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Objective:To investigate the sedative effect after congenital heart disease surgery in children under the bi-spectral index monitoring(BIS).Methods:A prospective cohort study was performed, we selected 264 children with congenital heart disease who were admitted to the cardiac intensive care unit at Shanghai Children′s Medical Center from September 2018 to August 2019, 126 cases in the intervention group, and 138 cases in the control group.The control group used Ramsay sedation score to evaluate the sedative effect, meanwhile the intervention group was evaluated by Ramsay sedation score and BIS.The incidence of adverse events related to extubation performed within 8 hours after congenital heart disease surgery, and the length of stay in ICU between two groups were compared.The average mechanical ventilation time of the patients whose mechanical ventilation time was more than 8 hours in two groups was compared.The use of sedative drugs midazolam and morphine in children with mechanical ventilation time for more than 24 hours and liver damage, and the incidence of respiratory depression during ventilator withdrawal were analyzed.Results:In children with early extubation, there were 62 cases in the intervention group and 70 cases in the control group.Compared with the control group, the intervention group had a low incidence of extubation-related adverse events (including unplanned extubation, dysphoria after sputum aspiration, and inhalation inhibition after extubation). The average mechanical ventilation time in the intervention group[(8.18±1.95)h] was less than that in the control group[(9.53±1.37)h, P<0.05] of the patients whose mechanical ventilation time was more than 8 hours but less than 24 hours.In children with mechanical ventilation time more than 24 hours, 28 cases were in the intervention group and 35 cases in the control group.The average doses of midazolam and morphine in the intervention group[(1.82±0.40)μg/(kg·min), (8.64±3.03)μg/(kg·h)] were less than those in the control group[(2.73±0.79) μg/(kg·min), (14.32±5.01)μg/(kg·h), all P<0.05]. Among the 28 children in the intervention group with mechanical ventilation time more than 24 hours, 13 cases had liver damage, and 15 cases of the 35 children in the control group had liver damage.The average doses of midazolam and morphine in the intervention group[(1.42±0.51)μg/(kg·min), (6.88±2.17)μg/(kg·h)] were lower than those in the control group[(2.25±0.62)μg/(kg·min), (11.88±3.56)μg/(kg·h), all P<0.05]. The incidence of inhalation inhibition in the intervention group was lower than that in the control group ( χ2=48.303, P<0.05). Conclusion:The sedation after congenital heart disease surgery in children under the BIS is effective.
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Objective@#The study was designed to analyze the clinicopanthologic characteristics, treatments and outcomes of a series of patients with primary angiosarcoma.@*Methods@#The clinical, surgical and pathological data and treatment of 68 patients with pathologically confirmed angiosarcoma admitted to Peking Union Medical College Hospital from January 1990 to June 2017 was retrospectively analyzed. Kaplan-Meier method and Log rank test were used for univariate survival analysis and Cox regression model was used for multivariate survival analysis.@*Results@#A total of 68 patients were enrolled, 38 were male, 30 were female. The median age at diagnosis was 50.5 years. The time from symptom onset to diagnosis was (7.5±7.5) months. The primary sites included face and scalp, breast, chest wall, lung, heart, liver, spleen, extremities, bones and so on. At diagnosis, the mean size of tumors were (7.4±7.3) cm, 28 patients (41.2%) had localized disease (stage Ⅰ+ Ⅱ) and 40 patients had metastatic disease (stage Ⅲ+ Ⅳ). There were 37 patients treated with surgery alone, three receiving radiotherapy alone, five receiving chemotherapy alone and sixteen receiving comprehensive treatment with 5 underwent surgery plus radiotherapy, three treated by surgery plus chemotherapy, four had surgery plus interventional therapy, two had chemoradiotherapy, one had radiotherapy and interventional therapy and 1 had surgery plus chemoradiotherapy and targeted therapy. Five patients received only palliative treatment, and 2 patients lost follow-up after diagnosed. Fifty patients were followed up with a median overall survival time of 8.5 months. The median survival time of patients with metastatic angiosarcoma was 6.6 months, significantly shorter than that of patients with localized disease (15.0 months, P=0.020). The median survival time of patients with cardiac angiosarcoma was 3.0 months, significantly shorter than that of patients with angiosarcoma at other sites (11.5 months, P=0.010). The median survival time of patients receiving comprehensive treatment was 31.0 months, significantly longer than that of patients without comprehensive treatment (5.6 months, P=0.007). Multivariate analysis showed that staging, heart occurrence and comprehensive treatment were independent factors for the prognosis of primary angiosarcoma (all P<0.05).@*Conclusions@#Angiosarcoma is a rare malignancy, and patients with metastatic disease or cardiac occurence have poor prognosis. Comprehensive treatment can improve the prognosis of patients with angiosarcoma.
