Jochman John D, Atkinson Douglas B, Quinonez Luis G, Brown Morgan L
Department of Anesthesiology, University of Wisconsin, Madison, WI.
Department of Anesthesiology, Perioperative and Pain Medicine, Division of Cardiac Anesthesia, Boston Children's Hospital, Boston, MA.
J Cardiothorac Vasc Anesth. 2017 Jun;31(3):918-921. doi: 10.1053/j.jvca.2017.02.006. Epub 2017 Feb 4.
Review the authors' institutional experience of the induction and perioperative airway management of children with tetralogy of Fallot with an absent pulmonary valve.
Retrospective chart review.
Large academic children's hospital.
Patients with the diagnosis of tetralogy of Fallot with absent pulmonary valve undergoing primary cardiac repair over a 20-year period.
None.
Forty-four patients were identified with tetralogy of Fallot with an absent pulmonary valve from January 1995 through August 2014. Forty-two patients (95%) required surgery in their first year of life. Sixteen patients (36%) required mechanical ventilation preoperatively, including 11 neonates. Of the 28 patients not intubated preoperatively, only 1 (3.8%) exhibited minor airway obstruction following induction that was managed uneventfully. All intubations in the operating room were performed in the supine position. Five patients who were mechanically ventilated preoperatively in a lateral or prone position were supinated in the operating room without significant cardiopulmonary compromise. There were no patients who suffered cardiopulmonary arrest or required mechanical circulatory support. The median time to extubation was 2 days (range 1-13 days) in those patients who were not mechanically ventilated prior to their surgery. Ultimately, 5 patients required tracheostomy and 1 patient underwent lobectomy. Although, there was no mortality at 30 days, 4 children died within 1 year of their surgery. All the children who died had a genetic syndrome and required mechanical ventilation preoperatively.
While there are theoretical concerns specific to the induction and airway management of tetralogy of Fallot with an absent pulmonary valve, there were no episodes of cardiorespiratory arrest or extracorporeal membrane oxygenation in the authors' series. Neonatal age at the time of surgery, preoperative need for mechanical ventilation, and concomitant genetic syndromes are risk factors for respiratory morbidity. Mortality in this study was low compared to historic reports, likely reflecting improvement in surgical technique and intensive care management.
回顾作者所在机构对法洛四联症合并肺动脉瓣缺如患儿的诱导期及围手术期气道管理经验。
回顾性病历审查。
大型学术儿童医院。
在20年期间接受初次心脏修复手术的法洛四联症合并肺动脉瓣缺如患者。
无。
1995年1月至2014年8月期间，共确定44例法洛四联症合并肺动脉瓣缺如患者。42例（95%）患者在出生后第一年内需要手术。16例（36%）患者术前需要机械通气，其中包括11例新生儿。在术前未插管的28例患者中，只有1例（3.8%）在诱导后出现轻微气道梗阻，经处理后情况平稳。手术室中的所有插管均在仰卧位进行。5例术前在侧卧位或俯卧位接受机械通气的患者在手术室中转为仰卧位，未出现明显心肺功能损害。没有患者发生心肺骤停或需要机械循环支持。术前未接受机械通气的患者拔管的中位时间为2天（范围1 - 13天）。最终，5例患者需要气管切开术，1例患者接受了肺叶切除术。虽然30天内无死亡病例，但4例患儿在术后1年内死亡。所有死亡患儿均患有遗传综合征，且术前需要机械通气。
虽然法洛四联症合并肺动脉瓣缺如的诱导期及气道管理存在一些理论上的问题，但在作者的系列研究中未出现心肺骤停或体外膜肺氧合事件。手术时的新生儿年龄、术前对机械通气的需求以及合并的遗传综合征是呼吸并发症的危险因素。与既往报道相比，本研究中的死亡率较低，这可能反映了手术技术和重症监护管理的改善。
