10kg以下婴幼儿心内直视手术的体外循环分析

Management of cardiopulmonary bypass during open heart surgery in infants with body weight less than 10 kg

目的探讨lokg以下婴幼儿先天性心脏病行心内直视手术的体外循环管理方法和经验。方法自2006年1月至2011年12月间，473例10kg以下婴幼儿行心内直视手术，月龄1～36个月，平均（10．2±4．8）个月；体质量2．7～10k，平均（6．9±1．7）垤。所有手术均使用进口婴儿中空纤维膜式氧合器。浅或中低温中高流量灌注。采用4：1冷氧合血灌注进行心肌保护。全组患者术中术后均使用改良超滤结合常规超滤。结果全组体外循环转流时间31～206min，平均（78±18）min，主动脉阻断时间11～108min，平均（39±11）min。术中灌注压30～60mmHg，转流过程平稳，尿量均〉2ml／（kg·min），心脏自动复跳率95．8％，全部顺利脱机，464例痊愈出院。术后死亡9例，死亡率1．90％。结论建立更适用于婴幼儿非生理状态下的婴幼儿体外循环过程，合理的预充和血液稀释，合适的灌注流量和灌注压，加强液体出入量平衡的管理，以及术中良好的心肌保护和超滤技术的应用，是提高婴幼儿围手术期成功率的重要手段和措施。

Objective To review the cardiopulmonary bypass management during open heart surgery in infants with body weight less than 10 kg. Methods The clinical data of 473 infants, who underwent open heart surgery with cardiopulmonary bypass for congenital heart disease from January 2006 to December 2011, were retrospectively reviewed. The patients were aged from 1 to 36 months, with median age （ 10.2 ＋4.8） months; and their weights were ranged from 2.7 to 10 kg, with median weight （6. 9 ± 1. 7 ） kg. The membrane oxygenator was used in patients. A low to moderate hypothermia and moderate to high flow perfusion strategy were adopted. Myocardium protection was achieved by mixture of cold oxygenated blood cardioplegia （4：1 for blood and crystal solution）. Results The cardiopulmonary bypass time was 31 -206 min with an average of 78 ±18 min. Aortic cross clamping time ranged from 11 - 108 rain with a median time of （ 39 ± 11 ） vain. The perfusion pressure during the operation was 30 -60 mmHg. All the extracorporeal circulations were uneventful and achieved reasonable urine output[ 〉2 ml/（ kg ·min） ]. The heart beat recovered spontaneously in 95.8% cases and no patient had difficulty in weaning off the cardiopulmonary bypass. Among 473 children, 9 died with a mortality of 1.9%. Conclusion It is very important to establish a more compatible cardiopulmonary bypass model for the non-physiological status during operation in infants. Several strategies should be used to increase the successful rate of the cardiac surgery, including appropriate prime and hemodilution, reasonable flow and perfusion pressure, careful fluid balance management, superior myocardium protection, and modified ultrafiltration application.