先天性心脏病患儿行体外循环心脏手术围术期死亡危险因素分析  

Analysis of perioperative mortality factors in children with congenital heart disease undergoing cardiopulmonary bypass

作　　者：崔晓征 沈冬炎 邹鹏[1] 詹雨 李永超 杨栩鹏 Cui Xiaozheng;Shen Dongyan;Zou Peng;Zhan Yu;Li Yongchao;Yang Xupeng(Department of Cardiac Surgery, Beijing Tsinghua Changgung Hospital Affiliated to Tsinghua University,Beijing 102218,China)

机构地区：[1]清华大学附属北京清华长庚医院心脏外科,102218

出　　处：《疑难病杂志》2020年第11期1084-1090,共7页Chinese Journal of Difficult and Complicated Cases

摘　　要：目的探讨体外循环下行心脏手术的先天性心脏病(CHD)患儿围术期死亡的危险因素。方法选取2018年1月—2019年12月清华大学附属北京清华长庚医院、中国人民解放军总医院第三分院和河北医科大学第一医院3家医院收治的行体外循环开放手术的CHD患儿350例,随访所有患儿术后30 d内死亡结局,Kaplan-Meier法绘制生存曲线。根据随访结局将CHD患儿分为存活组(n=323)和死亡组(n=27),比较2组基线资料及手术相关指标,多因素Logistic回归模型分析死亡的独立危险因素;决策树模型确定连续变量Logistic分析时的分层分界点。结果27例死亡病例中前3种疾病类型分别为大动脉转位9例(33.33%),房室间隔缺损8例(29.63%),法洛四联症6例(22.22%)。与存活组患儿相比,死亡组患儿体质量较低,多伴有紫绀症状,且ASA分级和RACHS-1分级较高,差异均具有统计学意义(t/P=2.586/0.010,χ^2/P=30.682/0.000、73.249/0.000,Z=32.672/0.000),死亡组患儿术前血肌酐水平和术中最低温度较低,术中输血量更高,且手术时间、体外循环时间、主动脉阻断时间、术后机械通气时间和ICU治疗天数均长于存活组,差异均具有统计学意义(P<0.01)。Logistic回归分为析表明,ASA分级≥Ⅲ级、RACHS-1分级≥3级、体外循环时间≥120 min、术中输血量≥150 ml并伴有紫绀均是CHD患儿死亡的独立危险因素。结论ASA分级和RACHS-1分级可用于对CHD患儿围术期死亡风险进行预测。临床手术中应尽可能缩短体外循环时间,采取适当的节约用血策略,对于紫绀患儿早期还应给予适当的神经营养药物以降低患儿围术期死亡风险。Objective To investigate the risk factors for perioperative death in children with congenital heart disease(CHD)undergoing cardiopulmonary bypass.Methods A total of 350 CHD children admitted to three third-level grade-A hospitals from January 2018 to December 2019 for open cardiopulmonary bypass were selected,and the death outcome within 30 days after surgery was followed up.Kaplan-meier method was used to draw the survival curve.Children with CHD were divided into a survival group(n=323)and a death group(n=27)according to follow-up results.Baseline data and surgical indicators of the two groups were compared,and independent risk factors for death were analyzed by multivariate logistic regression model.The hierarchical demarcation point in the Logistic analysis of continuous variables were analyzed by the decision tree model.Results Among the death cases,the first three disease types were aortoventricular septal defect in 9 cases(33.33%),atrioventricular septal defect in 8 cases(29.63%),and tetralogy of fallot in 6 cases(22.22%).ASA grade≥III,RACHS-1 score≥3,extracorporeal circulation time≥120 min,intraoperative blood transfusion≥150 ml and cyanosis were all independent risk factors for CHD death.Conclusion ASA grading and RACHS-1 score can be used to predict perioperative mortality risk of CHD children.In clinical surgery,extracorporeal circulation should be shortened as much as possible,appropriate blood saving strategies should be adopted,and appropriate neurotrophic drugs should be given to children with cyanosis in the early stage to reduce the risk of perioperative death.

关 键 词：体外循环心脏手术 先天性心脏病 围术期死亡 ASA分级 RACHS-1分级 

分 类 号：R54[医药卫生—心血管疾病]