选择性脑灌注在婴幼儿主动脉弓手术中的应用

Application of selective cerebral perfusion in aortic arch reconstruction procedure in infants

目的总结选择性脑灌注（SCP）技术在婴幼儿主动脉弓手术中的脑保护作用，以减轻术中脑损伤。方法选择复旦大学附属儿科医院心血管中心外科在2009年9月至2011年9月行主动脉弓手术中应用SCP技术的17例婴幼儿。年龄1～16个月[（3．5±4．2）个月]；体质量3．5～9．5kg[（4．6±1．5）kg]。其中主动脉弓中断伴心内畸形7例，主动脉缩窄伴心内畸形10例。全部患儿均逐级降温，待鼻咽温降至18～20℃，直肠温降至20—22℃时，将主动脉灌注管向上推动插入无名动脉内进行SCP。SCP的流量维持在30～40mL／（kg·min）。心肌保护均采用一次性低温康斯特保护液。体外循环术中全部患儿均采用常规超滤结合改良超滤的方法。结果体外循环总时间71—190min[（113．1±36．5）min]；主动脉阻断时间34～107min[（51．9±20．7）min]；SCP时间4～56min[（24．0±19．7）min]。自动复跳率100％。术后患儿常规镇静，术后苏醒时间6～8h；ICU气管插管时间22～305h[（164．3±63．2）h]；ICU停留时间72～605h[（252．7±128．3）h]。死亡1例，术后12d死于严重肺部感染。全组均无与体外循环相关的临床神经系统并发症，EEG检查未见明显异常。术后随访，存活16例，无病死病例。结论在婴幼儿主动脉弓手术中，SCP有助于减少术后神经系统并发症的发生率，是一种简单可行和有效的脑保护方法。

Objective To summarize the cerebral protective effect of selective cerebral perfusion （SCP） technique in aortic arch reconstruction procedure in infants, so as to alleviate brain injury during operation. Methods From Sep. 2009 to Sep. 2011,17 infants underwent aortic arch reconstruction procedure with SCP in Children＇s Hospital Affiliated to Fudan University. Median age at operation was （3.5 ±4.2） months （ range 1 - 16 months）, median weight was （ 4.6 ±1.5 ） kg（ range 3.5 - 9.5 kg）. Seven suffered from interrupted aortic with intracardiac anomaly, and 10 suffered from aortic coarctation with intracardiac anomaly. Temperature of nasopharynx was decreased slowly to 18 -20 ℃ , temperature of rectum was decreased slowly to 20 - 22 ℃. Then the arterial cannula was moved upward into innominate artery to perform SCP. The flow rate of SCP was 30 -40 mL/（kg·min）. Myocardial protection was established with single-dose cold constable＇s protection fluid （HTK solution）. During extracorporeal circulation, all patients underwent conventional ultrafihration and modified ultrafiltration to achieve a satisfactory hematocrit. Results Mean extracorporeal circulation time was （ 113.1 ±36.5 ） minutes （ 71 - 190 minutes）, mean aortic clamp time was （ 51.9 ±20.7 ） minutes （34 - 107 minutes） ,and mean SCP time was （24.0 ±19.7 ） minutes （4 - 56 minutes）, The spontaneous re-beating rate was 100%. Mean regain consciousness time was 6 - 8 hours. Mean intubation time in intensive care unit was （164. 3 ±63.2） hours（22 -305 hours） ,mean ICU stay time was （252.7 ±128.3） hours（72 -605 hours）. One infant died from serious lung infection at the 12th day after operation. There was no neurological complication in all infants. No obvious neurologic complication was observed and no abnormal electroencephalogram was observed in 16 survivals. Conclusion SCP is helpful to alleviate brain injury during operation and it is a feasible and effective technique in aortic arch reconstruction procedure in infants.