新生儿复杂先天性心脏病术后处理

Postoperative management of the neonates with complex congenital heart disease

目的总结新生儿复杂先天性心脏病术后处理体会。方法 2000-03～2005-05新生儿复杂先心病一期根治术后46例,男29例,女17例。年龄23h至28d,平均(14.8±6.9)d；体重2.2～4.3kg,平均(3.2± 0.4)kg。其中大动脉转位(TGA)21例；主动脉弓中断(IAA)7例(A型4例、B型3例)；法洛四联症(TOF)2 例；TOF合并肺动脉闭锁7例(Ⅰ型6例、Ⅱ型1例)；永存动脉干(PTA)5例(Ⅰ型4例、Ⅱ型1例)；完全性肺静脉异位连接(TAPVC)4例(心上型2例、心内型1例、心下型1例)。术毕均采用改良超滤,延迟关胸6例(2003年以前患者),呼吸机支持麻醉清醒前均采用压力控制(PC)模式,清醒后均采用压力控制同步间歇指令通气(SIMVPC)＋压力支持(PS)模式,术后均应用多巴胺、米力农,积极纠治酸、碱及电解质紊乱,2003年以后9例低心输出量综合征(低心排)和／或肾功能不全者给予腹膜透析。结果全组病死6 例,病死率13％；其中2003年以前病死4例。病死于低心排2例,肾功能不全2例,低心排合并肾功能不全2例。术后主要并发症包括：低心排、肾功能不全、低钙血症、低糖血症、低氧血症、右上肺不张、感染、气胸。结论积极防治术后肾功能衰竭和低心排是提高治愈率的关键,此外,选择合适的呼吸模式、加强基础护理和营养支持也很重要。

Objective To summarize the experience of postoperative management of neonatal complex heart disease.Methods From Mar. 2000 to May. 2005, the 46 neonates with complex congenital heart disease underwent corrective procedure, age ranged from 23h to 28d（average（14.0±6.9）d）, body weight ranged from 2.1 to 4.3kg （average （3.2±0.4）kg）.The diagnosis results included transposition of great artery （28 cases）, persistent trunk artery（5 cases）, tetrology of fallot with pulmonary atresia（5 cases）, interruption of aortic arch（4 cases）, and total anomalous pulmonaryvenous connection（4 cases）. All of the patients received modified uhrafiltration after cardiopulmonary bypass. 7 patients underwent peritoneal dialysis. 6 pateints underwent delayed sternal closure. Ventilation modes were chanded from PC to SIMV （PC）＋PS when the patients＇ consciousness were very well. All of the patients were administered inotropic support, including Dopamine and Amrinone. Disturbance of blood pH and Electrolytic were treated timely. Result Among the patients, 6 deaths occurred in the hospital,with morality rate of 13%. The causes of death were severe renal failure（2 cases）, low cardiac output （2 cases）, renal failure associated with low cardiac output （2 cases）. The main postoperative complication were renal failure （5 cases）, low cardiac output syndrome（4 cases）, renal failure associated with low cardiac output （4 cases）, hypocalcemia（9 cases）, hypoglycemia（5 cases） and hypoxemia（5 cases）.Conclusion The key of increasing postoperative healing rate is active treatment of renal failure and low cardiac out put. And proper ventilation mode, intensive base nursing, nutritional support were also important for the patients.