先天性心脏病术后脑组织氧饱和度与其预后的相关性分析

Relationship between postoperative cerebral oxygen saturation and clinical outcomes after congenital heart surgery

摘要:

目的：探讨先天性心脏病（congenital heart disease，CHD）患儿术后脑组织氧饱和度（cerebral tissue oxygen saturation，SctO2）与临床预后的相关性。方法：前瞻性队列研究。随机收集2016年12月至2017年10月于我院接受体外循环下CHD矫治术，并于术后转入重症监护室（intensive care unit，ICU）的患儿，共65例。采用美国CAS Medical System公司生产的Fore-sight近红外光谱仪（near-infrared spectroscopy，NIRS）对该65例患儿行术后24 h连续SctO2监测，分析监测期间最低SctO2（nadir of SctO2，nSctO2）、平均SctO2（mean of SctO2，mSctO2）与严重病情结局（adverse outcome，AO：包括低心排综合征、心肺复苏或死亡）、术后第三代24 h小儿死亡危险评分（pediatric risk of mortality Ⅲ，Prism-Ⅲ）、术后24 h最大血管活性药物指数（maximum of va－soactive-inotropic score，VISmax）、机械通气时间及ICU留置时间的相关性。结果：AO组患儿26例（40.00%），非AO组患儿39例（60.00%）；AO组nSctO2、mSctO2较非AO组均明显减低[44.00%（32.00%~47.25%）vs. 56.00%（50.00%~60.00%），P=0.000]、[61.94%（58.95%~65.15%） vs. 70.00%（66.67%~73.76%），P=0.000]。Spearman秩相关分析示nSctO2及mSctO2分别与Prism-Ⅲ评分负相关（rs=-0.653，P=0.000；rs=-0.593，P=0.000）、与VISmax负相关（rs=-0.346，P=0.005；rs=-0.422，P=0.000）、与呼吸机时间负相关（rs=-0.424，P=0.001；rs=-0.519，P=0.000）、与ICU留置时间负相关（rs=-0.407，P=0.000；rs=-0.528，P=0.001）；ROC曲线示nSctO2临界值51.50%对预测AO具有中等准确性（AUROC=0.849，P=0.000），95%CI=0.756~0.942，灵敏度为92.30%，特异度为74.40%。结论：CHD术后24 h内SctO2降低与不良预后有关，SctO2越低，持续时间越长，预后可能更差。nSctO2低于51.50%可能是预后不良的一个危险因素。

Abstract:

Objective：To explore the correlation between postoperative（PO） cerebral oxygen saturation（SctO2） and clinical outcomes in children after congenital heart surgery. Methods：A prospective cohort study was conducted in 65 patients who underwent congen－ital heart surgery with cardiopulmonary bypass and admitted to intensive care unit（ICU） afterwards from December 2016 to October 2017 in our hospital. The PO SctO2 within the first 24 hours was measured consecutively by near-infrared spectroscopy（Fore-sight，P/N01-06-2030C，CASmed，USA）. The nadir of SctO2（nSctO2） and the mean of SctO2 （mSctO2） were analyzed with adverse outcome（AO） （low cardiac output syndrome，cardio-pulmonary resuscitation or death），the pediatric risk of mortality Ⅲ（Prism Ⅲ） score of PO 24 hours，the maximum of vasoactive-inotropic score of PO 24 hours（VISmax），the duration of mechanical ventilation，and length of ICU stay. Results：２６ cases（40.00%） were divided into AO group，while the other 3９ cases（60.00%） were divided into non-AO group. The nSctO2 and mSctO2 were significantly lower in AO group than those in non-AO group [44.00% （32.00% to 47.25%） vs. 56.00%（50.00% to 60.00%），P=0.000；61.94%（58.95% to 65.15%） vs. 70.00%（66.67% to 73.76%），P=0.000]. The nSctO2 and mSctO2 were negatively correlated with the Prism Ⅲ score（rs=-0.653，P=0.000；rs=-0.593，P=0.000），the VISmax（rs=-0.346，P=0.005；rs=-0.422，P=0.000），the duration of mechanical ventilation time（rs=-0.424，P=0.001；rs=-0.519，P=0.000） and the length of ICU（rs=-0.407，P=0.000；rs=-0.528，P=0.001），respectively. ROC analysis indicated a cutoff point of 51.50% of nSctO2 in the first 24 hours to predict AO（AUROC=0.849，P=0.000），95%CI=0.756 to 0.942，with a sensitivity of 92.30% and a specificity of 74.40%. Conclusion：Both the amplitude and duration of SctO2 drop in the PO 24 hours were correlated with the poor clinical outcomes. SctO2 lower than 51.50% in PO 24 h may potentially act as a predictive factor.