[摘要] 目的:探讨改良超滤(MUF)对婴幼儿心内直视手术术后心肺功能的影响。方法:将40例行体外循环(CPB)下心内直视手术的婴幼儿随机分为MUF组(n=20)和无超滤对照组(简称对照组,n=20),动态观察CPB前、CPB停机以及MUF结束时(对照组在CPB停机20 min时)的血氧分压(PO2)及二氧化碳分压(PCO2)、术后呼吸机辅助呼吸时间、正性肌力药用量以及使用时间、左心室射血分数(LVEF)等心肺功能指标。结果:40例患儿无一例死亡。两组的PO2在CPB停机时与CPB停机前相比均明显下降,但MUF组在MUF结束时明显回升,接近CPB前水平,而对照组仅轻度回升,但仍明显低于CPB前;CPB停机20 min时MUF组PO2高于对照组。CPB停机后两组PCO2轻度升高,MUF后PCO2轻度下降,但组内、组间比较差异无统计学意义。术后MUF组呼吸机辅助时间、正性肌力药用量以及使用时间明显低于对照组。术后1周心脏超声心动图检查提示两组LVEF均较术前明显提高,但组间比较差异无统计学意义。结论:MUF有利于改善婴幼儿心内直视手术术后早期的心、肺功能。�
[关键词] 改良超滤; 体外循环; 心功能; 肺功能; 婴幼儿�
[中图分类号] R654.2[文献标识码] A[文章编号] 1671-7562(2010)01-0044-04�
doi:10.3969/j.issn.1671-7562.2010.01.012��
Influence of modified ultrafiltration on infant�s cardiopulmonary �
function after open heart surgery��
WANG Zhe-yan, LUO Xuan, YAO Hao, LIU Chang, CHEN Bao-jun, �
CAO Bin, WANG Dong-jin
(Department of Cardiovascular Surgery, Nanjing Drum Tower Hospital, Medical College of Nanjing University, Nanjing 210008, China)��
[Abstract] Objective: To investigate the influence of modified ultrafiltration(MUF) on infant�s cardiopulmonary function after open heart surgery with cardiopulmonary bypass(CPB). Methods: 40 infants with congenital heart diseases were randomly divided into the MUF group(n=20) and the control group(n=20). Arterial blood was measured to investigate PO2 and PCO2 before CPB at the end of CPB, at the end of MUF(or 20 minutes after CPB in control group). Besides, the doses of dopamine and LVEF before and after surgery were also measured. Results: No infants were dead in our research. Compared with the levels of PO2 before CPB, the levels of PO2 of the 2 groups were decreased significantly at the end of CPB. The level of PO2 in MUF group was increased significantly at the end of MUF, and it was close to the level before CPB, while the level of PO2 in control group was increased lightly at the end of MUF, and it was lower significantly than the level before CPB. Compared with the level of PO2 in control group, the level of PO2 in MUF group was increased significantly at 20 min after CPB. The levels of PCO2 of the 2 groups were increased lightly after CPB, and its levels were decreased lightly after MUF,but the differences between the 2 groups were not significant. Compared