发绀型先天性心脏病改良体-肺动脉分流术中血流动力学变化

Hemodynamic changes in cyanotic congenital heart disease children undergoing modified systemic-pulmonary shunt

目的:使用压力记录分析法(PRAM)监测发绀型先天性心脏病患儿改良体-肺动脉(m BT)分流术中血流动力学的变化,分析其临床应用价值,并以此作为选择容量治疗或强心治疗的依据。方法:选择28例择期行m BT分流术的先天性心脏病患儿,主要诊断法洛四联症19例,肺动脉狭窄+室间隔缺损6例,肺动脉闭锁+室间隔缺损3例,月龄2~24个月,中位月龄10.6(6.2,18.9)个月,体质量(10.5±5.1)kg,Nakata指数平均(125±41)mm^2/m^2。在切皮前(T0)、切心包1 min(T1)、部分阻断肺动脉1 min和10 min(T2、T3)、部分阻主动脉后(T4)、人工血管开放通血1 min和10 min(T5、T6)、术毕(T7),记录循环周期效率(CCE)、心排血指数(CI)、心每搏指数(SVI)、收缩压(SBP)、重脉压与舒张压差值(Pdic-a)、压力升支最大斜率(dp/dt_(max))、体循环阻力指数(SVRI)、脉压变异度(PPV)。结果:各时间点dp/dt_(max)的平均值均>1.0 mm Hg/ms(1mm Hg=0.133k Pa)。人工血管通血前(T0-T4),T3点CCE、CI、SVI均处于最低点,其中CCE_(T3)明显低于CCE_(T0-T1)(P均<0.05),CI_(T3)明显低于CI_(T0-T2)(P均<0.01),SVI_(T3)明显低于SVI_(T0-T2)(P<0.01,P<0.01和P<0.05);Pdic-a_(T4)处于最低点,显著低于Pdic-a_(T0-1)(P<0.01和P<0.05);SVRI_(T3)处于最高点,明显高于SVRI_(T0)(P<0.01)。人工血管通血后(T5-T7),T5点CCE、CI、SVI、Pdic-a均处于最低点,其中CCE_(T5)明显低于CCE_(T7)(P<0.05),CI_(T5)明显低于CI_(T6-T7)(P均<0.05),SVI_(T5)明显低于SVI_(T6-T7)(P均<0.05),Pdic-aT5明显低于Pdic-aT6-7(P<0.01);PPVT5明显高于PPVT6-T7(P<0.01)。在T6和T7点,PPV与Pdic-a呈显著负相关(r=-0.51,r=-0.53,P均<0.01)。结论:m BT术中血流动力学维护重点,在人工血管通血前以强心为主,应用正性肌力药维护心功能,在人工血管通血后通过扩容维护有效循环血容量。通过CCE、CI、SVI、dp/dt_(max)、PPV、Pdic-a等血流动力学监测指标,精准判断液体治疗和应用正性肌力药治疗的权重,从而积极防治患儿术中低氧血症,稳定血流动力学状态。

Objective： By using pressure recording analytical method（ PRAM） to monitor hemodynamic changes of cyanotic congenital heart disease children undergoing modified Blalock-Taussig shunt（ m BT）,to determine the weight of fluid treatment against cardiotonic therapy. Methods： A total of 28 patients with cyanotic congenital heart disease scheduled to receive m BT shunt were enrolled,primary diagnosis were tetralogy of Fallot（ n = 19）,pulmonary atresia ＋ ventricular septal defect（ n = 6）,pulmonary stenosis ＋ ventricular septal defect（ n = 3）,age 10. 6（ 6. 2,18. 9） months,weight（ 10. 5 ± 5. 1） kg,Nakata index（ 125 ± 41） mm^2/m^2.Hemodynamic data were monitored and recorded by PRAM including cardiac cycle efficiency（ CCE）,cardiac index（ CI）,stroke volume index（ SVI）,systolic blood pressure（ SBP）,difference between dicrotic pressure and diastolic blood pressure（ Pdic-a）,maximal slope of systolic upstroke（ dp/dt_（max））,systemic vascular resistance index（ SVRI）,pulse pressure variation（ PPV）,at before incision（ T0）,1 min after pericardiotomy（ T1）,1 min and 10 min after blocking pulmonary artery（ T2 and T3）,blocking the aorta（ T4）,1 min and 10 min after the artificial vascular graft bridge shunt was opened（ T5 and T6）,end of surgery（ T7）. Results：The mean value of dp/dt_（max） at each time point was above 1. 0 mm Hg/ms. Before artificial vascular graft bridge shunt was opened（ T0-T4）,CCE,CI and SVI were lowest at T3,CCE_（T3） was significantly lower than CCE_（T0-T1）（ P〈0. 05 for both）,CI_（T3） was significantly lower than CI_（T0-T2）（ P〈0. 01 for both）,SVI_（T3） was significantly lower than SVI_（T0-T2）（ P〈0. 01,P〈0. 01 and P〈0. 05,respectively）; Pdic-a_（T4） was at nadir and significantly lower than Pdic-a_（T0-1）（ P〈0. 01 and P〈0. 05）; SVRI_（T3） was at peak and significantly higher than SVRI_（T0）（ P〈0. 01）.After artificial vascular graft bridge shunt was opened（ T5-T7）,CCE,CI,SVI and Pdic-a were lowest at T5,CCE_（T5） was significantly than CCE_（T7）（ P〈0. 05）,CI_（T5） was significantly lower than CI_（T6-T7）（ P〈0. 05 for both）,SVI_（T5） was significantly than SVI_（T6-T7）（ P〈0. 05 for both）,Pdic-aT5 was significantly lower than Pdic-a_（T6-7）（ P〈0. 01 for both）; PPVT5 was significantly higher than PPV_（T6-T7）（ P〈0. 01）. At T6 and T7,PPV was significantly and negatively related with Pdic-a（ r =-0. 51,r =-0. 53,P〈0. 01 for both）. Conclusion： During m BT shunt procedure,hemodynamic management emphasis before artificial vascular graft bridge shunt opened is cardiotonic therapy,using inotropic agents to preserve cardiac function,after artificial vascular graft bridge shunt opened,emphasis is using fluid therapy to maintain effective circulating blood volume. By monitoring CCE,CI,dp/dtmax,PPV and Pdic-a,correctly determining the weight of fluid therapy against inotropic agents,intensively preventing and curing hypoxemia during procedure,hemodynamic status stable is achieved.