De Oliveira Nilto C, Ashburn David A, Khalid Faizah, Burkhart Harold M, Adatia Ian T, Holtby Helen M, Williams William G, Van Arsdell Glen S
Division of Cardiovascular Surgery, Hospital for Sick Children, and University of Toronto, Toronto, Ontario, Canada.
Circulation. 2004 Sep 14;110(11 Suppl 1):II133-8. doi: 10.1161/01.CIR.0000138399.30587.8e.
After modifications in our perioperative management protocol, we have observed a decrease in sudden circulatory collapse after the Norwood operation. The current study examines early outcomes after the Norwood operation in our unit in an attempt to identify variables that may have altered the risk of unexpected circulatory collapse.
We studied 105 consecutive neonates who underwent a Norwood operation in our institution. Our treatment protocol has changed in the past 3 years to include the use of alpha-blockade with phenoxybenzamine (POB) for systemic afterload reduction and selective cerebral perfusion. Forty-eight infants had selective cerebral perfusion. Forty-two infants received POB. Sixty patients had hypoplastic left heart syndrome. There was no difference in age, diagnosis, number of neonates with weight <2.5 kg, aortic size diameter <2 mm, highest preoperative lactate level, and shunt size indexed to body weight among patients with or without use of POB. Twenty-five infants had circulatory collapse during the first 72 hours. Twelve of them could be explained by technical issues. Thirteen others who appeared clinically stable had early sudden circulatory collapse without an apparent cause. Sixteen out of 25 neonates died. Of those with technical problems, 8 out of 12 died. Based on the hazard function, 3 incremental risk factors for early circulatory collapse were technical issue at operation (P<0.001), longer cross-clamp time (P<0.007), and no use of POB (P<0.002). For a technically successful operation, freedom from circulatory collapse at 72 hours is 95% with the use of POB versus 69% without (P<0.002). Diagnosis, aortic size, atrioventricular valve function, birth weight, age at operation, and total circulatory arrest time and were not predictive of early sudden circulatory collapse.
Recent changes in our treatment protocol have resulted in a decrease incidence of sudden circulatory collapse after the Norwood operation. Optimal surgical technique is the most important predictor of early survival. The use of aggressive afterload reduction with POB reduced the risk of early sudden arrest.
在我们对围手术期管理方案进行调整后，我们观察到诺伍德手术后突然循环衰竭的情况有所减少。本研究旨在探讨我们科室诺伍德手术后的早期结局，以确定可能改变意外循环衰竭风险的变量。
我们研究了在我们机构连续接受诺伍德手术的105例新生儿。在过去3年中，我们的治疗方案发生了变化，包括使用苯氧苄胺（POB）进行α受体阻滞以降低体循环后负荷以及选择性脑灌注。48例婴儿接受了选择性脑灌注。42例婴儿接受了POB治疗。60例患者患有左心发育不全综合征。使用POB和未使用POB的患者在年龄、诊断、体重<2.5 kg的新生儿数量、主动脉直径<2 mm、术前最高乳酸水平以及按体重指数计算的分流大小方面没有差异。25例婴儿在术后72小时内发生循环衰竭。其中12例可归因于技术问题。另外13例临床稳定的婴儿出现了无明显原因的早期突然循环衰竭。25例新生儿中有16例死亡。在有技术问题的患者中，12例中有8例死亡。根据风险函数，早期循环衰竭的3个递增风险因素是手术中的技术问题（P<0.001）、较长的阻断时间（P<0.007）以及未使用POB（P<0.002）。对于技术成功的手术，使用POB时72小时无循环衰竭的概率为95%，未使用时为69%（P<0.002）。诊断、主动脉大小、房室瓣功能、出生体重、手术年龄、总循环阻断时间均不能预测早期突然循环衰竭。
我们治疗方案的近期改变导致诺伍德手术后突然循环衰竭的发生率降低。最佳手术技术是早期生存的最重要预测因素。使用POB积极降低后负荷可降低早期突然心脏骤停的风险。
