的關(guān)聯(lián)性。結(jié)果:入選患兒共532例,其中男性306例,女性226例,手術(shù)年齡(中位數(shù))9月,手術(shù)時(shí)體重(中位數(shù))7.8kg,出生體重(中位數(shù))3.2kg,身高73.0± 17.1cm,術(shù)前血紅蛋白Hgb 128.2±28.3g/L,術(shù)前血清白蛋白42.3±3.7g/L,體外循環(huán)時(shí)間94.6±71.4min,主動(dòng)脈阻斷時(shí)間57.0±42.1min,機(jī)械通氣時(shí)間(中位數(shù))11小時(shí),ICU滯留時(shí)間2天,出現(xiàn)并發(fā)癥情況94例,占總數(shù)17%,其中死亡16例,占總數(shù)3%。營(yíng)養(yǎng)不良患兒309例,非營(yíng)養(yǎng)不良患兒223例,兩組間比較術(shù)前、術(shù)中及術(shù)后數(shù)據(jù),術(shù)前RACHS-1分級(jí)無(wú)明顯差異,兩組間術(shù)前體重、身高,出生體重存在統(tǒng)計(jì)學(xué)差異。術(shù)前化驗(yàn)方面,術(shù)前血紅蛋白Hgb,血清白蛋白無(wú)統(tǒng)計(jì)學(xué)差異。在術(shù)后指標(biāo)方面,營(yíng)養(yǎng)不良組術(shù)后機(jī)械通氣時(shí)間明顯延長(zhǎng),存在統(tǒng)計(jì)學(xué)差異,而ICU滯留時(shí)間不存在統(tǒng)計(jì)學(xué)差異,P值為0.059,接近存在統(tǒng)計(jì)學(xué)意義P值。術(shù)后并發(fā)癥,營(yíng)養(yǎng)不良組60例,占組內(nèi)病例總數(shù)19.4%,非營(yíng)養(yǎng)不良組出現(xiàn)并發(fā)癥34例,占組內(nèi)病例總數(shù)15.22%,兩組比較發(fā)生率無(wú)明顯差異。經(jīng)多因素分析,發(fā)現(xiàn)先天性心臟病患兒營(yíng)養(yǎng)不良的群體中,年齡、低出生體重可以加劇營(yíng)養(yǎng)不良程度。將并發(fā)癥進(jìn)行細(xì)化研究,營(yíng)養(yǎng)不良組患兒二次插管率及死亡率明顯多于非營(yíng)養(yǎng)不良組患兒,且具有統(tǒng)計(jì)學(xué)意義,其它并發(fā)癥兩組間比較差異不大。結(jié)論:先天性心臟病嬰幼兒中營(yíng)養(yǎng)不良患兒比例偏高,營(yíng)養(yǎng)不良嚴(yán)重程度與手術(shù)年齡,低出生體重有關(guān),營(yíng)養(yǎng)不良患兒先天性心臟病術(shù)后機(jī)械通氣時(shí)間延長(zhǎng),二次插管率及死亡率高于非營(yíng)養(yǎng)不良患兒,未來(lái)需要完善營(yíng)養(yǎng)評(píng)價(jià)體系,制定完整的先天性心臟病營(yíng)養(yǎng)支持策略,以期改善臨床預(yù)后。目的:分析阜外醫(yī)院小兒左冠狀動(dòng)脈起源于肺動(dòng)脈(Anomalous Left Coronary Artery From the Pulmonary Artery,ALCAPA)的外科治療早期結(jié)果,并總結(jié)此類疾病早期治療經(jīng)驗(yàn),以明確心臟功能變化與術(shù)后預(yù)后的關(guān)系。方法:選取2012年1月至2016年12月阜外醫(yī)院小兒外科中心收治左冠狀動(dòng)脈起源異常手術(shù)患兒共65例,其中男性37例,女性28例,收集患兒術(shù)前心功能指標(biāo),術(shù)前一般資料,術(shù)中體外循環(huán)時(shí)間,主動(dòng)脈阻斷時(shí)間,是否給予二尖瓣成形,術(shù)后超聲心功能情況、術(shù)后左室舒張末徑大小,術(shù)后呼吸機(jī)時(shí)間、ICU滯留時(shí)間、術(shù)后并發(fā)癥等術(shù)后相關(guān)指標(biāo)。對(duì)所有65例患兒按照術(shù)前射血分?jǐn)?shù)(簡(jiǎn)稱EF)30%分組,EF30%患兒26例,其余為39例,比較兩組間相關(guān)監(jiān)測(cè)指標(biāo)的差異。結(jié)果:總共入選患兒65例,其中男性37例,女性28例,手術(shù)年齡(中位數(shù))12月,術(shù)前體重(中位數(shù))8.5kg,術(shù)前射血分?jǐn)?shù)(EF)44.23±22.6%,左室舒張末徑大小39.69±7.73mm,體外循環(huán)時(shí)間121.67±56.04min,主動(dòng)脈阻斷時(shí)間(中位數(shù))67min,22例患兒因二尖瓣反流重而行二尖瓣成形,呼吸機(jī)支持時(shí)間(中位數(shù))24h,ICU滯留時(shí)間(中位數(shù))3天,死亡2例,二次插管7例,ECMO輔助3例,延遲關(guān)胸8例,腹膜透析6例。對(duì)于以射血分?jǐn)?shù)EF 30%作為患兒分組指標(biāo),EF30%患兒26例,其余為39例,比較兩組術(shù)前情況,EF30%組患兒年齡、術(shù)前體重明顯小于EF≥30%組,而EF≥30%組患兒術(shù)前左室舒張末徑大小小于EF30%組患兒,且具有統(tǒng)計(jì)學(xué)差異。兩組間體外循環(huán)時(shí)間、主動(dòng)脈阻斷時(shí)間,術(shù)中予ECMO輔助病例無(wú)明顯差異,EF≥30%組術(shù)中行二尖瓣成形數(shù)量明顯多于EF30%組。EF30%組患兒呼吸機(jī)支持時(shí)間和ICU滯留時(shí)間明顯多于EF≥30%組,且具有統(tǒng)計(jì)學(xué)差異。術(shù)后并發(fā)癥方面比較,EF30%組患兒二次插管、腹膜透析、延遲關(guān)胸?cái)?shù)量明顯多于EF≥30%組,具有統(tǒng)計(jì)學(xué)差異。死亡率比較,總體死亡病例2人,均為EF30%組患兒,兩組間比較無(wú)統(tǒng)計(jì)學(xué)差異�？傮w患兒自身對(duì)照,拔管時(shí)射血分?jǐn)?shù)EF較于術(shù)前無(wú)明顯差異,而出院時(shí)EF較術(shù)前存在明顯差異。左室舒張末徑大小比較,拔管時(shí)左室舒張末徑大小明顯小于術(shù)前左室舒張末徑大小,出院時(shí)左室舒張末徑大小明顯小于術(shù)前左室舒張末徑大小。結(jié)論:左冠狀動(dòng)脈起源于肺動(dòng)脈的小兒患者早期結(jié)果滿意,大部分患者心臟功能和二尖瓣反流都會(huì)有不同程度的改善。極差的心臟功能對(duì)術(shù)后早期結(jié)果有明顯影響,射血分?jǐn)?shù)EF30%患兒術(shù)后ICU時(shí)間、呼吸機(jī)使用時(shí)間明顯延長(zhǎng),二次插管、延遲關(guān)胸、腎替代治療危險(xiǎn)系數(shù)明顯增加,將經(jīng)歷較長(zhǎng)的延遲恢復(fù)的過(guò)程。
