Mills Kimberly I, van den Bosch Sarah J, Gauvreau Kimberlee, Allan Catherine K, Thiagarajan Ravi R, Hoganson David M, Baird Christopher W, Nathan Meena, DiNardo James A, Kheir John N
1Departments of Cardiology,Boston Children's Hospital,Boston,MA,USA.
4Department of Cardiovascular Surgery,Boston Children's Hospital,Boston,MA,USA.
Cardiol Young. 2018 Dec;28(12):1393-1403. doi: 10.1017/S1047951118001385. Epub 2018 Aug 28.
Following stage 1 palliation, delayed sternal closure may be used as a technique to enhance thoracic compliance but may also prolong the length of stay and increase the risk of infection.
We reviewed all neonates undergoing stage 1 palliation at our institution between 2010 and 2017 to describe the effects of delayed sternal closure.
During the study period, 193 patients underwent stage 1 palliation, of whom 12 died before an attempt at sternal closure. Among the 25 patients who underwent primary sternal closure, 4 (16%) had sternal reopening within 24 hours. Among the 156 infants who underwent delayed sternal closure at 4 [3,6] days post-operatively, 11 (7.1%) had one or more failed attempts at sternal closure. Patients undergoing primary sternal closure had a shorter duration of mechanical ventilation and intensive care unit length of stay. Patients who failed delayed sternal closure had a longer aortic cross-clamp time (123±42 versus 99±35 minutes, p=0.029) and circulatory arrest time (39±28 versus 19±17 minutes, p=0.0009) than those who did not fail. Failure of delayed sternal closure was also closely associated with Technical Performance Score: 1.3% of patients with a score of 1 failed sternal closure compared with 18.9% of patients with a score of 3 (p=0.0028). Among the haemodynamic and ventilatory parameters studied, only superior caval vein saturation following sternal closure was different between patients who did and did not fail sternal closure (30±7 versus 42±10%, p=0.002). All patients who failed sternal closure did so within 24 hours owing to hypoxaemia, hypercarbia, or haemodynamic impairment.
When performed according to our current clinical practice, sternal closure causes transient and mild changes in haemodynamic and ventilatory parameters. Monitoring of SvO2 following sternal closure may permit early identification of patients at risk for failure.
在一期姑息治疗后，延迟胸骨闭合可作为一种提高胸廓顺应性的技术，但也可能延长住院时间并增加感染风险。
我们回顾了2010年至2017年间在我院接受一期姑息治疗的所有新生儿，以描述延迟胸骨闭合的效果。
在研究期间，193例患者接受了一期姑息治疗，其中12例在尝试胸骨闭合前死亡。在25例行一期胸骨闭合的患者中，4例（16%）在24小时内出现胸骨重新开放。在156例术后4[3,6]天接受延迟胸骨闭合的婴儿中，11例（7.1%）有一次或多次胸骨闭合尝试失败。接受一期胸骨闭合的患者机械通气时间和重症监护病房住院时间较短。延迟胸骨闭合失败的患者与未失败的患者相比，主动脉交叉阻断时间更长（123±42对99±35分钟，p=0.029），循环停止时间更长（39±28对19±17分钟，p=0.0009）。延迟胸骨闭合失败也与技术操作评分密切相关：技术操作评分为1分的患者胸骨闭合失败率为1.3%，而评分为3分的患者为18.9%（p=0.0028）。在所研究的血流动力学和通气参数中，只有胸骨闭合后上腔静脉饱和度在胸骨闭合失败和未失败的患者之间存在差异（30±7对42±10%，p=0.002）。所有胸骨闭合失败的患者均在24小时内因低氧血症、高碳酸血症或血流动力学损害而失败。
按照我们目前的临床实践进行胸骨闭合时，会引起血流动力学和通气参数的短暂和轻微变化。胸骨闭合后监测SvO2可能有助于早期识别有失败风险的患者。
