| Background and objective:At present, congenital malformation has climbed to the top in the cause of death in domestic infant. However, congenital heart disease (CHD) accounted f or the main component. It will seriously affect the normal growth and develop ment of children. If not promptly treated surgically, it eventually died of recurr ent respiratory tract infections, pulmonary hypertension, or heart failure and los e the best time for treatment. Acute congestive heart failure associated with co ngenital heart disease is one of the most common critically ill in PICU. Childr en associated with congenital heart disease who has serious right heart failure or cyclical hypoxemia should be given continuous oxygen therapy. The traditio nal view is that nasal continuous positive airway pressure (NCPAP) increase ri ght hear load due to increased pulmonary pressure, so NCPAP has a negative i mpact on cardiac function. But in recent years, a growing number of studies h ave confirmed that NCPAP has the cardiopulmonary support function. NCPAP on left ventricular function of the failing heart has a direct and indirect treatm ent.With the rapid development of critical care medicine, mechanical ventilation as an important life-support systems, has been widely used in the clinical resc ue, respiratory therapy and other aspects. For mechanical ventilation in criticall y ill children, the artificial airway cause pain and discomfort, prone to irritabili ty, restlessness, man-machine confrontation Etc., it is necessary to give appropri ate sedation. At present, the study of analgesia and sedation in the PICU is la gging behind. Dose of sedative and analgesic drugs/security/combination therapy program is still a lack of data.In this study, we collect clinical data of75cases of acute congestive heart failure children associated with congenital heart disease. We evaluated the effe ctiveness of the early application of NCPAP treatment and factors affecting the NCPAP treatment effect. At the same time, we explored the efficacy and safet y of midazolam combined with fentanyl in the mechanical ventilation of acute congestive heart failure children associated with congenital heart disease.MethodsThe descriptive data study method was used in this clinical study, the data of all the case was collected prospectively. The starting point was that time on which children were admitted to the hospital and the end point death or disch arge. Factors examined included age, gender, type of congenital heart diseases; Vital signs:respiration, heart rate, systolic blood pressure; Blood gas analysis i ndex:PH, artery oxygen points pressure (PaO2), and carbon dioxide points pre ssure (PaCO2), and lactic acid value (Lac), at the same time, we calculate oxy gen collection index (PaO2/FiO2); Serological indexes:serum N-terminal pro-brain natriuretic peptide in type B (NT-pro BNP) level; Cardiac function index:left ventric ular ejection fraction (LVEF).The proportion requiring mechanical ventilation, d uration of mechanical ventilation, stay in PICU time and mortality; SpO2, PaC O2, PaO2, breathing, heart rate, systolic blood pressure level of each time poin t including before sedation,30minutes and6hours after administration, and3Omin after stopping; time of reach Ramsay3to4minutes (minutes), recovery time after stopping (minutes), the average amount of midazolam (ug/kg. h), d uration of mechanical ventilation, PICU length of stay. Eventually, the clinical materials were inputed into EXCEL to establish database for statistical analysis. Part Ⅰ—we collect clinical data of75cases of acute congestive heart failure c hildren associated with congenital heart disease. A total of60patients were inc luded in the study and randomly divided into the early NCPAP group (n=32) a nd early oxygen-Absorbing by Nasal Trachea group (n=28). Children with NCP AP treatment for Continuous5days after admission were grouped into continu ous NCPAP group (n=23); with nasal cannula oxygen for Continuous5days after admission were grouped into the continuous oxygen-Absorbing by Nasal Trachea group (n=19). Early group on admission (0d)/1d and Continuous gr oup on admission (0d)/5d take blood0.5ml to conduct Arterial blood gas analy sis by GEM Premier3000blood gas analyzer. We record pH, partial pressure of arterial oxygen (PaO2), carbon dioxide partial pressure (PaCO2), lactate (La c), calculate the oxygenation index (PaO2/FiO2); we take peripheral blood2ml to determination of serum amino-terminal B-type natriuretic