| This study investigated the perioperative risk factors of hypoxemia and postoperative pulmonary complications after cardiopulmonary bypass in pediatric congenital heart disease surgery;evaluated the security and validity of the lung protective ventilation strategy including small tidal volume ventilation,alveolar recruitment maneuver using incremental PEEP after CPB,and the optimal PEEP ventilation during congenital heart disease operation of children that had high risk of postoperative pulmonary complications under cardiopulmonary bypass;explored the lung injury and pulmonary aeration with lung ultrasound in these children.The main work contains two parts as follows:1.Risk factors of hypoxemia and postoperative pulmonary complications after cardiopulmonary bypass in pediatric congenital heart disease surgeryObjective: To study the perioperative risk factors of hypoxemia and postoperative pulmonary complications after cardiopulmonary bypass in pediatric congenital heart disease surgery.Methods: 223 pediactric patients that underwent the radical surgery therapy with the cardiopulmonary bypass(CPB)were enrolled in this case-control study retrospectively.The oxygenation of the patients were evaluated by the arterial blood-gas analyses after CPB to discharge from ICU.Hypoxemia was defined as PaO2/FiO2<300 at any measurement point.The possible risk factors perioperatively were analyzed by the univariate and multivariate logistic regression statistics.The features of the postoperative pulmonary complications and the hypoxemia were also discussed.Results: There were 109 cases(48.8%)that had developed hypoxemia.The multivariate logistic regression statistics showed preoperative pulmonary hypertension and right to left shunting were the independent risk factors,the age(months)and weight are the protective factors.The first hypoxemia time point(hour after the CPB)was0(0-96)hour.Most of the hypoxemia cases were happened within 2 hours(79.8%).The postoperative pulmonary complications were pneumonia,atelectasis,pleural effusion,pneumothorax or pneumomediastinum and ARDS.The incidence of postoperative complications of the hypoxemia cases and the non-hypoxemia cases were 36.7% and14.0% respectively.There were 63.3% hypoxemia children who had not any iconographic abnormality postoperative.Conclusion: The overall morbility of hypoxemia after cardiopulmonary bypass in pediatric congenital heart disease surgery was 48.8%.The age(months),weight,preoperative pulmonary hypertension and right to left shunting were associated with hypoxemia.The 79.8% hypoxemia cases were happened within 2 hours after CPB.The incidence of postoperative complications of the hypoxemia cases and the non-hypoxemia cases were 36.7% and 14.0% respectively.There were 63.3% hypoxemia children who had not any iconographic abnormality postoperative.2.Lung protective ventilation strategy in the congenital heart disease operation of infantsObjective: To evaluate the security and validity of the lung protective ventilation strategy during congenital heart disease operation of infants under cardiopulmonary bypass.Methods: 90 congenital heart disease infants(year?1)that selected for corrective operation under CPB with aorta cross-clamping were divided into conventional ventilation group(C group)and protective ventilation group(P group)randomly.The P group were ventilated with small tidal volume(6 ~ 8ml/kg),alveolar recruitment maneuver using incremental PEEP after CPB,and ventilated with the optimal PEEP determined by pulmonary dynamic compliance.The C group were ventilated with conventional tidal volume(10~12mg/kg).The basic vital signs and complication were observed during the whole procedure of P group.The PaO2/FiO2,Ppeak,Cdyn,A-aDO2 and Pa-ETCO2 were compared among after weaning from CPB(T1),10 mins after CPB(T2),operation finished(T3)and 2 hours after CPB(T4)in two groups.The hypoxemia incidence after CPB?extubation time?the length of ICU stay?the length of hospital stay postoperative and the postoperative pulmonary complications including atelectasis,pleural effusion,pneumothorax,pneumonia,pulmonary edema and ARDS;B line counts and the nonaerated lung area with sonographic measurement were both compared between two groups.Results: All the basic vital signs of the infants in P group were stable and within thenormal range,there were no serious complications.PaO2/FiO2 increased(P<0.01),A-aDO2 decreased(P<0.01)in group P at T2 and compared with T1;and the decrease of A-aDO2 lasted to T4(P<0.01).In group P :PaO2/FiO2 was higher(P<0.01)and A-aDO2 was lower at T2 and T3 than group C;Cdyn increased at T2?T3 and T4 compared with T1(P<0.01),and Cdyn was higher at T2 and T3 than group C;Pa-ETCO2 decreased at T2?T3 and T4 compared with T1,and Pa-ETCO2 was lower at T2(P<0.01)and T4(P<0.05)than group C;Ppeak was lower at T1?T2 and T3 than group(P<0.01).The incidence of hypoxemia after CPB in group P was lower(28.9% vs.55.6%,P<0.05)than that in group C.There were no statistical differences with the postoperative pulmonary complications,prognostic indicators including extubation time?the length of ICU stay?the length of hospital stay postoperative between two groups.There were no statistical difference with the B line counts and nonaerated lung area using lung ultrasound between two groups.Conclusions: The lung protective ventilation strategy could be applied in congenital heart disease operation of infants under CPB safely.The intrapulmonary shunt and dead space could be decreased,the pulmonary gas exchange ? ventilation-perfusion and pulmonary dynamic compliance could be improved with the lung protective ventilation strategy,these effects can be lasted to 2 hours after CPB.The oxygenation also could be improved and Ppeak could be decreased,but these effects were transitory relatively.It also could reduce the incidence of hypoxemia after CPB,but had no effect on postoperative pulmonary complications and prognostic indicators.It also had no effect on the lung injury and pulmonary aeration that evaluated with the sonographic measurement... |
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