[Abstract]:Objective: to assess the PICU of Fuwai Hospital in children with congenital heart disease and to analyze the nutritional status and the relationship between clinical prognosis after operation of congenital heart disease in children with nutrition, adverse incidence and clinical outcome of congenital heart disease, in order to regulate the nutritional risk assessment and nutritional support treatment and provide a theoretical basis. Methods: January 2015 -2016 in January in the pediatric surgery center of Fuwai Hospital of congenital heart disease in children under 2 years old children were given surgery, selection of surgical treatment of congenital heart diseases risk classification (RACHS-1 classification). The study set inclusion criteria and exclusion criteria, the clinical data were collected before, during and after surgery, the preoperative nutritional status assessment, understanding the nutritional status of children with congenital heart disease, differences in clinical indicators on the comparison of malnourished children and non malnourished children, or aggravate the influence analysis of congenital heart disease The risk factors of malnutrition in children with congenital heart disease, clear malnutrition and clinical prognostic relevance. Results: all the 532 cases, including 306 cases of male, female 226 cases, age at surgery (median) in September, at the time of surgery (median weight 7.8kg), birth weight (median) height 3.2kg, 73 + 17.1cm preoperative hemoglobin, Hgb 128.2 + 28.3g/L, preoperative serum albumin was 42.3 + 3.7g/L, 94.6 + 71.4min cardiopulmonary bypass time, aortic clamping time was 57 + 42.1min, mechanical ventilation time (median) 11 hours, ICU retention time of 2 days, complications of 94 cases, accounting for 17% of the total, including 16 cases of death, accounting for 3%. malnutrition in 309 children with non malnourished children in 223 cases, two groups preoperative, intraoperative and postoperative data, RACHS-1 grade had no significant difference between the two groups before surgery, preoperative weight, height, birth weight, there was a significant difference between the preoperative laboratory tests, Preoperative hemoglobin Hgb, no significant difference in serum albumin. Postoperative index, malnutrition group, postoperative mechanical ventilation time was significantly prolonged, there was significant difference, while the ICU residence time does not exist significant differences, the P value is 0.059, close to the P value had statistical significance. The postoperative complications, malnutrition group 60 cases, accounting for in 19.4% cases, complications occurred in 34 cases of non malnutrition group, accounting for the total number of cases in group 15.22%, two groups there was no significant difference. After multivariate analysis, found that the age group of malnutrition in children with congenital heart disease, low birth weight, can aggravate the degree of malnutrition. The detailed study of complications the two time, intubation rate and mortality rate of malnutrition group were significantly more than the non malnutrition group, and have statistical significance, other complications between the two groups has no significant difference. Conclusion: congenital heart disease in infants The children in the high proportion of children with malnutrition, malnutrition and the severity of the operative age, low birth weight, malnutrition in children with congenital heart disease after prolonged mechanical ventilation, intubation rate and death rate two times higher than that of non malnourished children, the future need to improve the nutrition evaluation system, develop a complete congenital heart disease and nutritional support the strategy, in order to improve the clinical prognosis. Objective: to analyze the Fuwai Hospital pediatric left coronary artery originated from pulmonary artery (Anomalous Left Coronary Artery From the Pulmonary Artery, ALCAPA) of the early surgical treatment results, and summarize the experience of treatment of this disease early, with prognosis of surgery and changes of cardiac function after clear. Methods: from January 2012 to December 2016 pediatric surgery center of Fuwai Hospital