本文關鍵詞： 室間隔缺損 危重病 外科手術 治療 預后　出處：《安徽醫(yī)科大學》2014年碩士論文　論文類型：學位論文

【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治療近期預后的相關危險因素； 2.針對性地強化術前病情評估、外科操作技術、體外循環(huán)和心肌保護、術后監(jiān)護等措施； 3.減少術后并發(fā)癥的發(fā)生和提高手術的效果； 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治療近期預后的情況，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、無頂冠狀靜脈竇等。術前均有持續(xù)或反復肺炎、心功能不全史，經兒內科、PICU等反復治療63例，部分術前需呼吸機輔助，治療好轉或無效時直接轉入心外科手術，其中1例持續(xù)到外科手術時。均采用氣管插管靜脈復合麻醉、膜式氧合器和改良超濾、淺或中低溫轉流，其中4例聯合深低溫/停循環(huán)。室間隔缺損用心包補片間斷（或連續(xù)）修補，同時處理合并的其它畸形，如結扎PDA、修補ASD、二或三尖瓣整形、糾治CoA、擴大肺動脈等；酌情放置左或右房和肺動脈測壓管、臨時起博導線。術后呼吸機支持，常規(guī)應用多巴胺、米力農，必要時加異丙腎上腺素、硝酸甘油等。術后存活156例。其中出現嚴重并發(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,再開胸探查止血2例、大量氣胸4例、呼吸道感染（同時痰培養(yǎng)有致病菌生長）16例，均經及時處理治愈。死亡5例，直接原因是嚴重低心排、肺出血、多器官功能衰竭等。根據治療過程和結果，將患兒分為預后好和預后差二組。后者包括術后死亡和嚴重并發(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，胸腔引流量多和時間長（≥5天）、正性肌力藥物評分（inotrope score;IS）＞20、血液和或痰培養(yǎng)有致病菌生長、急性腎功能不全需腹膜或血透析、再次開胸探查、ALT和或AST500U／L、CICU監(jiān)護時間＞4天、中等量以上氣胸、胸腔積液和乳糜胸等。根據上述描述，進入預后好組97例、預后差組60例。將手術時的年齡、體重、有無心內合并畸形和氣管狹窄、術前感染情況、肺動脈高壓程度、轉流和主動脈阻斷時間、室間隔缺損直徑、呼吸機支持時間、胸引量、正性肌力藥物評分（inotropescore;IS）、監(jiān)護時間等因素進行統(tǒng)計學分析，再把分布不同的可能因素納入多因素非條件Logistic回歸模型中進行分析，最后篩選出影響預后的危險因素。 結果 本組研究的161例人數中，死亡5例，死亡率3.1%。單因素分析結果顯示：體重、呼吸機支持時間、胸引量、心內合并的其他畸形、肺動脈高壓程度、有無氣管狹窄只在單因素分析中有差異。多因素Logistic逐步回歸分析而轉流和主動脈阻斷時間、IS、監(jiān)護時間在單、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)計學意義。 結論 轉流時間長、主動脈阻斷時間長、IS高、監(jiān)護時間長是影響手術治療近期預后的主要危險因素。監(jiān)護時間是一個間接的危險因素，是患兒病情的綜合體現。影響小嬰兒室間隔缺損急或亞急診手術治療近期預后的可能危險因素很多，，術前完備的評估病情、術中滿意的矯治畸形、術后有力的生命支持、并發(fā)癥的及時發(fā)現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.

【學位授予單位】：安徽醫(yī)科大學
【學位級別】：碩士
【學位授予年份】：2014
【分類號】：R726.5

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