Servet ERGÜN, Okan YILDIZ, Erkut ÖZTÜRK, Alper GÜZELTAŞ, Sertaç HAYDIN, İbrahim Cansaran TANIDIR, Bekir YÜKÇÜ

Doğuştan kalp defektli hastalarda ameliyat sonrası ultrasonografi ile diyafram fonksiyonunun değerlendirilmesi

Amaç: Bu çalışmada doğuştan kalp defektli hastalarda ultrasonografinin ameliyat sonrası diyafram fonksiyonunun değerlendirilmesindeki rolü araştırıldı. Çalışma planı: Bu prospektif çalışmaya Eylül 2018 - Mart 2019 tarihleri arasında doğuştan kalp cerrahisi yapılan toplam 360 hasta (176 erkek, 184 kadın; ort. yaş 2 yıl; dağılım, 1 ay-8 yıl) ve diyafram ultrasonografisi yapılan 44 hasta (22 erkek, 22 kadın; ort. yaş 1 yıl; dağılım, 1 ay-4 yıl) alındı. Mekanik ventilatörden ayrılmada zorluk yaşayan veya ameliyat sonrası a kciğer grafisinde patolojik bulgulara göre diyafram disfonksiyonu düşünülen hastalara ultrasonografi yapıldı. Bulgular normal, paresis veya paraliz şeklinde yorumlandı. Bulgular: Yirmi üç hastada (%6.3) diyafram disfonksiyonu, 11 hastada (%3) paraliz ve 12 hastada (%3.3) paresis görüldü. Hastaların 21’ine (%91) median sternotomi yapıldı ve bunların yedisi (%30) yeniden ameliyat olgusu idi. Beş hastada (%21) tek ventrikül fizyolojisi vardı. Altı hastaya diyafram disfonksiyonu nedeniyle girişim yapıldı. Girişimsel işlemler üç hastada (%0.8) diyafram plikasyonu ve üç hastada (%0.8) trakeostomi idi. Bunların üçünde tek ventrikül ve üçünde çift ventrikül fizyolojisi vardı. Ameliyat sonrası bu işlemlerin medyan uygulanma zamanı 36 gün idi. Bir hasta (%0.2) yoğun bakım ünitesinde kaybedildi. Ortalama yoğun bakım ünitesi ve hastanede kalış süresi sırasıyla 36±12 ve 48±21 gün idi. Sonuç: Doğuştan kalp cerrahisi yapılan hastalarda ve ameliyat sonrası uzamış entübasyona ihtiyacı olan kişilerde diyafram disfonksiyonu akla getirilmelidir. Ultrasonografi, diyafram disfonksiyonunu saptamada ve klinik durumun en iyi şekilde yönetilmesinde kullanılabilen noninvaziv bir tanı aracıdır.

Ultrasonographic postoperative evaluation of diaphragm function of patients with congenital heart defects

Background: This study aims to investigate the role of ultrasonographyin the postoperative evaluation of diaphragm function in patients withcongenital heart defect.Methods: This prospective study included a total of 360 patients(176 males, 184 females; mean age 2 years; range, 1 month to 8 years)who underwent congenital heart surgery and 44 patients (22 males,22 females; mean age 1 years; range, 1 month to 4 years) who underwentdiaphragm ultrasonography between September 2018 and March 2019.Ultrasonography was performed for the patients who had difficultyin weaning from mechanical ventilation or who were thought to havediaphragm dysfunction due to pathological findings on postoperative chestX-rays. The findings were interpreted as normal, paresis, or paralysis.Results: Diaphragm dysfunction was demonstrated in 23 patients(6.3%), paralysis in 11 patients (3%), and paresis in 12 patients(3.3%). A median sternotomy was performed in 21 patients (91%),and seven of them (30%) were redo cases. Five patients (21%) hadsingle ventricle physiology. Six patients (1.6%) needed an interventiondue to diaphragm dysfunction. The interventional procedures werediaphragm plication in three patients (0.8%) and tracheotomy in threepatients (0.8%). Three of these patients had a single ventricle and threehad biventricular physiology. The median time after surgery for theseprocedures was 36 days. One patient (0.2%) died in the intensive careunit. The mean length of stay in the intensive care unit and hospital was36±12 and 48±21 days, respectively.Conclusion: Diaphragm dysfunction should be kept in mind inpatients undergoing congenital heart surgery and in those whoneed prolonged intubation during the postoperative period.Ultrasonography is a non-invasive diagnostic tool which can be usedto identify diaphragm dysfunction and the best course of managementof this clinical condition.

