心脏不停跳小儿先天性心脏病姑息手术的体外循环管理

摘要

目的：总结心脏不停跳下行复杂先天性心脏病姑息手术的体外循环（ cardiopulmonary bypass ，CPB）管理特点。方法我院2011年1月至2013年12月在CPB心脏不停跳下行复杂先天性心脏病姑息手术30例，术中维持红细胞压积0．22～0．25，温度34～36℃，血浆胶体渗透压在正常范围，监测指标包括平均动脉压﹑中心静脉压、心率﹑静脉混合血氧饱和度﹑乳酸、尿量﹑血浆胶体渗透压、鼻咽温和肛温。结果全组CPB时间12～140 min[（45．06±27．27）min]，术后气管插管时间4～50 h [（17．26±8．29）h]，监护时间46～160 h [（93．05±32．92）h]，超滤量400～1200 ml [（713．66±209．80）ml]，尿量5～100 ml [（33．33±20．98）ml]，住院时间10～30 d [（18．83±4．43）d]，术后24 h胸引量30～120 ml [（70．40±27．07）ml]。患儿术中、终止CPB时红细胞压积（HCT）、氧分压（PaO2）、二氧化碳分压（PaCO2）、剩余碱（BE）、乳酸等指标与术前比较差异有统计学意义（P＜0．01）。所有患儿均顺利脱离CPB，无CPB相关并发症，术后恢复顺利。结论采用合适的预充方案，合理的血液稀释，严密监测术中指标，心脏不停跳下行复杂先天性心脏病姑息手术有更好的心肌保护，是安全可行的，可促进患儿早期恢复。%Objective To summarize the management characteristics of cardiopulmonary bypass ( CPB) palliative operations with beating heart for congenital heart disease in children .Methods The post-operation clinical data of 30 CPB palliative operations with beating heart during Jan .2011 to Dec.2013 in our hospital were retrospectively analyzed .We performed the surgeries with beating heart.Hematocrit was maintained from 0.22 to 0.25.Temperature ranged from 34°C to 36°C.The level of plasma colloid osmotic was normal.Mean arterial blood pressure,central venous pressure,heart rate,mixed venous oxygen saturation,lactic acid,urinary volume, plasma colloid osmotic pressure ,nasopharyngeal temperature and rectal temperature were monitored during the operations .Results The duration of CPB ranged from 12 to 140 (45.06 ±27.27 ) minutes.The postoperative intubation time ranged from 4 to 50 (17.26 ± 8.29) hours.The duration of monitoring ranged from 46 to 160(93.05 ±32.92)hours.The Ultra filtration volumes were 400 to 1200 (713.66 ±209.80)ml.The urinary volume ranged from 5 to 100(33.33 ±20.98)ml.The duration of inpatient ranged from 10 to 30 (18.83 ±4.43) days.The volumes of thoracic drainage during the first 24 hours post-operation ranged from 30 to 120 (70.40 ± 27.07) ml.The indexes such as HCT,PaO2,PaCO2,BE and lactic acid during the operation and at the end of CPB were obviously dif-ferent from pre-operation.The detachment of CPB in all patients was successful ,and the patients all recovered after the surgeries .Con-clusion CPB with a suitable pre charging scheme ,reasonable blood dilution and strictly intraoperative factors monitoring are safe and practicable .It provides better protection of the myocardium with beating heart utilized in palliative operations of CHD and can promote children early recovery .