单肺通气在婴幼儿腋下小切口心内直视手术中的应用

The application of one-lung ventilation in open heart surgery through right subaxillary minimally invasive small incision in infants

目的：探讨单肺通气在婴幼儿腋下小切口心内直视手术中应用的安全性及可行性。方法：回顾性分析2014年1-12月在我院采用右腋下小切口径路手术治疗的婴幼儿先天性心脏病患儿376例。所有患儿均采用普通气管导管行左侧支气管插管，术中行单肺通气。采用压力控制通气模式，FIO2100％。I：E1：1～1．5，通过调整呼吸频率（25～40次／min）和控制压力（15～30cmH20）水平来维持SpO2和ETCO2在正常范围之内；术中保持适度的头高位，CPB结束后常规超滤，严格控制液体入量。分别在诱导后OLV前（T1）、OLV10min（T2）、OLV30min（T3）、CPB结束后OLV10min（T4）及术毕恢复双肺通气后（T5）抽动脉血测定Pa02、PaCO2值，并记录各时点的HR、MAP值及术后患儿肺部并发症的发生率和拔管时间。结果：所有惠儿均安全度过围术期，术中通气侧无气胸发生；PaO2在他、T3、T4、T5时较T1降低（P〈0．05），差异有统计学意义，但数值均在正常生理范围内；PaCO2、HR、MAP在各时点比较无统计学差异。结论：在恰当的插管技巧、合理的通气策略及术中加强对肺的保护条件下单肺通气可以安全的应用于在婴幼儿腋下小切口心内直视手术中。

Objective To investigate theeffect of the one-lung ventilation （OLV） on open heart surgery with right subaxillary minimally invasive small incision in infants. Methods We conducted a retrospective analysis of 316 infants undergoing open heart surgery through right axillary straight mini-thoracotomy in ourhospital from Jan- uary 2014 to December 2014. Ordinary tracheal tube was inserted into left bronchus during OVL in all patients. OLV with pressure-control mode was performed with FiO2100% and I：E 1：1 ~ 1.5 and their respiratory rate and the pressure ventilation were adjusted to maintain SpO2 and ETCO2 in the normal range. Conventional ultrafihration was performed after CPB and fluid restrictions were intraoperatively maintained. Blood samples were obtained for deter- mination of PaO2 and PaCO2 after induction of anesthesia （T1）, at the time points： OLV 10 min （T2）, OLV 30 min （T3）, OLV10 min after CPB （T4） and the recovery TVL （T5）. The HR, MAP, incidence of pneumothorax and me- chanical ventilation time were recorded and monitored as well. Result All patients lived through perioperative pe- riod, without pneumothorax. There were no significant differences in PaCO2, HR and MAP between time points. But PaO2 at the time point of T1 significantly lowerthan those at other time points of T2, T3, T4 and T5, but its indexes at all time points were in normal range. Conclusion The appropriate skills ofintubation, rational strategy of ventila- tion and intensive prevention of the lung may be good for the safe application of OVL in open heart surgery through right subaxillary minimally invasive small incision in infants.