van Onna I E, Metz R, Jekel L, Woolley S R, van de Wal H J
Paediatric Heart Center, Wilhelmina Children's Hospital, Utrecht University, The Netherlands.
Eur J Cardiothorac Surg. 1998 Aug;14(2):179-84. doi: 10.1016/s1010-7940(98)00147-x.
Evaluation of an aggressive policy for the treatment of phrenic nerve palsy (PNP), following cardiac operations, with emphasis on early diaphragmatic plication. Attention was given to the incidence and predisposing factors for PNP and the potential for recovery following plication.
From 1 June 1991 to 1 January 1996 we prospectively screened patients for PNP following cardiac surgery. The diagnosis was suspected if difficulty was experienced in weaning the child from the ventilator. If abnormal elevation of the hemidiaphragm was present diaphragmatic plication was performed. Echocardiography was used to assess subsequent return of diaphragmatic function.
Seventeen children (nine boys, eight girls), out of 867 (1.9%) children younger than 16 years of age, undergoing cardiac operations were found to have PNP. The mean age was 66 days (range 1-17 months) with 16 patients below 1 year out of a total of 285 patients (incidence 5.6%) and one patient 17 months old. The incidence following open procedures was 11/190, following closed procedures 2/95 and following reoperation 4/83. PNP was diagnosed from 2 to 44 days (mean 14 days) following surgery. It was present on the right side in seven cases, the left in nine and was bilateral in one patient. Two patients were extubated at the time of diagnosis, one patient could be extubated shortly thereafter. Fourteen children underwent diaphragmatic plication, at a median 5 days post diagnosis. Extubation was possible 1-60 days (mean 4 days) after plication. Mean follow-up was 19 +/- 5 months. Subsequent recovery of diaphragmatic movement was documented in seven (41%) children. Time to recovery following plication was 16 months, without plication 38 months.
Prospective screening for PNP revealed an incidence in children younger than 1 year of 6%. Early plication substantially reduces the duration of ventilation, with its associated reduced morbidity and ICU stay.
评估一种积极的膈神经麻痹（PNP）治疗策略，该策略用于心脏手术后的治疗，重点在于早期膈肌折叠术。关注了PNP的发生率、诱发因素以及折叠术后的恢复潜力。
从1991年6月1日至1996年1月1日，我们对心脏手术后的患者进行了前瞻性的PNP筛查。如果患儿在脱离呼吸机时遇到困难，则怀疑患有该病。如果存在半侧膈肌异常抬高，则进行膈肌折叠术。使用超声心动图评估膈肌功能的后续恢复情况。
在867例16岁以下接受心脏手术的儿童中，有17例（9例男孩，8例女孩）被发现患有PNP。平均年龄为66天（范围1 - 17个月），在总共285例患者中，16例患者年龄小于1岁（发生率5.6%），1例患者为17个月大。开放手术术后的发生率为11/190，闭合手术术后为2/95，再次手术术后为4/83。PNP在术后2至44天（平均14天）被诊断出来。右侧出现7例，左侧9例，1例为双侧。2例患者在诊断时即已拔管，1例患者此后不久也可拔管。14例儿童在诊断后中位数5天接受了膈肌折叠术。折叠术后1至60天（平均4天）可进行拔管。平均随访时间为19±5个月。7例（41%）儿童记录到膈肌运动随后恢复。折叠术后恢复时间为16个月，未进行折叠术则为38个月。
对PNP进行前瞻性筛查显示，1岁以下儿童的发生率为6%。早期折叠术显著缩短了通气时间，及其相关的发病率降低和重症监护病房停留时间缩短。
