婴儿先天性心脏病体外循环术后的治疗

目的 探讨婴儿先天性心脏病体外循环术后的治疗及转归.方法 对我院2005年1月至2010年11月经体外循环治疗的217例婴儿的临床资料进行回顾性分析.结果 全组术后死亡11例,住院病死率为5.1%(11/217).其中因重症低心排出量综合征死亡4例,肺动脉高压危象死亡2例,低心排出量综合征合并急性肾功能不全死亡2例,重症感染死亡1例,严重低氧血症死亡1例,慢性心包填塞导致心跳骤停死亡1例.术后住院时间7～52 d,平均14 d.结论 随着外科治疗技术的提高,婴儿体外循环下心脏手术治疗可以取得良好的治疗效果.体外循环术后采取积极有效的治疗是降低围手术期病死率的关键.

Abstract：

Objective To study the treatment and outcome in infants with congenital heart disease after cardiopulmonary bypass. Methods The clinical data of 217 infants with congenital heart disease after cardiopulmonary bypass in Shengjing Hospital from Jan 2005 to Nov 2010 were retrospectively reviewed. Results Eleven infants died and the mortality was 5. 1% ( 11/217 ). Four infants died of severe low cardiac output syndrome,2 died of pulmonary hypertension crisis,2 died of low cardiac output syndrome complicated with acute renal insufficiency, 1 died of severe infection, 1 died of severe hypoxemia,and 1 died of chronic pericardial tamponade. The postoperation length of hospital stay was 7 ～ 52 d, 14 d in average. Conclusion With the improvement of surgical techniques,cardiac surgery with cardiopulmonary bypass on infants can result in good clinical effect. Active and effective treatment can reduce the perioperative mortality after cardiopulmonary bypass.     

纤维支气管镜在PICU中的应用

Objective To explore the efficacy and safety of clinical application of bronchofibroscope (BFS) in PICU. Methods Seventy-nine critically ill children in our PICU were operated with BFS in 89 cases and the etiology of these children was analyzed. The blood-gas analysis and oxygenation index both before and after the treatment had been compared, and syndrome was observed as well. For 40 cases in which critically ill children received bronchoalveolar lavage in addition to mechanical ventilation, and the index of respiratory mechanics was analyzed. Analysis and summary had been performed on the culture results of bronchoalveolar lavage fluid in 74 cases. Results The primary disease in these cases was mainly respiratory diseases (64/79). There was no major change in oxygenation index and blood pH ( P ＞0. 05 ) before and after operation with BFS. No severe syndrome,such as sudden cardiac arrest and pneumothorax, was recorded. However,transient decrease in SpO2 was most frequently observed in minor syndromes (15/79). The children treated with mechanical ventilation were recorded with significant decrease in air way resistance ( P ＜ 0. 05 ) after bronchoalveolar lavage. However,dynamic compliance and work of breathing only changed slightly (P ＞0. 05 ). The culture positive rate of bronchoalveolar lavage fluid was 29. 1% (23/79) ,mainly gram-negative bacteria, which coincided with disease spectrum of PICU. Conclusion The application of BFS in PICU can improve salve and tracheobronchial management for critically ill children. The diagnosis and treatment is safe and reliable by strictly grasping the examination indication by BFS under the custody of PICU.     

早产儿视网膜病1082例筛查报告及诊治分析

Objective To explore the early diagnosis and treatment of retinopathy of prematurity (ROP). Methods Totally premature infants with gestational ages of ＜ 34 weeks or a birth-weight ＜ 2 000 gwho were born in our hospital from July, 2004 to June, 2009, received ROP screen that was carried out by ophthalmologists with particular expertise in ROP using binocular indirect ophthalmoscope. The first screening began at 4 to 6 weeks postnatal age or 32 weeks of postconceptional age. The infants with threshold and prethreshold type Ⅰ ROP(severe) were treated with retinal laser photocoagulation. The infants with immature retinal blood vessels or stage 1 ～ 2 ROP or pre-threshold type Ⅱ ROP (mild) were followed up until retinal vessels are seen in zone Ⅲ or it gets to threshold and pre-threshold type Ⅰ ROP level. All clinical data were analyzed retrospectively. Results 1 082 of total 2 295 premature infants (47. 14% ) received ROP screening ia our department during the past5 years. 14. 23% ( 154/1 082) infants were diagnosed as ROP,the mild and severe ROP accounted for 7.94% (86/1 082) and 6. 28% (68/1 082) respectively. Six infants had to be rehospitalized as they developed into severe ROP during follow-up period. Of all the 68 infants with severe ROP,two infants with severe ROP were confirmed to be bilaterally blind because they had intermitted therapy for one year. Sixty-six infants ( 132 eyes) received various treatments. Sixty-three cases were treated with photocoagulation therapy alone. Of the remaining 3 infants with aggressive posterior ROP, two infants were injected intravitreously with antagonist of vascular endothelial growth factor (Avastin) and photocoagulation,One who was found retinal detachment after photocoagulation therapy alone and then treated with vitrectomy,was blind finally. The eyesight of total 65 infants were saved successfully, the success rate of treatment was 98.48% (65/66). During the surveillance period, none of the infants who had received photocoagulation died,but 10 infants died of the deterioration of the original disease before they were able to receive photocoagulation. Conclusion ROP screening is an effective measure to prevent the progression of ROP. Laser photocoagulation is a safe and effective method for the infants with severe ROP. Photocoagulation combined with Avastin can save the sight of the premature infants with aggressive posterior ROP.     

