›› 2011, Vol. 31 ›› Issue (9): 1272-.doi: 10.3969/j.issn.1674-8115.2011.09.014

• 论 著 • 上一篇    下一篇

Fontan术后的临床转归和监护

李志浩, 徐志伟, 郑景浩, 张海波, 史珍英, 徐卓明   

  1. 上海交通大学 |医学院附属儿童医学中心心胸外科监护室, 上海 200127
  • 出版日期:2011-09-28 发布日期:2011-09-27
  • 作者简介:李志浩(1968—), 主治医师, 博士;电子信箱: lizhihao0108@126.com。

Clinical outcome and intensive care after Fontan operation

LI Zhi-hao, XU Zhi-wei, ZHENG Jing-hao, ZHANG Hai-bo, SHI Zhen-ying, XU Zhuo-ming   

  1. Department of Cardiac Intensive Care Unit, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, Shanghai 200127, China
  • Online:2011-09-28 Published:2011-09-27

摘要:

目的 总结Fontan术后的临床转归及其血流动力学特点,探讨其术后监护的要点。方法 收集2008年7月—2009年7月期间的79例Fontan手术病例,通过分析其术后血流动力学特点和监护过程,对术后监护要点和临床转归进行总结。结果 79例Fontan病例中,术后早期死亡5例,病死率为6.33%;其中一期手术无死亡病例,二期手术病死率为9.3%,三期手术病死率为14.3%。术后床旁心脏超声显示,下腔静脉流速普遍减慢,术后第1天管道开孔处均为右向左分流。早期撤离呼吸机有助于术后血流动力学的恢复。术后脏器功能不全发生率较高。结论 术前血流动力学评估对手术结果至关重要。Fontan术后腔静脉流速缓慢,术后早期管道开孔处以右向左分流为主,可影响脏器的灌注,提倡尽早撤离呼吸机;Fontan术后心、肺功能关系密切,应及时排除肺部并发症;改善心功能以扩容、强心和降低肺阻力为主,强调米力农在术后监护中的作用。

关键词: Fontan手术, 管道开孔, 临床转归, 术后监护

Abstract:

Objective To summarize the clinical outcome and hemodynamic feature after Fontan operation, and explore the main points of intensive care after operation. Methods Seventy-nine patients undergoing Fontan operation between July 2008 and July 2009 were collected. The main points of intensive care after operation and clinical outcome were summarized through analysis of the hemodynamic feature and course of intensive care. Results Five patients died early after operation, and the mortality was 6.33%. There was no death in stage 1 operation, the mortality of stage 2 operation was 9.3%, and the mortality of stage 3 operation was 14.3%. The echocardiogram demonstrated the generalized reduction in blood flow in inferior vena cava after operation, and right to left shunt in fenestration was observed on the first day after operation in all cases. Early withdrawl of mechanical ventilation led to an optimal recovery in hemodynamics. There was a higher incidence of organ dysfunction after operation. Conclusion Hemodynamic assessment before operation is important for the clinical outcome of Fontan operation. The slow flow in inferior vena cava and the dominant right to left shunt in fenestration after operation may affect the perfusion of organs, and the early withdrawl of mechanical ventilation is recommended. The close relationship between heart and lung after Fontan operation demands the management of pulmonary complications without delay. The main points to improve the low cardiac output are volume resuscitation, suitable inotropic support and pulmonary resistance reduction. The unique effect of milrinone in the treatment after Fontan operation is emphasized.

Key words: Fontan operation, fenestration, clinical outcome, postoperative care