peptide precurso r (NT-pro BNP)levels with Elecsys (r))2012-electrochemiluminescence immunoa ssay. While using the United States Agilent Sonos5500cardiac ultrasound diag nostic apparatus to direct measure of left ventricular ejection fraction (LVEF).W e compared arterial blood gases, serum NT-pro BNP level and improvement of cardiac function, as well as the proportion of requiring mechanical ventilation, duration of mechanical ventilation, stay in the PICU and mortality before and after treatment.Part Ⅱ—we filter39cases of acute congestive heart failure children associat ed with congenital heart disease who on admission exist type Ⅱ respiratory fail ure or severe type I respiratory failure, has indications of tracheal intubation in vasive for mechanical ventilation. They were randomly divided into midazolam group (n=14), fentanyl and midazolam group (n=15). Ventilator mode were S IMV (PC)+PS, PRVC, A/C, and adjust mode according to condition of Ch ildren. On each time point including before sedation, after treatment for30mi nutes/6hours,30min after discontinuation,two groups of children were taken ar terial blood0.5ml to conduct arterial blood gas analysis by GEM On premier3000blood gas analyzer, determination of arterial oxygen (PaO2), carbon dioxid e partial pressure (PaC02);We continuous monitoring and record SpO2, respirati on, heart rate, systolic blood pressure using Multi-function ECG of two groups at each time point and recorded date in EXCEL form. Sedation effect was a ssessed using The Ramsay Sedation Scale (RSS). Form the start of the sedatio n, assessment was conducted every30minutes. We record the time of reach R amsay3to4(minutes), recovery time after stopping (minutes), the average amo unt of midazolam (ug/kg.h), duration of mechanical ventilation, length of hospit al stay in PICU. The United States Agilent Sonos5500cardiac ultrasound diag nostic equipment was used to measure directly the pulmonary artery pressure b efore treatment.Results1.60cases were included in the study, male:female:2.9:1; the maximum age:11m, minimum age:1d.With invasive echocardiography (UCG) on admission, t he number of ventricular septal defect (VSD) was10cases, Patent ductus arter iosus(PDA)7cases, PDA+atrial septal defect(ASD)5cases, VSD+ASD+PDA4cases, VSD+double outlet of right ventricular4cases, PDA+mitral valve prolapse and severe reflux3cases, Triatriatum+unroofed coronary sinus+AS D2cases, Complete transposition of great arteries(CTGA)+VSD4cases, C TGA+PDA3cases, total anomalous pulmonary venous drainage(TAPVD)+ASD2cases, TAPVD+the PDA2cases, TAPVD (supracardiac)+patent fora men ovale (PFO)1cases, scimitar syndrome+PDA1cases, complete atrioventric ular septal defect2cases, partial atrioventricular septal defect2cases, interrupt ed aortic arch+VSD+ASD lcases, aortic contraction+ASD+VSD+PD A+persistent left superior vena cava1cases, Ebstein+VSD lcases, hypopl astic left heart syndrome1cases. The number of analgesic-sedation39cases, i ncluding midazolam group14cases, and midazolam combined with fentanyl gr oup15cases. With invasive echocardiography (UCG) on admission, the number of ventricular septal defect (VSD) was9cases, Patent ductus arteriosus (PDA)3cases. PDA+atrial septal defect(ASD)7cases, VSD+ASD5cases, VSD+A SD+PDA2cases, VSD+double outlet of right ventricular2cases, PDA+mitr al valve prolapse and severe reflux4cases, CTGA+VSD3cases, CTGA+PD A2cases, TAPVD)+ASD1cases, interrupted aortic arch+VSD+ASD1cas es.2. Comparison between early NCPAP group and early oxygen-Absorbing b y Nasal Trachea group(1) before treated, the difference of vital signs (respiration, heart rate)/arterial blood gas (PH, PaO2, PaCO2, PaO2/FiO2,Lac)/serological (NT-proBNP) and UCG cardiac function indicators (LVEF) between early NCPAP group and oxygen-Absorbing by Nasal Trachea group had no statistically significant (P>0.05).(2) After treatment of one day, compared with early oxygen-Absorbing by Nasa1Trachea group, breathing, heart rate, PaO2, PaO2/FiO2, Lac, NT-proBNP1evels of early NCPAP group had a significant difference (P<0.05); pH, Pa CO2, LVEF had no significant difference (P>0.05).(3) Compared with admission, breathing, heart rate, PaO2, PaO2/FiO2, Lac, Pa CO2, NT-pro BNP of early NCPAP group after treatment of one day had a significant difference (P<0.05); The value of PH, LVEF had no significa nt difference (P>0.05).(4) Compared with admission, breathing, heart rate, PaO2day of early oxygen-Absorbing by Nasal Trachea group after treatment of one day had a signif icant difference (P<0.05); PH, PaCO2, PaO2/FiO2, Lac, NT-pro BNP,LV EFhad no significant difference (P>0.05).