小儿心内直视手术后急性呼吸窘迫综合征的危险因素与防治对策

Objective To analyze the risk factors,prevention and management strategies of acute respiratory distress syndrome(ARDS)after cardiopulmonary bypass(CPB).Methods Between January 2001 and October 2008,1 408 patients undergoing open heart surgery were recruited for study.Univariate and multivariate logistic regression analysis were used to identify the risk factors.Results Thirty-two patients (2.27%)developed ARDS.The mortality for ARDS was 46.9 %(15/32).Univariate risk factors included cyanotic congenital heart disease,CPB lime,aortic cross-clamping time,mechanical ventilation time,the volume of postoperative drainage per kilogram of body weight,perioperative unexpected events and postoperative complications.Multivariate logistic regression analysis showed that CPB time ＞ 180 rain,postoperative drainage volume per kilogram of body weight ＞ 18 ml,perioperative unexpected events,postoperative multiple organ dysfunction syndrome(MODS)were risk factors.Condusion Active and effective treatments should be carried out in the children with high risk factors of ARDS following open heart operation.It would play an important role in the prevention,early diagnosis and management of ARDS.     

Risk factors for death in children with severe adenovirus pneumonia in southwest Chongqing北大核心CSCD

Objective To investigate the risk factors for death in children with severe adenovirus pneumonia (SAP) in pediatric intensive care unit (PICU), and to provide reference basis for clinical reasonable treatment and reducing the adverse outcome. Methods The clinical data of 68 children with SAP hospitalized in PICU, Children′s Hospital of Chongqing Medical University from August 2018 to September 2019 were retrospectively analyzed.They were divided into the death group and the survival group according to their condition.The age, basic diseases, complications and laboratory examination results of children were collected for univariate analysis, and multivariate Logistic regression analysis was performed for those with significant univariate analysis. Results Among the 68 children with SAP, 50 were males and 18 were females, and 46 cases (67.6%) aged between 6 months and 2 years.Fifty-five cases(80.9%) of SAP occurred in spring and summer.There were 61 cases (89.7%) with the spike over 39 ? and 21 cases (30.9%) had fever for over 2 weeks; 42 cases (61.8%) were infected with mixed other pathogens.Intrapulmonary and extrapulmonary complications at varying severity were observed.There were 23 cases (33.8%) deaths.Univariable Logistic regression analysis showed that the rates of congenital heart disease(13 cases vs. 9 cases), alanine transaminase >100 U/L(12 cases vs. 8 cases), acute respiratory distress syndrome (ARDS)(13 cases vs. 9 cases) and severe extrapulmonary complications (19 cases vs. 14 cases) were significantly higher in the death group than those in the survival group (all P<0.05). Multivariate Logistic regression analysis showed that congenital heart disease, ARDS and severe extrapulmonary complications were independent risk factors for death in children with SAP (all P<0.05). Conclusions Children with SAP in PICU are mostly 6 months to 2 years old.SAP mainly occurs in spring and summer, which is featured by the high spike of fever, long duration of fever, easy to be infected with other pathogens, high incidences of systemic complications, and high mortality.The combination of congenital heart disease, ARDS and severe extrapulmonary complications increases the risk of death in children with SAP in PICU. © 2022 Chinese Medical Journals Publishing House Co.Ltd. All rights reserved.     

