深低温停循环选择性脑灌注在小体重婴幼儿一期主动脉弓重建中的应用

Application of Selective Cerebral Perfusion During One Stage Repair of Aortic Arch with Deep Hypothermia Circulatory Arrest in Low Weight Infants

目的总结深低温停循环（deep hypothermia circulatory arrest，DHCA）结合选择性脑灌注（selective cerebral perfusion，SCP）技术在小体重婴幼儿一期主动脉弓重建过程中的脑保护效果。方法回顾分析北京安贞医院小儿心脏外科于2007年1月至2008年7月间完成的15例8kg以下行一期主动脉弓重建患儿的临床资料。患儿月龄1．2—21（6．1±5．2）个月，体重4～8（5．9±1．4）kg。全部病例温度均逐级降温至鼻咽温度18℃～20℃，直肠温度降至19℃～22℃，在主动脉弓重建过程中使用DHCA，通过无名动脉进行SCP（25—30ml／kg）的体外循环（extracorporeal circulation，ECC）管理方法。心肌保护均采用一次性低温康斯特器官保护液（HTK液）。ECC前采用洗血球机（cellsaver）处理库血以及ECC中应用常规超滤（conventional uhrafiltration，CUF）结合改良超滤（modifled ultrafiltration，MUF）的方法。结果全组均无与ECC相关的神经系统并发症。死亡2例，1例于术后9天死于严重肺部感染，另1例于术后16d死于严重左心功能衰竭。ECC时间116～591（231．5±127．4）min，主动脉阻断时间25～258（103．5±77．0）min，SCP时间20—80（32．6±18．4）min，自动复跳率100％。患儿术后常规镇静，清醒时间1～8（4．2±2．0）d，ICU气管插管时间20～321（177．2±76．8）h，ICU停留时间92—544（237．2±136．6）h。结论对小体重婴幼儿行一期主动脉弓重建术中，使用DHCA结合SCP等综合保护策略有助于重要器官的保护，尤其减少术后神经系统并发症发生率。

OBJECTIVE To summarize the cerebral protective effect of selective cerebral perfusion（SCP） technique during one stage repair of aortic arch with deep hypothermia circulatory arrest （DHCA） in low weight infants and young children. METHODS Fifteen patients whose weight was below 8 kilogram underwent one stage repair of aortic arch with DHCA and SCP between January 2007 and July 2008. Median age at operation was 6.1 ± 5.2 months （ range 1.2 - 11.5 months） ; median weight was 5.9 ± 1.4 kg （ range 4 - 8 kg）. Temperature of nasopharynx was decreased to 18℃ - 20℃, temperature of rectum was controlled at 19℃ -22℃. DHCA and SCP by innominate artery were applied for repairing the aortic arch. The flow rate of regional perfusion was maintained with 25 -30 ml/（kgomin）. Myocardial protection was established with single - dose cold histidine - tryptophan - ketoglucotarate （HTK） solution. Before extracorporeal circulation（ ECC）, we processed banked blood with cell saver. During ECC, all patients underwent conventional ultrafiltration （CUF） and modified uhrafiltration （MUF） to achieve a satisfactory hematocrit. RESULTS There was no neurological complication in all patients. In this group, two infants died. One was died from serious lung infection at the 9th day after operation; the other one died with left heart failure at the 16th day after operation. Mean extracorporeal circulation time was 231.5 ± 127.4 min, and mean aortic clamp time was 103.5 ± 77.0 min. Mean duration of SCP was 32.6 ± 18.4 min. The spontaneous re - beating rate was 100%. Mean intubation time in intensive care unit （ICU） was 177.2 ±76.8 hours ; mean ICU stay was 237.2 ± 136.6 hours. CONCLUSION Deep hypothermic circulatory arrest combined with regional cerebral perfusion is valid for the protective effect of the major organs during one stage repair of aortic arch in low weight infant and young children.