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1. Qureshi A. Diaphragm paralysis. Semin Respir Crit Care Med 2009;30:315-20.
2. Hamadah HK, Kabbani MS, Elbarbary M, Hijazi O, Shaath G, Ismail S, et al. Ultrasound for diaphragmatic dysfunction in postoperative cardiac children. Cardiol Young 2017;27:452-8.
3. Baker CJ, Boulom V, Reemtsen BL, Rollins RC, Starnes VA, Wells WJ. Hemidiaphragm plication after repair of congenital heart defects in children: quantitative return of diaphragm function over time. J Thorac Cardiovasc Surg 2008;135:56-61.
4. Gil-Juanmiquel L, Gratacós M, Castilla-Fernández Y, Piqueras J, Baust T, Raguer N, et al. Bedside ultrasound for the diagnosis of abnormal diaphragmatic motion in children after heart surgery. Pediatr Crit Care Med 2017;18:159-64.
5. Sanchez de Toledo J, Munoz R, Landsittel D, Shiderly D, Yoshida M, Komarlu R, et al. Diagnosis of abnormal diaphragm motion after cardiothoracic surgery: ultrasound performed by a cardiac intensivist vs. fluoroscopy. Congenit Heart Dis 2010;5:565-72.
6. Srinivasan S, Cornell TT. Bedside ultrasound in pediatric critical care: a review. Pediatr Crit Care Med 2011;12:667-74.
7. Jenkins KJ, Gauvreau K, Newburger JW, Spray TL, Moller JH, Iezzoni LI. Consensus-based method for risk adjustment for surgery for congenital heart disease. J Thorac Cardiovasc Surg 2002;123:110-8.
8. Lacour-Gayet F, Clarke D, Jacobs J, Comas J, Daebritz S, Daenen W, et al. The Aristotle score: a complexity-adjusted method to evaluate surgical results. Eur J Cardiothorac Surg 2004;25:911-24.
9. Lemmer J, Stiller B, Heise G, Hübler M, Alexi-Meskishvili V, Weng Y, et al. Postoperative phrenic nerve palsy: early clinical implications and management. Intensive Care Med 2006;32:1227-33.
10. Joho-Arreola AL, Bauersfeld U, Stauffer UG, Baenziger O, Bernet V. Incidence and treatment of diaphragmatic paralysis after cardiac surgery in children. Eur J Cardiothorac Surg 2005;27:53-7.
11. Akbariasbagh P, Mirzaghayan MR, Akbariasbagh N, Shariat M, Ebrahim B. Risk factors for post-cardiac surgery diaphragmatic paralysis in children with congenital heart disease. J Tehran Heart Cent 2015;10:134-9.
12. Akay TH, Ozkan S, Gultekin B, Uguz E, Varan B, Sezgin A, et al. Diaphragmatic paralysis after cardiac surgery in children: incidence, prognosis and surgical management. Pediatr Surg Int 2006;22:341-6.
13. Miller SG, Brook MM, Tacy TA. Reliability of twodimensional echocardiography in the assessment of clinically significant abnormal hemidiaphragm motion in pediatric cardiothoracic patients: Comparison with fluoroscopy. Pediatr Crit Care Med 2006;7:441-4.
14. Epelman M, Navarro OM, Daneman A, Miller SF. M-mode sonography of diaphragmatic motion: description of technique and experience in 278 pediatric patients. Pediatr Radiol 2005;35:661-7.
15. Gerard-Castaing N, Perrin T, Ohlmann C, Mainguy C, Coutier L, Buchs C, et al. Diaphragmatic paralysis in young children: A literature review. Pediatr Pulmonol 2019;54:1367-73.
16. Bhaskar P, Lone RA, Sallehuddin A, John J, Bhat AN, Rahmath MR. Bilateral diaphragmatic palsy after congenital heart surgery: management options. Cardiol Young 2016;26:927-30.
17. Georgiev S, Konstantinov G, Latcheva A, Mitev P, Mitev I, Lazarov S. Phrenic nerve injury after paediatric heart surgery: is aggressive plication of the diaphragm beneficial? Eur J Cardiothorac Surg 2013;44:808-12.
18. Talwar S, Agarwala S, Mittal CM, Choudhary SK, Airan B. Diaphragmatic palsy after cardiac surgical procedures in patients with congenital heart. Ann Pediatr Cardiol 2010;3:50-7.