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Objective@#To improve the clinical outcomes and critical care quality for pediatric extracorporeal membrane oxygenation (ECMO), the multidisciplinary team including doctors, nurses and respiratory therapist designed a daily checklist for patients with ECMO and evaluated the effect of the checklist.@*Methods@#A daily checklist for ECMO patients was designed based on the expert consensus and multi-centers relevant researches. ECMO patients from January 2015 and May 2017 in the pre-application group, while the other patients from June 2017 to December 2018 in the post-application group were compared in the clinical outcomes.@*Results@#All 78 pediatric patients used the venoarterial extracorporeal membrane oxygenation (VA-ECMO) including 27 patients in the pre-application group and the other 51 patients in the post-application group. The mortality rate was 49.02%(25/51) in the post-application group and 81.48%(22/27) in the pre-application group, the differences were significant (χ2=7.768, P=0.005). The rates of central line-associated bloodstream infection, pressure injury and the body weight change was 2/5, 4/5, -2.70(-3.50--2.05) in the pre-application group and 3.85%(1/26), 26.92%(7/26), -0.09(-1.00-0.00) in the post-application group,the differences were significant (χ2=4.505, 5.161, Z=3.252, P<0.05 or 0.01).@*Conclusions@#It is helpful for clinical staff to follow up the progress of the multiple organs when using the daily checklist, to facilitate team communication for, and to improve nursing management through setting the daily targets for individual VA-ECMO patients.
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Objective To simplify regional citrate anticoagulation(RCA) in continuous veno-venous hemofiltration (CVVH) with a calcium-containing replacement solution for children after congenital heart surgery.Methods The clinical data of 20 children with RCA in CVVH after congenital heart surgery were retrospectively analyzed.All cases were divided into two groups:the traditional group(12 cases) using a calcium-free replacement solution and the modified group(8 cases) using a calcium-containing replacement solution.The blood gas data,plasma ionic calcium,total calcium/ionic calcium ratio,circuit survival time,calcium supplement and the number of adjustments of replacement fluid formula were compared between the two groups after CVVH.Results During RCA-CVVH,serum HCO3-,pH,systemic ionized calcium,and the ratio of total calcium / ionic calcium were higher than those before RCA-CVVH,but all in normal range.There was no significant difference in circuit survival time between two groups [(50.5 ± 2.3) h vs.(48.8 ± 4.7)h,respectively,P ＞0.05].Calcium supplementation in the traditional group was significantly higher than that in the modified group[2.5％ calcium chloride supplementation was(0.43 ±0.11) ml/(kg-h) in the traditional group and(0.13 ± 0.17) ml/(kg-h) in the modified group].The number of replacement solution adjustment was (2.7 ± 1.1) times in traditional group,while the modified group did not change the replacement formula.Conclusion RCA using a calcium-containing replacement fluid in hemofiltration,can reduce the supplement of calcium and the times of the replacement solution adjustment,which is easy to operate.It can be used safely,effectively and conveniently in CVVH children after congenital heart surgery.
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Objective To estimate the effect of early fluid removal on the early postoperative recov-ery in children after surgical repair of congenital heart disease with enlarged right ventricle via a randomized trial. Methods One hundred and twenty patients with right-sided complex congenital heart defect who un-derwent cardiac surgery by cardiopulmonary bypass during January 2017 to June 2017 were enrolled and were divided into two groups,Group-E and Group-C,when the hemodynamics was stable within 3 hours after the surgery. Patients in Group-E were treated with early fluid removal,but Group-C remained conventional thera-py. The data of the hemodynamics and outcomes were collected from the postoperative day to the 2nd day post-operation. Results Fluid removal therapy was started in Group-E at (4. 39 ± 0. 85) h postoperatively vs (10. 17 ± 2. 77) h in Group-C (P < 0. 05). Patients in Group-E showed lower extravascular lung water index (ELWI),lower fluid overload and lower NT-proBNP compared with patients in Group-C on the first day of post-operation(P < 0. 01). Also, the advantages remained in Group-E on the second day but the ELWI showed no remarkable difference. The rate of reintubation(P < 0. 05),the duration of mechanical ventilation and the length of ICU stay (P < 0. 01)were significantly reduced in Group-E. Conclusion In patients with right ventricle enlarged complex congenital heart defect who underwent cardiac surgery by cardiopulmonary bypass,utilizing early negative fluid balance when the hemodynamics are stable and the right ventricle is ob-viously enlarged could achieve negative fluid balance,get extubated and discharge from ICU earlier,also pres-ent lower extravascular lung water index, lower incidence of weaning-induced pulmonary edema and reintubation.
