法洛四联症根治术后早期并发症的临床分析与处理

Clinical analysis and processing of early complications after complete repair of tetralogy of Fallot

目的:总结法洛四联症(tetralogy of Fallot,TOF)患儿根治术后早期处理经验,以降低TOF根治术后早期并发症的发生率及病死率。方法:回顾性分析2012年1月至12月完成的TOF根治术188例,将其分为并发症组31例,非并发症组157例。对比两组患儿年龄、体质量,术前血色素、血氧饱和度、McGoon比值,术中体外循环时间、主动脉阻断时间,术后呼吸机辅助时间、体质量监护室停留时间,正性肌力药物评分以及术后右心室流出道压力差。结果:并发症组术前McGoon比值(1.54±0.21)vs.(2.01±0.42),体外循环时间(112.54±33.32)vs.(97.03±26.1)min、主动脉阻断时间(65.38±15.41)vs.(61.87±15.38)min,呼吸机辅助时间(85.64±35.38)vs.(44.62±21.84)h、监护室停留时间5.0(2.0,7.0)vs.3.0(1.0,5.0)d,正性肌力药物评分(18.21±6.27)vs.(10.16±3.18)与非并发症组比较差异有统计学意义(P<0.05)。术后右心室流出道压力差21.5(12.3,33.8)vs.24.0(17.0,32.0)mmHg(1mmHg=0.133kPa),并发症组与非并发症组比较差异无统计学意义。并发症包括低心排出量综合征(低心排)9例,渗漏综合征12例,心律失常5例,灌注肺损伤2例,感染5例。其中死亡5例(病死率2.66%)。结论:严格把握手术适应证,缩短体外循环时间,术后合理应用正性肌力药物,积极腹膜透析是预防和控制TOF根治术后低心排和渗漏综合征的有效方法。呼吸机辅助通气呼气末正压治疗及高频振荡呼吸机治疗可以控制大多数灌注肺,必要时可介入封堵侧枝。

Objective：In order to reduce the incidence and mortality caused by early complications after complete repair of tetralogy of Fallot （TOF）,we summarized the relevant clinical experiences in daily practice.Methods：We retrospectively reviewed the medical records of 188 patients receiving TOF resection during the period between January 2012 and December; 188 of them,31 cases had complications and the remaining did not have.Demographic and clinical characteristics including age,weight,preoperative hemoglobin,oxygen saturation,McGoon,intraoperative cardiopulmonary bypass（CPB） time,aortic clamping time,postoperative ventilation time,ICU stay,positive inotropic agents score and right ventricular outflow tract pressure difference were compared between the two groups.Results：There were significant difference between the complication and non-complication groups in terms of post-operation McGoon （1.54 ± 0.21） vs.（2.01 ± 0.42）,intraoperative CPB time （112.54 ±33.32） vs.（97.03 ± 26.1） min,aortic clamping time （65.38 ± 15.41） vs.（61.87 ± 15.38） min,postoperative ventilation time （85.64 ± 35.38） vs.（44.62 ± 21.84） h,guardianship chamber residence time 5.0（2.0,7.0） vs.3.0（1.0,5.0）d,inotropic score （18.21 ±6.27） vs.（10.16 ±3.18） （P ＜ 0.05）.Postoperative fight ventricular outflow tract pressure difference 21.5 （12.3,33.8） vs.24.0 （17.0,32.0） mmHg,no significant difference between the complication group and non-complication group.Complications included low cardiac output syndrome （9 cases）,capillary leak syndrome （12 cases）,arrhythmia （5 cases）,lung perfusion injury （2 cases） and infection （5 cases）.A total of 5 patients （2.66％） died of complications.Conclusion：Comprehensive measures including strictly control of surgical indications,shortening the duration of CPB and appropriate use of inotropic drugs following operations and active peritoneal dialysis where necessary are useful to prevent and control low cardiac output syndrome and leak syndrome after complete repair of TOF.In addition,mechanical ventilation PEEP therapy and High frequency ventilation can control most of perfusion lung.If necessary,interventional occlusion major aorto pulmonary collateral arteries.