鼻塞式呼吸机间歇指令通气联合肺表面活性物质治疗早产儿肺透明膜病的临床研究

Objective To evaluate the effect of nasal intermittent mandatory ventilation (NIMV)combined with pulmonary surfactant for the treatment of hyaline membrane disease in premature children and to compare the clinical efficacy with conventional mechanical ventilation and continuous positive airway pressure (CPAP). Methods Seventy-four babies with severe respiratory syndrome were given curosurf[100 mg/(kg·dose)],25 of them were given to NIMV, another 25 were given conventional intermittent mandatory ventilation (IMV), the last 24 patients were given conventional CPAP. Blood gas analysis parameters and incidences of respiratory complications including respiratory tract infection and chronic lung disease,frequent apnea and carbon dioxide retention, were compared among the three groups. Results After treatment of 1 h, symptoms and signs of the patients markedly improved. All the three groups showed an increase in arterial oxygen partial pressure, but arterial pressure of carbon dioxide and oxygen index decreased significantly by the time of 6,12,24 h after treatment and there were not significantly difference among the three groups. The rates of respiratory infection and chronic lung disease in NIMV group were less than that of conventional IMV group[(8% vs 36% ) ,(20% vs 72% )],the rates of frequent apnea and carbon dioxide retention in NIMV group were less than that of CPAP group[(8% vs 36% ), (20% vs 72% )]. Conclusion NIMV combined with pulmonary surfactant is a potentially efficient therapy for hyaline membrane disease in premature infants. NIMV treatment of hyaline membrane disease in premature infants can reduce or avoid ventilation-associated pneumonia,chronic lung disease and other complications,but also efficiently reduce the incidence of frequent apnea and carbon dioxide retention.     

Early risk factors for death in neonates with persistent pulmonary hypertension of the newborn treated with inhaled nitric oxide北大核心CSCD

Objective To evaluate the early risk factors for death in neonates with persistent pulmonary hypertension of the newborn (PPHN) treated with inhaled nitric oxide (iNO). Methods A retrospective analysis was performed on 105 infants with PPHN (gestational age ≥34 weeks and age <7 days on admission) who received iNO treatment in the Department of Neonatology, Children's Hospital of Nanjing Medical University, from July 2017 to March 2021. Related general information and clinical data were collected. According to the clinical outcome at discharge, the infants were divided into a survival group with 79 infants and a death group with 26 infants. Univariate and multivariate Cox regression analyses were used to evaluate the risk factors for death in infants with PPHN treated with iNO. The receiver operating characteristic (ROC) curve was used to calculate the cut-off values of the factors in predicting the death risk. Results A total of 105 infants with PPHN treated with iNO were included, among whom 26 died (26/105, 24.8%). The multivariate Cox regression analysis showed that no early response to iNO (HR=8.500, 95%CI: 3.024-23.887, P<0.001), 1-minute Apgar score ≤3 points (HR=10.094, 95%CI: 2.577-39.534, P=0.001), a low value of minimum PaO2/FiO2 within 12 hours after admission (HR=0.067, 95%CI: 0.009-0.481, P=0.007), and a low value of minimum pH within 12 hours after admission (HR=0.049, 95%CI: 0.004-0.545, P=0.014) were independent risk factors for death. The ROC curve analysis showed that the lowest PaO2/FiO2 value within 12 hours after admission had an area under the ROC curve of 0.783 in predicting death risk, with a sensitivity of 84.6% and a specificity of 73.4% at the cut-off value of 50, and the lowest pH value within 12 hours after admission had an area under the ROC curve of 0.746, with a sensitivity of 76.9% and a specificity of 65.8% at the cut-off value of 7.2. Conclusions Infants with PPHN requiring iNO treatment tend to have a high mortality rate. No early response to iNO, 1-minute Apgar score ≤3 points, the lowest PaO2/FiO2 value <50 within 12 hours after admission, and the lowest pH value <7.2 within 12 hours after admission are the early risk factors for death in such infants. Monitoring and evaluation of the above indicators will help to identify high-risk infants in the early stage. © 2022 Xiangya Hospital of CSU. All rights reserved.     

