黄继红，周燕萍，朱德明



Fontan术后患儿撤离呼吸机前后全身及局部血流动力学改变

黄继红，周燕萍，朱德明

［摘要］：目的 研究Fontan手术患儿在撤离呼吸机前后的全身及局部血流动力学变化。方法 26例Fontan病例,术后入ICU后开始常规监测,包括心率,血压,中心静脉压,尿量等。近红外光谱仪连续测量组织氧合指数,包括脑组织,肠系膜组织氧合指数。撤机前、后30 min,分别测量超声心排指数、动脉血气、上腔静脉氧饱和度,计算心率血压乘积。结果 随着呼吸机的撤离,中心静脉压从(17±3)mm Hg降至(15±3)mm Hg,心排指数,收缩压和脑氧指数分别从(3.58±0.39)L/(min·m2),(82±9)mm Hg和(64.9±5.7)%升至(4.13±0.45)L/(min·m2),(101±14)mm Hg和(70.6±8.5)%。心率血压乘积从(10 760± 2 740)bpm×mm Hg增加到(12 470±2 950)bpm×mm Hg。心率、动脉氧饱和度、上腔静脉氧饱和度、乳酸、肠系膜氧合指数无显著改变。结论 Fontan患儿撤离呼吸机后,心排量和脑氧改善明显,肠系膜氧合改善不显著。说明胸内压的降低有利于改善心排量和脑血流量。撤离呼吸机后,增加的心排量优先供应至心脏、脑和呼吸系统,而肠系膜组织灌注仍低于正常。

［关键词］：近红外光谱仪；Fontan手术；局部血流动力学；撤离呼吸机

Global and regional hemodynamics change in patients undergoing Fontan procedure：positive pressure ventilation vs spontaneous breathing

Huang Ji-hong,Zhou Yan-ping,Zhu De-ming
Department of Pediatric Cardiovascular and Thoracic Surgery,Shanghai Children＇s Medical Center,Shanghai 200127,China
Corresponding author:Zhu De-ming,Email:scmccpb1@ aliyun.com

［Abstract］：Objective To investigate the effects of extubation on global and regional hemodynamics in patients undergoing Fontan procedure.Methods 26 patients undergoing Fontan procedure,standard hemodynamic variables,including heart rate,blood pressure,central venous pressure,urine output were monitored on intensive care unit admission.Near infrared spectroscopy of cerebral and mesenteric were measured continuously.Cardiac index derived from aortic diameter and Doppler wave velocity,arterial blood gas,oxygen saturations of superior vena cava were measured and rate pressure products were calculated at 30 minutes before and after extubation.Results After extubation,the central venous pressure decreased significantly from(17±3) to(15±3) mm Hg.The cardiac index,systolic blood pressure,cerebral oxygen saturation increase from(3.58±0.39) L/min/m2,(82±9) mmHg,(64.9±5.7)%to(4.13±0.45) L/min/m2,(101±14) mmHg,(70.6±8.5)%,respectively.Rate pressure product increase from(10 760±2 740) to(12 470±2 950) bpm*mmHg.The heart rate,arterial oxygen saturation,superior vena cava oxygen saturation,lactate,and mesenteric oxygen saturation remained unchanged.Conclusion After Fontan procedure,both cardiac index and cerebral oxygen saturation improved significantly,while mesenteric oxygen saturation remained unchanged.It suggests that the reduction of intra-thoracic pressure could improve cardiac output and cerebral perfusion.After extubation,increased cardiac output is preferentially supplied to myocardium,brain and respiratory muscles,while the mesenteric perfusion is still lower than normal.

［Key words］： Near-infrared spectroscopy；Fontan procedure；Regional hemodynamics；Extubation

正压通气对于Fontan等肺血流依赖体静脉压力驱动的循环而言,增加了体静脉血流经肺循环的阻力,从而降低心排量。术后早期撤离呼吸机有利于体静脉回流、增加心排量及脏器血流灌注[1]。然而,拔管后机体呼吸做功增加,必然伴随膈肌等呼吸肌群血流增加,在心排量增加幅度有限条件下,其他脏器如大脑,内脏的血流供应是否能够增加尚不明确。

近红外光谱仪( near infrared spectroscopy,NIRS)测得局部组织的氧合指数,能够实时、无创反映测量部位的氧代谢情况及微循环灌注[2]。……