小儿复杂先天性心脏病姑息手术的体外循环管理

The cardiopulmonary bypass management in children＇s palliative surgery with complex congenital heart disease

目的总结48例复杂先天性心脏病行姑息手术患者的体外循环（CPB）管理经验。方法回顾性分析2010年6月至2013年5月体外循环下行复杂先天性心脏病姑息手术48例的临床资料，其中男性2l例，女性27例，年龄（20．35±27．40）个月，体重（8．44±5．91）kg。手术方法包括右室流出道重建、右室流出道疏通、左右肺动脉共汇重建、肺动脉重建、glenn、改良B—T分流术。病种包括肺动脉闭锁合并室间隔缺损28例、永存动脉干1例、法洛四联症14例、右室双出口合并肺动脉闭锁3例、右室双出口1例、左肺动脉缺如1例。采用常温并行循环30例、浅低温10例、中低温8例。采用复方电解质注射溶液、红细胞、血浆、20％人血白蛋白、万汶等预充，血液稀释后红细胞压积25％-33％。CPB中监测指标包括平均动脉压、中心静脉压、心率、静脉混合血氧饱和度、乳酸、尿量、血浆胶体渗透压、鼻咽温和肛温。结果体外循环时间27-106（64．39±27．68）min。主动脉阻断16-62（35．95±14．21）min，呼吸机辅助时间2-7（3．60±1．38）h，监护时间24-56（34．01±11.00）h；超滤量400-900（716．27±404．88）ml，尿量50-250（145．53±117．89）ml；住院15-27（34．01±11．00）d；术后胸引量10-100（37．35±21．72）ml。自动复跳率100％。所有患儿均顺利脱离体外循环。并发症包括低心排综合征3例、肺不张1例、气胸1例、肾功能不全1例、纵隔感染1例、低氧血症3例、消化道出血1例。延迟关胸2例，再次开胸止血1例。术后死亡1例，死亡率2．08％，死亡原因为心肺功能衰竭。结论CPB下行小儿复杂先天性心脏病姑息手术，采用个体化管理和综合措施是手术成功的保障。

Objective To summarize the experience of cardiopulmonary bypass management in 48 cases with complex congenital heart disease using palliative surgery. Methods Retrospective analysis of the experience of cardiopulmonary bypass management in 48 cases with complex congenital heart disease using palliative surgery form June 2010 to May 2013, of which 21 males and 27 females, age（20.35±27.40）months, weight（8.44±5.91）kg. The surgical methods include reconstruction of the right ventricular outflow tract, right ventricular outflow tract dredge, left-right pulmonary artery converge reconstruction, pulmonary artery reconstruction, Glenn method and modified BT shunt. Diseases including pulmonary atresia with ventricular septal defect in 28 cases, 1 case of per- sistent truncus arteriosus, Tetralogy of Fallot patients in 14 cases, double outlet right ventricle with pulmonary a- tresia in 3 cases, 1 case of double outlet right ventricle, the left pulmonary artery in 1 case. A parallel loop was used at room temperature in 30 cases, 10 cases of mild hypothermia, low temperature in 8 cases. Pre-charged with Compound Electrolytes injectable solution, red blood cells, plasma, 20% human serum albumin and Valuvensolution, the hemodilution hematocrit was controlled of 25% to 33%. During CPB, mean arterial blood pressure, CVP, heart rate, mixed venous oxygen saturation, lactic acid, urine, plasma colloid osmotic pressure, nasopha- ryngeal and rectal temperature were measured. Results CPB time 27-106 （64.39±27.68）min, aortic occlusion 16-62（35.95±14.21 ）min, ventilation time 2-7（3.60±1.38）h, monitoring time 24-56（34.01±11.00）h. Ultra filtra- tion volume 400-900（716.27±404.88）ml, urine 50-250（145.53±117.89）ml, hospitalization time 15-27（34.01± 11.00）d, chest drainage volume 10-100（37.35±21.72）ml. The auto-resuscitation rate was 100%. All patients were successfully weaned from CPB. There were 15 cases of complications, complications include low cardiac output syn- drome in 3 cases, 1 ease of atelectasis, pneumothorax in 1 ease, 1 case of renal insufficiency, mediastinal infec- tion in 1 ease, hypoxemia in 3 cases, gastrointestinal bleeding 1 cases, delayed sternal 2 eases, 1 case of re-ex- ploration for bleeding, 1 patient died after surgery, the mortality rate was 2.08%. Cause of death was heart and lung failure. Conclusion CPB children with complex congenital heart disease during palliative surgery, the use of individualized surgical management and comprehensive measures are guarantee of success.