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Objective To analyze the safety and effect of non-invasive pressure support ventilation in 32 patients by using a helmet and to give the appropriate way of patients who need non-invasive ventilation ( NIV) support after congenital heart disease surgery. Methods Patients over one year old after congential heart disease surgery were admitted in our Department of Cardiovascular Thoracic Surgery from July 2015 to December 2015. Patients who get clinically improved within one hour were divided into the early improved group( Group-E) ,otherwise they were classified to non-early improved group( Group-NE) . The general infor-mation,diagnosis, indication of NIV, ICU and hospital stay, complications, and mortality were collected. Results Thirty-two patients were engaged in this study,including 18 patients(56. 25%) in Group-E and 14 patients(43. 75%) in Group-NE. Patients who got improved in the first hour might have a higher incidence of avoiding reintubation[83. 33%(15/18) vs. 42. 86%(6/14),P=0. 02]. The heart rate,respiratory rate, pH,PaO2/FiO2 and lactate were improved in Group-E compared with Group-NE after the first hour by using helmet. At the end of NIV,the oxygenation showed no difference but the PaCO2 was lower in Group-E. In Group-E,the values showed a trend of improvement,while the values in Group-NE showed not only no statis-tical significance in different time points but also seemed to have a tendency of hypercapnia and reduced com-fort behavior scale in the end of NIV. There were 6 cases in Group-E and 10 cases in Group-NE developed ventilation associated pneumonia with the incidence of 33. 33%(6/18) and 71. 43%(10/14),respectively, which was significant difference (χ2 =4. 571,P =0. 03). The total duration of mechanical ventilation of Group-E was shorter than that of Group-NE [ ( 136. 72 ± 151. 49 ) h vs. ( 252. 79 ± 155. 33 ) h, P <0. 05 ] . Conclusion NIV through a helmet in children could be well tolerated and avoid re-intubation. Patients who get improved earlier may have more clinical advantages,such as less time of mechanical ventilation and lower incidence of postoperative complications. Early improvement can be considered as a valuable indicator wheth-er the patient needs to use NIV continuously.
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Objective To explore the value of polymerase chain reaction(PCR) to detect pathogens in ventilator-associated pneumonia(VAP) in children undergoing congenital heart disease(CHD) operation. Methods Forty-eight children selected from 95 cases with VAP underwent CHD operation were admitted in the department of CICU in our hospital from November 2016 to July 2017.Sputum specimens were separately collected by the bronchoalveolar lavage(BAL) and endotracheal tube attracts(ETA) methods,and the patho-gens were detected by culture and PCR assay.Results Nineteen specimens were found to be positive after 72 h of culture.A total of 20 pathogens were detected and 2 samples were mixed infection(more than one pathogen),and the positive rate was 39.2%(19/48).For PCR assay,44 pathogens from 31 samples were detected for just 24 h,22 samples were single pathogen infection,9 samples were mixed pathogen infection, and the positive rate was 65.3%(31/48).Compared with culture method,PCR assay could sharply increase the detection rate of every pathogen.Besides,the positive rate of the BAL or ETA for PCR assay was almost the same(45/48). Conclusion PCR assay for detecting pathogens is rapid,accurate and effective,which should be combined with culture method to detect for infectious pathogen.The ETA is the desired method to collect the sputum of the patients.