were abnormal origin of left coronary artery surgery were 65 cases, male 37 cases, female 28 cases, collected from Children preoperative heart function index, preoperative general data, intraoperative extracorporeal circulation time, aortic clamp time, whether to give the mitral valve, cardiac function of ultrasound after operation, postoperative left ventricular end diastolic diameter, postoperative ventilation time, ICU stay time, postoperative complications related to all 65 indicators. Patients according to preoperative ejection fraction (EF) of 30% groups, 26 cases of children with EF30%, the remaining 39 cases, the difference between the two groups of related monitoring indicators. Results: a total of 65 cases of patients, including male 37 cases, female 28 cases, age at surgery (median) in December, preoperative weight 8.5Kg (median), preoperative ejection fraction (EF) 44.23 + 22.6%, left ventricular end diastolic diameter was 39.69 + 7.73mm, 121.67 + 56.04min cardiopulmonary bypass time, aortic clamping time (median 67min), 22 cases with mitral regurgitation and tricuspid valve repair two weight, ventilation support time (median 24h). IC U retention time (median 3 days), 2 cases of death, two ECMO assisted intubation in 7 cases, 3 cases of delayed sternal closure in 8 cases, 6 cases of peritoneal dialysis. The ejection fraction with EF 30% as indicators, 26 cases of children with EF30%, the remaining 39 cases, compared two groups before operation. EF30% group of children with age, preoperative weight was less than that of EF = 30% and EF = 30% group, group with preoperative left ventricular end diastolic diameter less than EF30% group, and has statistically significant difference between the two groups. The cardiopulmonary bypass time, aortic clamping time, intraoperative ECMO assistance to cases had no obvious difference, EF = 30% group underwent mitral valvuloplasty significantly more than the number of EF30% group.EF30% group of children with ventilator support time and ICU retention time was more than EF = 30% group, and has statistically significant difference. Compared complication after operation, patients in group EF30% were two times of intubation, peritoneal dialysis, delayed sternal closure number were lower than that in the EF = 30% group, statistically The overall mortality difference. Compared with 2 deaths, were EF30% group, no significant difference between the two groups. The children with their own control, extubation compared with preoperative ejection fraction EF had no obvious difference, and the discharge EF are obviously different. Compared with the preoperative left ventricular end diastolic diameter, pull when the left ventricular end diastolic diameter was significantly less than the preoperative left ventricular end diastolic diameter, left ventricular end diastolic diameter was significantly smaller than the size of preoperative left ventricular end diastolic diameter. Conclusion: the origin of the left coronary artery from the pulmonary artery in children patients with satisfactory results, most patients with cardiac function and mitral regurgitation are will have different degrees of improvement. Poor cardiac function in early postoperative results have obvious effect, ICU time scores of EF30% patients after ejection, ventilator time prolonged, two times of intubation, delayed sternal closure, renal replacement therapy significantly increased the number of dangerous system, It will undergo a longer process of delayed recovery.

【學(xué)位授予單位】：北京協(xié)和醫(yī)學(xué)院
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2017
【分類號(hào)】：R726.5

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