摘要
目的探讨体外循环下行心脏手术的5 kg以下先天性心脏病(congenital heart disease,CHD)患儿手术死亡的相关危险因素。方法收集2017年2月至2020年2月在空军军医大学第一附属医院行体外循环开放手术的CHD患儿225例的临床资料,进行回顾性病例对照研究。计量资料两组间比较采用独立样本t检验,计数资料组间比较采用χ^(2)检验或χ^(2)校正检验,等级分布资料组间采用Mann-Whitney秩和检验,影响CHD患儿手术死亡的因素采用多因素Logistic回归分析。结果225例患儿手术存活204例(90.67%,204/225),死亡21例(9.33%,21/225)。单因素分析结果显示,死亡组患儿年龄(2.48±0.68)月、体质量(2.28±0.56)kg明显低于存活组患儿年龄(4.92±0.65)月(t=16.33,P<0.001)、体质量(4.26±0.52)kg(t=16.38,P<0.001);而女性比例[66.67%(14/21)];营养不良比例[无:14.28%(3/21)、轻度:42.86%(9/21)、重度:42.86%(9/21)];姑息性手术比例[28.57%(6/21)];根治性手术比例[71.43%(15/21)];CHD手术的风险调整-1(risk adjustment for surgery for congenital heart disease-1,RACHS-1)分级比例[<3级:23.81%(5/21)、≥3级:76.19%(16/21)];体外循环时间(135.24±11.19)min;主动脉阻断时间(78.24±8.20)min;手术时间(178.43±13.82)min;心脏畸形复杂比例[复杂:47.62%(10/21)、简单:52.38%(11/21)];ICU治疗时间(4.76±0.77)d;术后机械通气时间(121.33±12.66)h明显高于存活组患儿女性比例[41.67%(85/204),χ^(2)=4.83,P=0.028];营养不良比例[无:38.24%(78/204)、轻度:42.15%(86/204)、重度:19.61%(40/204),z=2.72,P=0.007];姑息性手术比例8.82%(18/204);根治性手术比例91.18%(186/204)(校正χ^(2)=5.86,P=0.016);RACHS-1分级比例[<3级:77.45%(158/204)、≥3级:22.55%(46/204),χ^(2)=27.44,P<0.001];体外循环时间(106.87±11.12)min(t=11.12,P<0.001);主动脉阻断时间(58.68±9.26)min(t=9.32,P<0.001);手术时间(167.24±13.75)min(t=3.55,P<0.001);心脏畸形复杂比例[复杂:78.92%(161/204)、简单:21.08%(43/204)(χ^(2)=10.23,P<0.001)];ICU治疗时间(3.67±0.87)d(t=5.52,P<0.001);术后机械通气时间(109.74±13.75)h(t=3.70,P<0.001)。Logistic回归分析结果显示手术时间(OR=1.064,95%CI:1.019~1.110,P=0.004)、术后机械通气时间(OR=1.083,95%CI:1.031~1.138,P=0.002)、ICU治疗时间(OR=5.317,95%CI:2.410~11.730,P<0.001)和营养不良(OR=2.974,95%CI:1.291~6.850,P=0.010)会导致5 kg以下CHD患儿体外循环心脏手术后手术病死率增加。结论5 kg以下低体质量CHD患儿行体外循环手术的病死率较高,手术时间、ICU治疗时间、营养不良程度、术后机械通气时间的增加均会增大患儿死亡的几率,临床应采取针对性措施以降低患儿的手术病死率。
Objective To investigate the risk factors for surgical death in children with congenital heart disease(CHD)less than 5 kg undergoing cardiopulmonary bypass.Methods The clinical data of 225 children with CHD who underwent open cardiopulmonary bypass in the First Affiliated Hospital of Air Force Military Medical University from February 2017 to February 2020 were collected for a retrospective case-control study.The independent sample T test was used for inter-group comparison of measurement data,Chi square test or chi squre correction test was used for the comparision between count data.Mann-Whitney rank-sum test was used for rank distribution data and multiple Logistic regression analysis was performed for factors affecting surgical death of children with CHD.Results Among the 225 cases,204(90.67%,204/225)survived surgery and 21(9.33%,21/225)died.Univariate analysis showed that age(2.48±0.68)months and body weight(2.28±0.56)kg in the death group were significantly lower than that in the survival group(4.92±0.65)months(t=16.33,P<0.001)and body weight(4.26±0.52)kg(t=16.38,P<0.001),while the proportion of female(66.67%(14/21)),malnutrition(none:14.28%(3/21);Mild:42.86%(9/21).Severity:42.86%(9/21)),palliative surgery proportion(28.57%(6/21)),emergency surgery proportion(71.43%(15/21)),congenital heart surgery risk assessment(RACHS-1)grading ratio(<grade 3:23.81%(5/21),≥grade 3:76.19%(16/21)),CPB time(135.24±11.19)min,aorta blocking time(78.24±8.20)min,operation time(178.43±13.82)min,heart malformation complex ratio(complex:47.62%(10/21),simple:52.38%(11/21)),ICU treatment days(4.76±0.77)d,postoperative mechanical ventilation time(121.33±12.66)h were significantly higher than the female survival group(41.67%(85/204),χ^(2)=4.83,P=0.028),malnutrition rate(none:38.24%(78/204);Mild:42.15%(86/204));Severe:19.61%(40/204)(z=2.72,P=0.007),palliative surgery proportion 8.82%(18/204),proportion of radicalsurgery91.18%(186/204)(χ^(2)=5.86,P=0.016),RACHS-1 grading ratio(<grade 3:77.45%(158/204);≥grade 3:22.55%(46/204),χ^(2)=27.44,P<0.001),CPB time(106.87±11.12)min(t=11.12,P<0.001),aorta occlusion time(58.68±9.26)min(t=9.32,P<0.001),operation time(167.24±13.75)min(t=3.55,P<0.001),heart malformation complex ratio(complex:78.92%(161/204),simple:21.08%(43/204)(χ^(2)=10.23,P<0.001)),ICU treatment time(3.67±0.87)d(t=5.52,P<0.001),postoperative mechanical ventilation time(109.74±13.75)h(t=3.70,P<0.001).Logistic regression analysis showed that operation time(OR=1.064,95%CI:1.019-1.110,P=0.004),postoperative mechanical ventilation time(OR=1.083,95%CI:1.031~1.138,P=0.002),ICU treatment time(OR=5.317,95%CI:2.410-11.730,P<0.001)and malnutrition(OR=2.974,95%CI:1.291-6.850,P=0.010)were independent risk factors for surgical death after cardiopulmonary bypass in children with CHD less than 5 kg.Conclusions The mortality rate of CHD patients with low body weight less than 5 kg was relatively high.The increase of operation time,ICU treatment time,degree of malnutrition and postoperative mechanical ventilation time will increase the probability of death.Targeted measures should be taken to reduce the surgical mortality of children.
作者
杨景娟
段维勋
李艳艳
Yang Jingjuan;Duan Weixun;Li Yanyan(Department of Cardiac Surgery,The First Affiliated Hospital of Air Force Military Medical University,Xi'an 710000,China;Department of General Diagnosis and Treatment,The First Affiliated Hospital of Air Force Military Medical University,Xi'an 710000,China)
出处
《中国综合临床》
2022年第1期73-78,共6页
Clinical Medicine of China
基金
国家重点研发计划基金项目(2016YFC1301904)。
