体外循环中二氧化碳衍生参数与婴幼儿心脏术后急性肾损伤的相关性

Correlation of carbon dioxide derived parameters during cardiopulmonary bypass with acute kidney injury after pediatric cardiac surgery

目的探讨体外循环(CPB)中静脉-动脉二氧化碳分压差(Pv-aCO_(2))与动静脉氧含量差(Ca-vO_(2))的比值(Pv-aCO_(2)/Ca-vO_(2))及Pv-aCO_(2)与婴幼儿心脏术后急性肾损伤(AKI)的相关性。方法回顾性分析2021年3月至2022年8月在四川大学华西医院接受CPB下心内直视手术的1个月~3岁患儿的临床资料。收集患儿CPB期间的所有成对血气(动静脉血采样时间间隔在10 min之内)。根据改良儿童肾脏疾病风险分级(pRIFLE)诊断标准,将患儿分为AKI组和非AKI组,采用多因素logistic回归模型分析婴幼儿心脏术后发生AKI的危险因素。结果共纳入213例患儿,男101例,女112例,年龄[M(Q_(1),Q_(3))]12(6,24)个月,其中84例(39.4%)心脏术后发生AKI。AKI组中3例(3.6%)患儿死亡,非AKI组无死亡病例。与非AKI组比较,AKI组患儿术后低心排血量综合征(LCOS)发生率更高[29.8%(25/84)比7.0%(9/129),P<0.001],且苏醒时间[15(6,78)比6(3,19)h,P<0.001]、机械通气时间[17(7,97)比6(4,20)h,P<0.001]、重症监护病房(ICU)停留时间[6(4,11)比3(2,5)d,P<0.001]及住院时间[12(9,18)比9(8,11)d,P<0.001]均更长。共分析317对动静脉血气:主动脉阻断后30 min 207对、60 min 75对和90 min 35对。单因素logistic分析结果显示,与非AKI组患儿相比,AKI组患儿主动脉阻断30 min Pv-aCO_(2)/Ca-vO_(2)(P=0.015)、主动脉阻断60 min Pv-aCO_(2)(P=0.041)和Pv-aCO_(2)/Ca-vO_(2)(P=0.014)、Pv-aCO_(2)峰值(P=0.009)、Pv-aCO_(2)/Ca-vO_(2)峰值(P<0.001)及Pv-aCO_(2)/Ca-vO_(2)平均值(P=0.001)均更高。多因素logistic回归分析结果显示,CPB时间长(OR=1.013,95%CI:1.003~1.023,P=0.012)、Pv-aCO_(2)/Ca-vO_(2)峰值高(OR=1.337,95%CI:1.037~1.723,P=0.025)是婴幼儿心脏术后发生AKI的危险因素。结论婴幼儿心脏术后AKI的发生与近期不良临床预后相关,CPB时间长及CPB中Pv-aCO_(2)/Ca-vO_(2)峰值高是心脏术后AKI的危险因素。

Objective To explore the correlation of the ratio of venous-arterial carbon dioxide(CO 2)tension difference to arterial-venous O 2 content difference(Pv-aCO_(2)/Ca-vO_(2))and venous-arterial CO 2 gradient(Pv-aCO_(2))during cardiopulmonary bypass(CPB)with acute kidney injury(AKI)after pediatric cardiac surgery.Methods The clinical data of children(1 month≤age≤3 years old)who underwent open heart surgery under CPB in West China Hospital of Sichuan University from March 2021 to August 2022 were retrospectively analyzed.All paired blood gases of the children during CPB(the sampling time interval of arterial and venous blood was within 10 minutes)were collected.According to the Failure,Loss,End-Stage Renal Disease(pRIFLE)diagnostic criteria,the children were divided into AKI group and non-AKI group.Multivariate logistic regression analysis was performed to identify the risk factors of postoperative AKI in pediatric cardiac surgery.Results A total of 213 children were enrolled(101 males and 112 females),aged 12(6,24)months,and 84 of them(39.4%)developed AKI.Three children died in AKI group,with a mortality of 3.6%.There were no deaths in non-AKI group.The incidence of postoperative low cardiac output syndrome(LCOS)was higher in AKI group[29.8%(25/84)vs 7.0%(9/129),P<0.001].In addition,compared with the non-AKI group,children in AKI group had longer recovery time[15(6,78)h vs 6(3,19)h,P<0.001],mechanical ventilation time[17(7,97)h vs 6(4,20)h,P<0.001],intensive care unit(ICU)stay[6(4,11)d vs 3(2,5)d,P<0.001],and hospital stay[12(9,18)d vs 9(8,11)d,P<0.001].A total of 317 arterial and venous blood gas pairs from 30(n=207),60(n=75)and 90 min(n=35)after aortic clamping were included in the analysis.Univariate analysis showed that Pv-aCO_(2)/Ca-vO_(2)(P=0.015)at 30 min after aortic clamping,Pv-aCO_(2)(P=0.041)and Pv-aCO_(2)/Ca-vO_(2)(P=0.014)at 60 min after aortic clamping,peak Pv-aCO_(2)(P=0.009),peak Pv-aCO_(2)/Ca-vO_(2)(P<0.001)and the average value of Pv-aCO_(2)/Ca-vO_(2)(P=0.001)were higher in AKI group.Multivariate logistic regression analysis showed that longer duration of CPB(OR=1.013,95%CI:1.003-1.023,P=0.012),higher peak Pv-aCO_(2)/Ca-vO_(2)(OR=1.337,95%CI:1.037-1.723,P=0.025)were risk factors for AKI.Conclusion The occurrence of AKI after pediatric cardiac surgery is related to the short-term adverse clinical prognosis,and longer duration of CPB and higher peak Pv-aCO_(2)/Ca-vO_(2)are independent risk factors for AKI.