山东大学耳鼻喉眼学报  2018, Vol. 32 Issue (2): 34-37  DOI: 10.6040/j.issn.1673-3770.0.2017.533
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仇书要, 刘大波, 钟建文, 杨李强. 儿童阻塞性睡眠呼吸暂停低通气综合征等离子消融术后并发症分析[J]. 山东大学耳鼻喉眼学报, 2018, 32(2): 34-37.DOI: 10.6040/j.issn.1673-3770.0.2017.533.
QIU Shuyao, LIU Dabo, ZHONG Jianwen, YANG Liqiang. Analysis of coblation complications in children with obstructive sleep apnea-hypopnea syndrome[J]. Journal of Otolaryngology and Ophthalmology of Shandong University, 2018, 32(2): 34-37. DOI: 10.6040/j.issn.1673-3770.0.2017.533.

第一作者

仇书要。E-mail:qiushuyao@126.com

通讯作者

刘大波。E-mail:daboliu@126.com

文章历史

收稿日期:2017-12-21
修回日期:2018-02-10
儿童阻塞性睡眠呼吸暂停低通气综合征等离子消融术后并发症分析
仇书要, 刘大波, 钟建文, 杨李强     
南方医科大学深圳医院儿童耳鼻咽喉科,广东 深圳 518100
收稿日期:2017-12-21;修回日期:2018-02-10
第一作者:仇书要。E-mail:qiushuyao@126.com.
通讯作者:刘大波。E-mail:daboliu@126.com
摘要目的 探讨儿童阻塞性睡眠呼吸暂停低通气综合征(OSAHS)低温等离子消融术后并发症产生原因,总结并发症处理方案及预后。方法 2007年10月至2017年6月,行低温等离子消融手术的OSAHS患儿3 106例,均在全麻下行腺样体等离子消融术,伴或不伴扁桃体切除术。统计3 106例患儿中术后出血、发热、腭咽弓穿孔、鼻腔反流等并发症的患者数量,分析原因。结果 3 106例中术后出血76例(2.44%),再次全麻手术止血12例,手术止血后送PICU,原因为失血过多行输血治疗1例,止血术前麻醉时出现呕吐物窒息并抢救1例;术后1周内出现体温超过38.5 ℃的患儿44例,经对症处理后体温正常。术后患儿出现腭咽弓穿孔5例,因患者无症状未做特殊处理,穿孔自行愈合3例。腭瘘患者术后出现进食时鼻腔反流1例,经保守治疗后愈合。结论 儿童OSAHS低温等离子消融术后并发症发生率较低,但如果处理不恰当可造成严重后果,甚至可危及患儿生命。临床上应注意预防并发症发生,妥善处理,尽量减轻并发症给患者带来的伤害。
关键词睡眠呼吸暂停, 阻塞性    低温等离子消融术    并发症    儿童    
Analysis of coblation complications in children with obstructive sleep apnea-hypopnea syndrome
QIU Shuyao, LIU Dabo, ZHONG Jianwen, YANG Liqiang     
Department of Pediatric Otolaryngology, Shenzhen Hospital, Southern Medical University, Shenzhen 518100, Guangdong, China
Abstract: Objective To explore the causes of complications after low-temperature coblation surgery in children with obstructive sleep apnea-hypopnea syndrome (OSAHS), and to summarize the treatment and outcome of these complications. Methods The subjects were 3 106 patients with OSAHS who underwent low-temperature coblation adenoidectomy with or without tonsillectomy under general anesthesia in our department, between October 2007 and June 2017. We counted the number of patients with postoperative complications including postoperative bleeding, fever, perforation of palatopharyngeal arch, and nasal reflux, and analyzed the causes of complications. Results The postoperative bleeding rate was 2.44% (76/3 106). Twelve patients underwent reoperation for hemostasis under general anesthesia, 2 patients were sent to the pediatric intensive care unit, 1 required transfusion because of excessive blood loss, and another experienced choking during anesthesia. Forty-four patients showed fever in the week after the operation, with body temperatures higher than 38.5 ℃, but the temperatures were reduced to normal after symptomatic treatment. Pharyngopalatine arch perforation occurred in 5 cases, of which 3 were self-healing. One patient experienced nasal cavity reflux when eating because of a palatine fistula after the operation; this patient was healed after conservative treatment. Conclusion The complication rate for low-temperature coblation surgery is low in children with OSAHS, but if not handled properly, complications can cause serious, and even life-threatening, consequences. Therefore, we should try to prevent complications, to deal with them in a timely manner, and to minimize the damage they cause.
Key words: Sleep apnea, obstructive    Coblation    Complication    Children    

