FHF Tsang, LC Cheng, TC Yung, AKT Chau, CSW Chiu

Abstract

Purpose: To review the results of ligation of patent ductus arteriosus in premature babies in an intensive care unit. Method: Retrospective review of premature babies who underwent ligation of patent ductus arteriosus in the intensive care unit, Grantham Hospital, during the period from January, 1999 to December, 2002. Results are compared with those who underwent ligation of patent ductus arteriosus in the operating theatre during the same period. Results: A total of 33 premature babies were recruited. Eighteen babies, including 11 male and 7 female babies with a mean gestation of 25.7 weeks (ranged from 24 to 30 weeks) and a mean birth weight of 835 grams (ranged from 625 to 1439 gram) underwent ligation of patent ductus arteriosus via a left thoracotomy in the intensive care unit. The mean body weight at the time of operation was 1132 grams with a range of 700 to 2700 grams. The indications were respiratory failure and congestive heart failure. The babies were referred from 4 different hospitals. All except 2 babies had a trial of indomethacin induction for closure of patent ductus arteriosus. All except 1 baby received surfactant treatment. The mean ductal size was 3 mm with a range of 2 to 5 mm. There were no statistical difference between the babies operated in the intensive care unit and the operating theatre in terms of the presence of bronchopulmonary dysplasia, necrotizing enterocolitis, pre-operative use of indomethacin, the size of the duct, the mean duration of anaesthesia, the mean change in oxygen requirement, ventilatory support and inotropic support. Babies undergoing ligation of the patent ductus arteriosus in the intensive care unit are significantly smaller in terms of their birth weight and their weight at surgery (p< 0.001). They tend to be more premature (p< 0.001) and sick as compared with those who have their surgery done in the operating theatre, with more babies having respiratory distress syndrome and intraventricular haemorrhage (p< 0.05 and p< 0.001, respectively). There is a significant decrease in body temperature (p< 0.05) after operation in those babies who have ligation of patent ductus arteriosus performed in the operating theatre, and such a change is not observed in those with ligation of patent ductus arteriosus done in the intensive care unit. There was one hospital-mortality due to torrential bleeding from the posterior wall of the duct in the intensive care unit group. Blood loss was minimal in other infants and there was no empyema or wound dehiscence. Most of the patients were transferred back to the referring neonatal intensive care units the next day after surgery to manage other problems arising from prematurity (16 intraventricular haemorrhage, 3 bronchopulmonary dysplasia, 6 necrotizing enterocolitis, 18 respiratory distress syndrome). None of the patients required readmission for management of late surgical complications. Conclusion: Ligation of patent ductus arteriosus in the intensive care unit is safe and effective and outcomes are comparable to that performed in the operating theatre. Risks, including hypothermia, encountered during transfer of preterm infants to the operating theatre can be avoided and continuity of care can be provided when patent ductus arteriosus is ligated in the intensive care unit. The availability of an experienced multidisciplinary cardiac team to handle preterm babies during operation in the intensive care unit is essential for the success of such a practice.

目的：回顧性地總結了我院在 ICU 為患先天性動脈導管未閉（PDA）的早產兒進行 PDA 結扎手術的經驗。方法：本文對 1999 年 1 月至 2002 年 12 月期間在葛量洪醫院 ICU 進行早產兒 PDA 結扎術的治療結果，與在手術室進行同類手術的治療結果進行對比性研究。結果：33 例早產兒，ICU 組 18 例，患兒來自 4 間不同醫院（男 11 例，女 7 例），平均出生胎齡 25.7 週（24-30 週），平均出生時體重 835 克（625-1439 克）。手術時早產兒的平均體重為 1132 克（700 -2700 克），所有患者均在 ICU 床旁經左胸切口結扎 PDA。手術指證為患兒出現呼吸衰竭及充血性心力衰竭。除 2 例患者外，術前其他患兒都曾用 Indomethacin 進行誘導 PDA 閉合治療。除 1 例外，其他患兒還接受了胎糞治療，都未能成功閉合 PDA。結扎的未閉導管的平均直徑為 3 毫米（範圍 2-5 毫米）。兩組患兒的臨床表現：如肺小支氣管發育不良、壞死性小腸結腸炎、術前 Indomethacin 的使用情況、動脈導管的大小，平均麻醉時間，需氧氣的情況，呼吸機維持治療以及強心藥的使用情況均無明顯差異。但 ICU 組患兒出生時體重較手術室組患兒出生時體重輕（p<0.001 ），前者的胎齡也較後者小（p<0.001）。一般狀態也較差，較多患兒出現呼吸窘迫綜合症及腦室內出血（分別為 p<0.05 及 p<0.001）。手術室組患兒術後體溫有較明顯的下降（p<0.05），而 ICU 組則無此現象。ICU 組 1 例因導管後壁大出血而院內死亡。其他患兒手術過程中失血量小，術後無一例出現膿胸或傷口裂開情況。兩組患兒大多數術後第二天即可送回原醫院的新生兒監護室，繼續治療其他的因早產所引起的疾患（16 例腦室內出血，3 例肺小支氣管發育不良，6 例壞死性小腸結腸炎，18 例呼吸窘迫綜合症），所有術後患兒都不需要再入院手術結扎 PDA。結論：在 ICU 結扎PDA 是安全有效的手術方法，其治療效果與手術室組無明顯差異，因手術是在 ICU 進行，因此可避免運送手術室過程中造成的術後低溫症，也更便於術後的綜合護理。為保証手術過程順利，參與手術的心臟科醫生需具備多學科的專業知識。