Hoskote Aparna, Cohen Gordon, Goldman Allan, Shekerdemian Lara
Cardiothoracic Unit, Great Ormond Street Hospital for Children, London, United Kingdom.
J Thorac Cardiovasc Surg. 2005 Oct;130(4):1086-93. doi: 10.1016/j.jtcvs.2005.03.049.
Respiratory insufficiency in children after cardiothoracic surgery delays weaning from the ventilator and prolongs intensive care unit stay. There is little consensus as to the indications for tracheostomy and its safety in this population.
We reviewed our institutional experience in 37 consecutive infants and children (median age, 8.6 months; weight, 7.2 kg) requiring a tracheostomy after cardiothoracic surgery between January 1998 and December 2001, with follow-up to June 2003.
Twenty-four children underwent tracheostomy after corrective (n = 15) or palliative (n = 9) surgery for congenital heart disease, 8 had undergone thoracic transplantation, and 5 had undergone thoracic surgery. Median duration of pretracheostomy ventilation was 30 days, and median total duration of ventilation was 73 days. Tracheostomy was performed earlier in patients undergoing transplantation (median of 20 days postoperatively), with a duration of ventilation of 34 days. No patient experienced mediastinitis, and a wound infection in 1 child was the only identified complication. Twenty-two children survived to hospital discharge, of whom 15 have since been decannulated; 6 still have a tracheostomy in situ and 1 has been lost to follow-up. A number of preoperative and postoperative factors were identified in this cohort. These were preoperative respiratory insufficiency, a history of neonatal ventilation, the need for cardiac reoperations, diaphragmatic paralysis, tracheobronchomalacia, neurological comorbidity, and associated chromosomal abnormalities.
Tracheostomy can be performed safely and without increased risk of complications in infants and children early after cardiothoracic surgery. The presence of identifiable factors in patients in whom weaning has been unsuccessful should alert clinicians to early consideration of tracheostomy.
心胸外科手术后儿童出现呼吸功能不全，会延迟呼吸机撤机时间，并延长重症监护病房住院时间。对于该人群气管切开术的指征及其安全性，目前几乎没有共识。
我们回顾了1998年1月至2001年12月期间在我院连续37例心胸外科手术后需要气管切开术的婴儿和儿童（中位年龄8.6个月；体重7.2kg）的病例，并随访至2003年6月。
24例儿童因先天性心脏病接受矫正（n = 15）或姑息性（n = 9）手术后行气管切开术，8例接受了胸段移植，5例接受了胸外科手术。气管切开术前通气的中位时间为30天，通气总中位时间为73天。接受移植的患者气管切开术实施时间较早（术后中位20天），通气时间为34天。没有患者发生纵隔炎，仅1例儿童出现伤口感染是唯一确定的并发症。22例儿童存活至出院，其中15例已拔除气管套管；6例仍保留气管切开，1例失访。在这组病例中确定了一些术前和术后因素。这些因素包括术前呼吸功能不全、新生儿通气史、心脏再次手术的需要、膈神经麻痹、气管支气管软化、神经合并症以及相关染色体异常。
在心胸外科手术后早期，婴儿和儿童可以安全地进行气管切开术，且并发症风险不会增加。对于撤机失败的患者，存在可识别因素应提醒临床医生尽早考虑气管切开术。