(5) The proportion of mechanical ventilation, duration of mechanical ventilation, stay at the PICU、mortality between early NCPAP group and early oxyge n-Absorbing by Nasal Trachea group had a significant difference (P<0.05).3. Comparison between continuous NCPAP group and the continuous oxyge n-Absorbing by Nasal Trachea group(1) Before treated, the difference of vital signs (respiration, heart rate)、arterial blood gas (PH, PaO2, PaCO2, PaO2/FiO2,Lac)、serological (NT-pro BNP) a nd UCG cardiac function indicators (LVEF) between continuous NCPAP gr oup and the continuous oxygen-Absorbing by Nasal Trachea group had no statistically significant (P>0.05).(2) After treatment of one day, compared with the continuous oxygen-Absorbin g by Nasal Trachea group, breathing, heart rate, pH, PaO2, PaO2/FiO2, Lac, NT-pro BNP, LVEFof continuous NCPAP group had a significant diffe rence (P<0.05); PaCO2had no significant difference (P>0.05).(3) Compared with admission, breathing, heart rate, PaO2, PaO2, PaCO2, PaO2/FiO2Lac, NT-pro BNP, LVEFof continuous NCPAP group after treatment o f5day had a significant difference (P<0.05); The value of PH had no si gnificant difference (P>0.05).(4) Compared with admission, breathing, heart rate, PaO2, PaO2/FiO2, Lac of continuous oxygen-Absorbing by Nasal Trachea group after treatment of5day had a significant difference (P<0.05); pH, PaCO2, NT-pro BNP, LVE Fhad no significant difference (P>0.05).4. Comparison between the NCPAP success group and failure group Univariate analysis was performed on a number of factors which may affect NCPAP treatment effect, we found that breathing, pH, PaCO2, LVEFon admissionand PaCO2, PaO2/FiO2after treatment for6h had a significant difference (P<0.05)5. Comparison of SpO2PaCO2, PaO2, breathing, heart rate, systolic blood pressure between midazolam group and midazolam combined with fentanyl group at different time points.Two groups of children can obtain a satisfactory sedative effect. Compared with pre-sedation, SpO2, PaCO2, PaO2of two groups of children after treatmen t for30minutes/6hours,30min after discontinuation had a significant differenc e.(P<0.05); However, each index between the two groups in the corresponding time point had no significant difference (P>0.05). Compared with pre-sedatio n, breathing, heart rate of two groups after treatment for30minutes/6hours,30mi n after discontinuation had a significant difference.(P<0.05); Breathing between the two groups in the corresponding time point had no significant difference (P >0.05). Compared with the midazolam group, heart rate after treatment for30minu tes/6hours of midazolam combined with fentanyl group was significantly lower, th e difference had a statistically significant (P<0.05).6. Comparison of Clinical outcomesForm sedative effect of the two group, we can see that compared with the midazolam group, the time of obtaining a satisfactory sedative effect, recovery time after stopping, the average dose of midazolam, PICU length of stay, pulmo nary artery pressure of midazolam combined with fentanyl group after treatment were lower, the difference had a statistically significant (P<0.05); the time of mechanical ventilation had no significant difference (P>0.05).Conclusion(1) The early use of noninvasive NCPAP for eligible patients with acute CHF complicated by CHD seems to improve their prognosis by reducing left ve ntricular and right ventricular afterload and improving the left ventricular f unction.(2) The monitor and evaluation cardiac function, serum NT-pro BNP level is more sensitive than bedside UCG.(3) Factors that may affect the success or failure of NCPAP treatment is breat hing frequency, pH, PaCO2, LVEF before treated and P aCO2, PaO2/Fi02after treated for6h.(4) Two groups of children can obtain a satisfactory sedative effect, compared with the midazolam group, the time of obtaining a satisfactory sedative eff ect, recovery time after stopping, the average dose of midazolam, PICU le ngth of stay, pulmonary artery pressure of midazolam combined with fenta nyl group after treatment were lower, the difference had a statistically signi ficant (P<0.05); Both the two group had no significant effect on respiratio n, heart rate, blood pressure. Sedation with midazolam combined with fenta nyl is a good combination of mechanical ventilation in PICU. |
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