早期液体负平衡对右室增大性先天性心脏病术后早期恢复的影响

Effect of early negative fluid balance on the early postoperative recovery in children after surgical repair of congenital heart disease with enlarged right ventricle

目的通过对右室增大性先天性心脏病（先心病）患儿进行早期液体负平衡的随机对照研究，验证是否该治疗措施有利于改善这部分患儿的早期预后。方法选取2017年1月至2017年6月在我院行体外循环下纠治手术、右心受累的120例复杂先心病患儿，在术后3h内循环状况稳定后分为早期液体负平衡组（Group—E组）以及对照组（Group—C组）。分别对两组患儿治疗前、术后第1天及术后第2天相关的血流动力学参数和预后指标进行比较。结果Group—E组施行液体负平衡治疗开始于术后（4．39±0．85）h，Group—C组为术后（10．17±2．77）h（P〈0．05）。术后第1天Group—E组的血管外肺水指数（ELWI）明显低于Group—C组，液体负平衡更为明显（P〈0．01），N-末端脑利钠肽（NT—proBNP）更低（P〈0．01）；术后第2天，两组患儿ELWI对比无明显差异，而Group—E组在NT—proBNP（P〈0．01）、液体负平衡率（P〈0．05）仍保持更低的水平。Group—E组的再插管发生率明显低于Group—C组（P〈0．05），呼吸机支持时间和ICU滞留时间也明显低于Group—C组（P〈0．01）。结论右室增大的复杂先心病患儿在术后无明显容量反应性、右室明显增大、室间隔左偏的状态下，早期施行液体负平衡能更早实现液体负平衡，减少血管外肺水，减少撤机相关性肺水肿的发生，减少再插管率，帮助患儿更早撤离呼吸机以及缩短ICU滞留时间。

Objective To estimate the effect of early fluid removal on the early postoperative recovery in children after surgical repair of congenital heart disease with enlarged right ventricle via a randomized trial. Methods One hundred and twenty patients with right-sided complex congenital heart defect who underwent cardiac surgery by cardiopulmonary bypass during January 2017 to June 2017 were enrolled and were divided into two groups, Group-E and Group-C, when the hemodynamics was stable within 3 hours after the surgery. Patients in Group-E were treated with early fluid removal, but Group-C remained conventional therapy. The data of the hemodynamics and outcomes were collected from the postoperative day to the 2nd day post-operation. Results Fluid removal therapy was started in Group-E at （4. 39 ± 0. 85 ） h postoperatively vs （ 10. 17 ± 2. 77 ） h in Group-C （P 〈 0. 05 ）. Patients in Group-E showed lower extravascular lung water index （ELWI） ,lower fluid overload and lower NT-proBNP compared with patients inGroup-C on the first day of post-operation（ P 〈 0.01 ）. Also, the advantages remained in Group-E on the second day but the ELWI showed no remarkable difference. The rate of reintubation（ P 〈 0. 05 ）, the duration of mechanical ventilation and the length of ICU stay （P 〈 0. 01 ） were significantly reduced in Group-E. Conclusion In patients with right ventricle enlarged complex congenital heart defect who underwent cardiac surgery by cardiopulmonary bypass, utilizing early negative fluid balance when the hemodynamics are stable and the right ventricle is ob- viously enlarged could achieve negative fluid balance, get extubated and discharge from ICU earlier, also present lower extravascular lung water index, lower incidence of weaning-induced pulmonary edema and reintubation.