with the control group, the time of using life-support machine, the time of using cardiotonic drug,and the dosage of cardiotonic drug were lower significantly in MUF group. The LVEF of the 2 groups were improved significantly than before surgery at 1 week after surgery, but the difference between the 2 groups was not significant. Conclusion: Modified ultrafiltration can improve cardiopulmonary function of infants after open heart surgery.�
[Key words] modified ultrafiltration; cardiopulmonary bypass; cardiac function; pulmonary function; infants��
在婴幼儿体外循环(CPB)过程中,由于低温、低体重、血液稀释、炎症介质释放等原因造成毛细血管通透性增加,导致CPB后婴幼儿体内水分的大量潴留,由此造成的组织水肿及脏器功能不全尤其严重[1]。改良超滤(moditied ultrofiltration,MUF)可以在不增加CPB时间的前提下,迅速排除体内过多的液体,提高红细胞压积(HCT),同时去除循环血中部分炎症因子,减少术后出血量和ICU停留时间[2-3]。我科2008年1月~2009年3月在对20例15 kg以下婴幼儿行CPB下心内直视手术时施行MUF,取得了较好的效果。现就MUF对婴幼儿心内直视手术术后早期的心、肺功能影响进行探讨。�
1 资料与方法�
1.1 一般资料和分组�
40例先天性心脏病患儿,男25例,女15例;体重6~15 kg,年龄8~37个月。ASAⅠ~Ⅱ级。其中室间隔缺损(VSD)21例,房间隔缺损(ASD)8例,室间隔缺损合并肺动脉狭窄(VSD+PS)6例,室间隔缺损合并动脉导管未闭(VSD+PDA)5例。将40例患儿随机分为MUF组(n=20)和无超滤对照组(简称对照组,n=20)。患儿术前一般资料见表1。两组间年龄、性别、体重、术前心功能等差异均无统计学意义。
1.2 麻醉、CPB和MUF方法�
1.2.1 麻醉方法 应用Drager Narkomed麻醉机。所有患儿均采用静吸复合麻醉,气管插管机械通气,潮气量10 ml•kg-1,通气频率20~24 次•min-1。常规咪唑安定、芬太尼和维库溴铵诱导,术中芬太尼和维库溴铵间断推注维持。�
1.2.2 CPB 使用Jostra型人工心肺机和希健婴儿膜式氧合器,预充液为乳酸林格液、血浆200 ml加红细胞悬液2 U、20%白蛋白50 ml、20%甘露醇(2.5 ml•kg-1)、5%碳酸氢钠20 ml、甲基泼尼松龙40 mg。CPB为浅中度低温,鼻咽温控制在28～30 ℃。灌注流量120~150 ml•kg-1•min-1,阻断升主动脉后于根部灌注冷晶体停跳液10~15 ml•kg-1行心肌保护,平均动脉压维持在40~70 mmHg(1 mmHg=0.133 kPa)。复温前抽取血标本测动脉血气及血红蛋白值,调节血液PaCO2、酸碱度、电解质在正常水平,调整血红蛋白在70~80 g•L-1。复温后增加灌注流量,对照组酌情使用速尿5~20 mg,保证转中尿量1 ml•kg-1•h-1以上。心脏复跳、各项生命指征稳定后可逐步降低流量,直至脱离CPB。停机时血红蛋白>10 g•L-1,肛温>36 ℃。�
1.2.3 超滤方法 采用德国Fresenius公司ultraflux AV600S血液滤过器,进出口分别连接在左心吸引管道和静脉回路上,CPB前将超滤器和超滤管道常规预充排气,CPB中钳闭超滤管道,使回路处于备用状态。CPB结束待循环基本稳定后MUF组行MUF术:钳闭静脉回流管近贮血器一端,开放超滤通路;这时经主动脉灌注针头的动脉血在附加泵的控制下形成倒流,经过超滤器后回至右心房。超滤器内液体的流速控制在10~15 ml•kg-1•min-1。同时监测动脉血压、左心房压。如机体容量不足,在主泵的控制下随时由贮血瓶内的液体补充血容量,贮血器内液面不足可继续加入乳酸林格液,保持CPB处于备用状态,如患儿情况不稳定可立即恢复CPB转流。心肺机内剩余液体用完后停止超滤,整个超滤过程一般10~15 min。对照组不进行超滤术。�
1.3 观察指标�
应用I-Stat血气分析仪,CPB前、CPB停机、MUF结束时或CPB停机后20 min抽取桡动脉血检测氧分压(PO2)及二氧化碳分压(PCO2)。术后早期监测呼吸机辅助呼吸时间、血管活性药物用量及使用时间,术前及术后1周心脏超声心动图测左心室射血分数(LVEF)。1.4 统计学处理�
所有数据采用SigmaPlot统计软件进行处理,计量资料以±s表示,组间比较用单因素方差分析,组内比较采用配对t检验。P