低温等离子技术近年来广泛应用于儿童阻塞性睡眠呼吸暂停低通气综合征(obstructive sleep apnea hypopnea syndrome, OSAHS)手术中,该系统工作界面温度为40 ℃ ~70 ℃,手术时间短,患者术中出血少、术后疼痛轻,然而国内外目前关于手术后并发症的方面的研究并不多[1-3]。我科自2007年开展儿童OSAHS低温等离子手术,有关其术后并发症的情况也进行过一些初步统计和研究报道[4]。2007年10月至2017年6月,在我科行OSAHS低温等离子消融术的患儿共3 106例,现将术后并发症进行统计分析的结果报告如下。

1 资料与方法 1.1 一般资料

3 106例中男1 862例(59.95%),女1244例(40.05%); 1~14岁,平均(5.7±2.1)岁。所有患儿手术前均行整夜多导睡眠监测(polysomnography, PSG)确诊,诊断标准为呼吸暂停低通气指数(apneahypopneaindex, AHI)≥5次/h或阻塞性呼吸暂停指数(obstructive apnea index, OAI)≥1次/h且最低血氧饱和度(the lowest of oxygen Saturation, LSaO2)<92%[5]。本组患儿AHI范围(3.6, 78.2),中位数(25分位数,75分位数)为15.6(8.5, 25.4)、OAI范围(0.6, 28.4), 中位数(25分位数,75分位数)为5.2(2.4, 8.6), 夜间LSaO2 54%。住院后完善相关术前检查,包括血常规、肝肾功能、凝血功能、胸片、心电图等,所有患儿均无明确手术禁忌证。

1.2 手术方法

气管插管全麻后患儿取仰卧位,将低温等离子手术系统(Arthrocare Ⅱ型,美国)主机Coblate设置为7档,Coag设置为5档,采用EVac70刀头(美国)或一体化等离子射频刀(EVacXtraHP型,美国),先用导尿管拉起软腭,间接喉镜或鼻内窥镜下消融增生的腺样体,然后沿扁桃体被膜完整切除双侧扁桃体。术后根据患者情况采取抗感染治疗、补充电解质,康复新漱口。3 106例接受手术的患儿,其中单纯腺样体消融术1 864例,扁桃体联合腺样体消融术1 242例。

2 结果 2.1 术后出血

术后出血的患者76例(2.44%),所有患儿均为扁桃体术后创面出血,未见有腺样体创面术后出血的病例。25例(0.8%)为唾液伴新鲜血丝,其中51例(1.64%)患者术后出血伴呕吐,再次入院观察,12例患者再次全麻手术止血,2例患者术后送PICU监护,其中1例因失血过多行输血治疗,另1例止血术前麻醉时出现呕吐物窒息并抢救,所有患儿均顺利出院。

2.2 术后发热

术后1周内出现体温超过38.5 ℃的患儿44例,其中扁桃体联合腺样体消融术后34例,单纯腺样体消融术后10例,口服布洛芬后均可退热。所有患儿术前白细胞计数均在正常范围,发热患儿中40例行血常规复查,其中28例白细胞高于正常,中性粒占比超过70%的患儿26例,12例白细胞总数不高的患儿有7例流感病毒检测为阳性,2例手足口病毒检测结果为阳性。3例患者术后复查胸片,2例为支气管炎,1例确诊为肺炎。

2.3 术后腭咽弓穿孔或腭瘘

扁桃体联合腺样体消融术后患儿5例,出现腭咽弓组织缺损致穿孔(如图 1),穿孔最大径0.3~0.6 cm。因患者无症状未做特殊处理,3例患儿穿孔2个月内自行愈合。扁桃体联合腺样体消融术后出现腭瘘1例,患者术后出现进食时鼻腔反流,经保守治疗后愈合(如图 2图 3)。