Timing of surgical ligation of patent ductus arteriosus in very low birth weight infants北大核心CSCD

Objective To study the effect of timing of surgical ligation of patent ductus arteriosus (PDA) on the prognosis of very low birth weight infants (VLBWI). Methods The medical data of VLBWI who underwent transthoracic ligation for PDA from June 2018 to May 2021 were reviewed retrospectively. The infants were divided into early ligation group (≤21 days of age) and late ligation group (>21 days of age) based on the age of ligation. The two groups were compared in terms of perioperative clinical features, complications, and mortality. The risk factors for early surgical ligation were analyzed. Results A total of 72 VLBWI were enrolled, with 19 infants (26%) in the early ligation group and 53 infants (74%) in the late ligation group. There were significant differences in birth weight, gestational age, weight at operation, days of age at operation, rates of preoperative invasive and noninvasive mechanical ventilation, incidence rate of pulmonary hemorrhage, incidence rate of hypotension, preoperative PDA internal diameter (mm/kg), intraoperative PDA external diameter (mm/kg), incidence rate of post-ligation cardiac syndrome, and duration of postoperative invasive mechanical ventilation between the two groups (P<0.05). A binary logistic regression analysis showed that pulmonary hemorrhage was an indication of early surgical ligation of PDA (P<0.05). There were no significant differences in the incidence rates of post-operative complications and the mortality rate between the early ligation and late ligation groups. Conclusions Early surgical ligation may be performed for VLBWI who are experiencing pulmonary hemorrhage and hemodynamically significant PDA confirmed by cardiac ultrasound after birth. However, post-ligation cardiac syndrome should attract enough attention. In addition, early surgical ligation of PDA does not increase the risk of surgery-related and long-term complications or death, indicating that it is a safe and feasible treatment option. © 2022 Central South University. All right reserved.     

Treatment status of extremely premature infants with gestational age<28 weeks in a Chinese perinatal center from 2010 to 2019

Background There is a paucity of studies conducted in China on the outcomes of all live-birth extremely premature infants(EPIs)and there is no unifed recommendation on the active treatment of the minimum gestational age in the feld of perinatal medicine in China.We aimed to investigate the current treatment situation of EPIs and to provide evidence for formulating reasonable treatment recommendations.Methods We established a real-world ambispective cohort study of all live births in delivery rooms with gestational age(GA)between 24+0 and 27+6 weeks from 2010 to 2019.Results Of the 1163 EPIs included in our study,241(20.7%)survived,while 849(73.0%)died in the delivery room and 73(6.3%)died in the neonatal intensive care unit.Among all included EPIs,862(74.1%)died from withholding or withdrawal of care.Regardless of stratifcation according to GA or birth weight,the proportion of total mortality attributable to withdrawal of care is high.For infants with the GA of 24 weeks,active treatment did not extend their survival time(P=0.224).The survival time without severe morbidity of the active treatment was signifcantly longer than that of withdrawing care for infants older than 25 weeks(P<0.001).Over time,the survival rate improved,and the withdrawal of care caused by socioeconomic factors and primary nonintervention were reduced signifcantly(P<0.001).Conclusions The mortality rate of EPIs is still high.Withdrawal of care is common for EPIs with smaller GA,especially in the delivery room.It is necessary to use a multi-center,large sample of real-world data to fnd the survival limit of active treatment based on our treatment capabilities.     

Treatment status of extremely premature infants with gestational age<28 weeks in a Chinese perinatal center from 2010 to 2019

Background There is a paucity of studies conducted in China on the outcomes of all live-birth extremely premature infants(EPIs)and there is no unifed recommendation on the active treatment of the minimum gestational age in the feld of perinatal medicine in China.We aimed to investigate the current treatment situation of EPIs and to provide evidence for formulating reasonable treatment recommendations.Methods We established a real-world ambispective cohort study of all live births in delivery rooms with gestational age(GA)between 24+0 and 27+6 weeks from 2010 to 2019.Results Of the 1163 EPIs included in our study,241(20.7%)survived,while 849(73.0%)died in the delivery room and 73(6.3%)died in the neonatal intensive care unit.Among all included EPIs,862(74.1%)died from withholding or withdrawal of care.Regardless of stratifcation according to GA or birth weight,the proportion of total mortality attributable to withdrawal of care is high.For infants with the GA of 24 weeks,active treatment did not extend their survival time(P=0.224).The survival time without severe morbidity of the active treatment was signifcantly longer than that of withdrawing care for infants older than 25 weeks(P<0.001).Over time,the survival rate improved,and the withdrawal of care caused by socioeconomic factors and primary nonintervention were reduced signifcantly(P<0.001).Conclusions The mortality rate of EPIs is still high.Withdrawal of care is common for EPIs with smaller GA,especially in the delivery room.It is necessary to use a multi-center,large sample of real-world data to fnd the survival limit of active treatment based on our treatment capabilities.