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Objective To investigate the riskf actors associated with sepsis following surgery of con-genital heart disease in children, for early-recognizing and diagnosing, improving prognosis and decreasing mortality.Methods Retrospective study wa s employed,52 patients of sepsis and 104 patients of non-sepsis with similar age,sex,na d the same diseases were enrolled during Jan 2012 to Apr 2015 in cardiac intensive care unit.Variables such as age,sex,preoperative infection,delayed sternum closure,diaphragmatic paralysis, exploraot ry chest,cardiopulmonaryb ypass time, placed invasive catheter were included in the research fac-tors.The Logistic regression model was set up,OR and 95%CI were calculta ed.Results In sepsis group,the more shock and dysfunction organs,longre hospital stays,longer ICU stays and higher mortality were found compared to the non-sepsis group[25.32%vs.6.73%,3.5 ±1.1 vs.1.1 ±0.7,(35.1 ±11.2)d vs.(11.3 ±3.1)d,(21.3 ±7.1)d vs.(7.1 ±2.3)d,19.23%vs.4.81%,P<0.05].In the Logistic regres ion mod-e l,variables significantly associated with sepsisw ere preoperative infection,deal yed sternal closure,explorato-ry chest,and placed more invais ve duct,diahp ragmatic paralysis(P<0.05).OR value (95%CI) were 10.53 (1.73,64.2),26.66(2.69,263.83),19.47(1.87,203.02),4.99(1.36,18.31),8.32 (0.12,16.46 ), respectively.Conclusion Preoperative infection,delayed sternal closure,exploratory chest,placed more inva-sive duct,diaphragmatic paralysis are the risk factors of sepsis.Children with sepsis had poor clinical outcome compared to those without sepsis.
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Objective To study the risk factors of prolonged postoperative recovery after the total cavopulmonary connection(TCPC) in the current era.Methods Data on all patients admitted to the cardiac intensive care unit (CICU) after a TCPC between January 2013 and March 2014 were retrospectively analyzed.We excluded all patients who died and required TCPC takedown.The study cohort was further divided into a prolonged recovery group that included patients with 75％ ile for duration of mechanical ventilation or pleural drainage,and a standard recovery group which included all other patients.A multivariable logistic regression model was used to compare demographic,anatomic,and physiological variables between the prolonged and standard recovery groups.Then,the cohort was separated into a high volume resuscitation group and a low volume resuscitation based on the 75％ ile for volume resuscitation(ml/kg) administered on the first three days after the TCPC.Results Totally 118 TCPC operations were performed.Of the study population (n =118),the median age was 3.8 years (3.1 to 4.8 years) and median weight was 14.8 kg(13.3 to 17.1 kg).The most common diagnosis was double outlet of right ventricle (n =47,39.8％).The extracardiac conduit fenestrated TCPC was the most common surgery(n =79,66.9％).Within the study population,43 (39.8％) patients met criteria for prolonged recovery.Univariate risk factors for prolonged recovery included higher preoperative mPAP(P =0.022),atrioventricular valve regurgitation (P =0.000),longer total bypass time (P =0.044),higher postoperative central venous pressure (P =0.000),AST (P =0.001),ALT (P =0.010),NT-proBNP (P =0.000),SaO2 (P =0.012),I n-otropic score (P =0.001),higher incidence of arrhythmia (P =0.000),low cardiac output syndrome (P =0.000),need for peritoneal dialysis (P =0.000),and requirement for greater volume resuscitation during the 72 postoperative hours(75％ for the entire group,P =0.000).In a multivariable Logistic model,need for greater volume resuscitation (OR 10.860,95 ％ CI 2.681,43.987) and the higher postoperative central venous pressure (OR 1.446,95 ％ C I 1.113,1.879) were the only two independent risk factors for prolonged outcome after the TCPC.Conclusion The need for high volume expansion and higher central venous pressure were the risk factors of mediate prolonged recovery.
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Pulmonary arterial hypertension is common in patients with congenital heart disease.An effective reduction in pulmonary vascular resistance could improve the survival rate in the future.Research in the pathophysiology of pulmonary arterial hypertension shows that phosphodiesterase 5 inhibitors result in pulmonary vasodilation,decrease vascular resistance.Sildenafil,a inhibitor of phosphodiesterase 5 has been permitted to treat pulmonary arterial hypertension oversea now.Phosphodiesterase 5 inhibitors are proved to reduce pulmonary vascular resistance significantly,improve the survival rate in the future and be well tolerated.This review contains the changes of hemodynamics,exercise tolerance,side effect and pharmacokinetics of phosphodiesterase 5 inhibitors.