影响婴儿心脏手术后近期预后的危险因素分析

Risk Factors for Short-term Adverse Events in Infants Receiving Open Heart Surgery

目的分析影响先天性心脏病婴儿行心脏手术后近期预后的危险因素,以采用适当的治疗措施加以干预,改善患者的预后。方法回顾性分析2009年11~12月期间北京阜外心血管病医院98例在体外循环（CPB）下行先天性心脏病矫治术婴儿患者的临床资料,依据术后是否发生并发症将98例患者分为两组,无并发症组（n=40）：男24例,女16例,年龄7.60±0.40个月,体重7.80±0.30 kg;有并发症组（n=58）：男42例,女16例,年龄6.20±0.40个月,体重6.70±0.20 kg。记录两组患者的围术期临床指标,包括术前空腹血糖、肌酐、术中主动脉阻断时间、改良超滤或零平衡超滤、术后血糖水平、乳酸浓度、血管活性药物应用和并发症的发生情况等。根据先天性心脏病手术风险校正评分（RACHS-1）对患者进行手术风险分级。采用单因素和logistic多因素回归分析影响婴儿手术后近期预后的危险因素。结果围术期因循环衰竭死亡1例（1.02%）。需2种正性肌力药物支持〉48 h 37例次,机械通气时间〉24 h 29例次,需二次气管内插管5例次,气管切开1例次,发生院内感染31例次,切口感染4例次,肾功能衰竭3例次,肝功能异常1例次。logistic回归分析结果显示：年龄（OR=0.750,P=0.012）、脉搏血氧饱和度（OR=0.840,P=0.005）、主动脉阻断时间（OR=1.040,P=0.008）和术后血糖水平（平均血糖水平〈8.33 mmol/L的患者术后发生不良事件的概率升高约5倍;OR=5.051,P=0.011）是影响行先天性心脏病矫治术婴儿近期预后的危险因子。结论年龄、术前脉搏血氧饱和度和主动脉阻断时间与行先天性心脏病矫治术婴儿患者术后近期不良预后有关。现有证据尚不足以证实围术期高血糖是不良预后的危险因子。

Objective To identify the risk factors for short-term adverse events in infants with congenital heart diseases receiving open heart surgical correction with cardiopulmonary bypass（CPB）,in order to improve the outcome by adopting appropriate treatment measures.Methods We retrospectively analyzed the clinical data of 98 consecutive children with congenital heart diseases who underwent surgical correction with CPB in Beijing Fu Wai Hospital from November 2009 to December 2009.The patients were divided into two groups according to the post-operative complications.Among the patients without complications（n=40）： there were 24 males and 16 females with an age of 7.60±0.40 months and a weight of 7.80±0.30 kg.In the patients with complications（n=58）： there were 42 males and 16 females with an age of 6.20±0.40 months and a weight of 6.70±0.20 kg.In both groups,peri-operative data were recorded,including pre-operative fast blood glucose,creatinine,time of aortic cross-clamp,modified or zero-balanced ultrafiltration,post-operative glucose level,concentration of lactate, inotrope score and complications.Risk stratification was performed by Risk Adjusted Classification for Congenital Heart Surgery（RACHS-1）.Univariate analysis and logistic regression analysis were used to identify the risk factors for short-term adverse events.Results One patient（1.02%） died of circulatory failure during the peri-operative period.Thirty-seven patients were supported by at least 2 vasoactive drugs for more than 48 hours,29 by mechanical ventilation for more than 24 hours,5 needed re-intubation,1 experienced tracheotomy,31 suffered from noscomial infection,4 had wound infection,3 developed renal failure,and 1 developed hepatic dysfunction.By logistic regression analysis,age（OR=0.750,P=0.012）,percutaneous oxygen saturation（OR=0.840,P=0.005）,aortic cross-clamp time（OR=1.040,P=0.008）,post-operative glucose level（patients with a mean glucose level lower or equal to 8.33 mmol/L had a probability of developing adverse outcomes five times higher;OR=5.051,P=0.011） were found to be the risk factors for short-term adverse outcomes.Conclusion Age,percutaneous oxygen saturation and aortic cross-clamp time are associated with the short-term adverse outcome of infants undergoing congenital heart disease correction with CPB.The present results do not support peri-operative hyperglycemia as a risk factor for adverse outcome.