Sakagoshi N, Nakano S, Shimazaki Y, Kaneko M, Miyamoto Y, Nishimura M, Nakahara K, Takeda S, Matsuda H
First Department of Surgery, Osaka University Medical School, Japan.
Nihon Kyobu Geka Gakkai Zasshi. 1992 Oct;40(10):1859-65.
We clarified the problems in respiratory management in patients with phrenic nerve palsy (PNP) after open heart surgery. From December 1988 to March 1991, 248 adult patients underwent open heart surgery with topical myocardial cooling. In these patients PNP was diagnosed in 17 patients (6.9%). Age of these patients at operation ranged from 25 to 76 years with a mean age of 57 years. 9 patients were valvular heart disease (7 were reoperation), 7 were coronary artery disease, and one patient was aortic aneurysm. PNP was diagnosed by chest roentgenogram or percutaneous phrenic nerve stimulation test (PNST). Frequency of long-term intubation (> 14 days) was higher in complete PNP patients than incomplete PNP patients. 2 patients, who were observed effort dyspnea at the time of respiratory weaning, were extubated followed by respiratory and circulatory deterioration, and were reintubated. PNP were confirmed after reintubation by PNST. These patients died of pneumonia. Another 2 patients were observed effort dyspnea during respiratory weaning, and were doubted of PNP. PNP were confirmed by PNST before extubation. After hemodynamic stabilization and respiratory physiotherapy, these patients were extubated without any trouble. One patient, who required repeated intubation, was diagnosed PNP by PNST. This patient was extubated after confirmation of improvement of PNP by follow-up PNST. The incidence of PNP was higher in patients with previous open heart surgery than without previous operation. We supposed that the dissection around the heart might be one of major cause of postoperative PNP. So, in recent 4 cases of mitral reoperation, we attempted to reach mitral valve through atrial septum with minimum dissection.(ABSTRACT TRUNCATED AT 250 WORDS)
我们明确了心脏直视手术后膈神经麻痹（PNP）患者呼吸管理中的问题。1988年12月至1991年3月，248例成年患者接受了局部心肌降温的心脏直视手术。其中17例（6.9%）被诊断为PNP。这些患者手术时的年龄在25岁至76岁之间，平均年龄为57岁。9例为瓣膜性心脏病（7例为再次手术），7例为冠状动脉疾病，1例为主动脉瘤。PNP通过胸部X线片或经皮膈神经刺激试验（PNST）诊断。完全性PNP患者长期插管（>14天）的频率高于不完全性PNP患者。2例在呼吸脱机时出现劳力性呼吸困难的患者，拔管后出现呼吸和循环恶化，再次插管。再次插管后通过PNST确诊为PNP。这些患者死于肺炎。另外2例在呼吸脱机时出现劳力性呼吸困难，怀疑为PNP。拔管前通过PNST确诊为PNP。在血流动力学稳定和呼吸物理治疗后，这些患者顺利拔管。1例需要反复插管的患者通过PNST诊断为PNP。该患者在随访PNST证实PNP改善后拔管。有心脏直视手术史的患者PNP发生率高于无手术史的患者。我们推测心脏周围的解剖可能是术后PNP的主要原因之一。因此，在最近4例二尖瓣再次手术中，我们试图通过房间隔以最小的解剖操作到达二尖瓣。（摘要截断于250字）
