功能性单心室Ⅱ期全腔静脉-肺动脉连接术后的监护管理

The postoperative management of the patients with functional single ventricle after two stage total cavopulmonary connection

目的探讨分期全腔静脉-肺动脉连接术（total cava-pulmonany correction，TCPC）治疗功能性单心室的疗效。方法自2002年12月至2007年9月为18例既不适宜进行双心室解剖矫治、也不适宜Ⅰ期生理矫治的复杂先天性心脏病患儿施行了分期TCPC术。男13例，女5例。年龄4．0～16．0岁（Md=8．0岁）。体重11．0～52．0kg（Md=19．5k）。所有患儿在Ⅰ期和Ⅱ期手术前均行心脏超声和心导管检查确诊。全组患儿入ICU后采取上身抬高30°，下身抬高15°体位。机械辅助呼吸期间避免使用高PEEP，尽早撤离呼吸机。观察头面部、四肢水肿情况，根据上、下腔静脉压力调整补液方案。术后根据肺动脉压力增高程度应用各种选择性肺血管扩张药物降低肺动脉压力。无明显活动性出血者，术后早期使用小剂量肝素（0．05～0．1mg·kg^-1·h^-1）抗凝治疗。出ICU后改为口服华法令或阿斯匹林抗凝治疗。结果术后早期存活16例，死亡2例，病死率11．1％。死亡原因为重度低心排出量综合征。全组辅助呼吸时间为9-157h，平均：（27．0±35．0）h，Md=17．5h。术后住院天数为11～86d（Md=17d）。术后并发症有胸内出血2例，乳糜胸1例。存活病例术后经皮血氧饱和度（98．0±3．9）％，较术前数值（82．0±6．4）％显著上升（P〈0．01）。结论根据1℃PC术后病理生理的改变，制定合理的治疗方案，对于提高TCPC术后成功率和减少术后并发症发生率有重要的作用。

Objective To summarize the experience of postoperative management of the total cavapulmonary correction （TCPC） in the patients with single functional ventricle Methods From December 2002 to September 2007, 18 patients with functional single ventricle, which were confirmed by echocardiography and cardiac catheterization, underwent two stage TCPC. Of the 18 patients, 13 were male and 5 female Mean age at operation was 8 years old （ 4-16 years）. Mean weight was 19. 5 kg （ 11-52 kg）. After operation, the patients were positioned in supine position with their thinks devated at 30° and lower limb at 15°. High PEEP was avoided during mechanical ventilation. Withdrawl of the mechanical ventilation was performed im mediately after patients＇ clinical condition permited. Fluid infusion was calculated based on the superior and inferior vena cava pressure, and the severity of edema. Pulmonary vasodilators were also given to the patients to decrease pulmonary artery pressure Low dose heparin （0. 05-0. 1 mg,kg^-1·h^-1 ） was administered to the patients without active bleeding. After ICU discharge, heparin was replaced with warfarin or aspirine. Remits Among the 18 patients, 16 survived and 2 succumbed, with a mortality of 11.1%. The patients were dead for severe low cardiac output. The mean mechanical ventilation time was 17. 5 hours（9-157 hours）. The mean duration of postoperative hospital stay was 17 days （11 86 days）. The operative complications included mediastinal active bleeding in 2 cases and chylothorax in 1 case The transcutaneous oxygen saturation was significantly improved after TCPC （98. 0 ± 3. 9% vs82.0±6.4%）. Conclusions To reduce the mortality and complications, postoperative management after TCPC should be carried out based on patients＇ individual physiopathologic conditions.