图 1 腭咽弓穿孔 Figure 1 Palatopharyngeal arch perforation
图 2 腭瘘 Figure 2 Palatine fistula
图 3 腭瘘愈合 Figure 3 Palatine fistula healed
3 讨论

术后出血是儿童阻塞性睡眠呼吸暂停低通气综合征低温等离子术后比较常见的并发症,大样本研究(1 700例)发现,低温等离子手术的初学者发生迟发性出血率比有经验的术者高,等离子手术操作少于50例的术者,迟发性出血率在3%左右,随着手术例数的增加,迟发性出血率逐渐下降,手术操作多于250例的术者,迟发性出血率下降到1%[6-8], 这与我们报道的结果基本相符。术后出血通常是术后扁桃体窝出血,如处理不及时可出现出血性休克、窒息,严重者可危及患儿生命。术后出血可分为原发性出血和继发性出血。原发性出血是指手术结束后24 h之内发生的出血,多发生于术后6 h之内。扁桃体术后出血可能与患者扁桃体反复发炎导致被膜分界不清、术中遗留扁桃体残体、术后剧烈咳嗽或肾上腺素后作用相关。原发性出血一旦出现需要立即使用止血药并加强补液,如不能及时止血应尽快行全麻手术止血。继发性出血是指手术后24 h之后出现的出血,多见于术后7~10 d。我科曾对低温扁桃体术后继发性出血患者进行统计,发现扁桃体术后出血与术者经验、扁桃体炎反复发作、术后进食不当或剧烈运动相关[9-10]。术后出现继发性出血的患者应再次收入院治疗,立即复查血常规,冰盐水漱口,静脉用止血药物,并加强补液对症治疗。经初步处理后仍有活动性出血的患者,需要全麻手术止血。手术止血时要严防出血窒息,我科曾遇到1例患者麻醉诱导时因胃内血性分泌物反流导致窒息,紧急插管抢救成功后送监护室,所以麻醉前一定要准备好负压吸引并做好抢救准备。

术后发热也是比较常见的并发症,通常认为术后3 d内38.5 ℃以下的低热多与术后反应相关,可予冰敷,进食情况不佳的患者可补液对症处理[11]。如出现38.5 ℃以上的发热要注意有无出现创面感染或其他部位感染,创面感染的患者通常咽痛比较剧烈,检查时可发现扁桃体窝白膜较厚,表面污秽,颜色灰黄,咽部黏膜水肿明显。术后反复发热的患者应行血常规检查,如提示细菌感染应使用抗生素加强抗感染治疗,并加强漱口,必要时可行血培养,如合并有咳嗽、痰多症状可行胸片检查。反复高热的患者还应排除流感或手足口病的可能,对可疑的患者可行咽拭子进行病毒检测,如确诊相关疾病,应做好隔离,必要时转传染科诊治。

术后腭咽弓穿孔或腭瘘临床上偶有见到,穿孔最大径一般为0.3~0.6 cm,通常认为与等离子刀的热辐射有关。腭咽弓穿孔的发生常继发于扁桃体术后,术中扁桃体被膜边界不清晰,尤其是反复扁桃体炎的患者,瘢痕粘连较重,术中等离子刀损伤腭咽弓的肌肉和黏膜导致穿孔的发生。腭咽弓穿孔患者多数无不适症状,可不做特殊处理,部分患者可自行愈合。腭瘘发生率极低,通常认为与腺样体消融术有关,推测原因可能与腺样体严重堵塞后鼻孔造成手术标志不清或术中出血多,视野受影响相关,也有文献报道可能与术中等离子刀的热辐射导致血管闭塞引起组织缺血坏死有关[12]。我科曾报道1例术后腭瘘的患儿,出院后出现进食时鼻腔反流,予重组牛生长因子凝胶涂抹穿孔周围组织,术后5个月患儿腭瘘愈合,症状消失[13]。如果患者腭瘘长时间不愈合而且伴有反流症状则需要行腭瘘修补术,手术宜在腭瘘发生6个月后进行[14]

综上所述,儿童阻塞性睡眠呼吸暂停低通气综合征低温等离子消融术后并发症的发生率较低,但如果处理不恰当可危及患儿生命。临床上应注意预防并发症的发生,一旦出现,应及时处理,尽量减少并发症给患儿带来的伤害。

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