胫前动脉穿刺可行性及心肺流转下胫前动脉与桡动脉压力监测的一致性研究

Feasilility of tibial artery puncture and consistency between radial artery blood pressure and tibial artery blood pressures in patients undergoing cardiopulmonary bypass

目的实践并分析胫前动脉穿刺的可行性,评价心肺转流（CPB）下胫前动脉（TA）穿刺与桡动脉（RA）穿刺监测动脉血压的一致性。方法选择2014年6-8月于南京医科大学附属南京医院择期在CPB下行单纯瓣膜置换术患者12例。所有患者入室均行穿刺RA和TA两处同时测压,麻醉诱导相同,术中麻醉维持均采用静吸复合麻醉。同步监测RA和TA血压,记录收缩压（SBP）、舒张压（DBP）、平均动脉压（MAP）,采集麻醉诱导前（T1）,诱导插管后2 min（T2）,诱导插管后5 min（T3）,静脉推注去氧肾上腺素50μg提升血压后1 min（T4）、3 min（T5）,给予去氧肾上腺素100μg升血压后1 min（T6）、3 min（T7）;在CPB开始后每5分钟记录1次共10次分别为（T8-17）,共计17个时点动脉血压数据对。两种方法的一致性分析采用Bland-Altman一致性检验。结果最后有效病例为10例。SBP数据70对测量值,桡动脉的收缩压（SBPra）测量值平均为（121.8±20.1）mm Hg,胫前动脉收缩压（SBPta）值平均为（134.9±22.7）mm Hg;平均偏差为-13.1 mm Hg,95%的一致性界限为-44.9-18.7 mm Hg。DBP数据70对测量值,桡动脉的舒张压（DBPra）值平均为（62.1±12.6）mm Hg,胫前动脉舒张压（DBPta）值平均为（60.8±12.7）mm Hg;平均偏差为1.3 mm Hg,95%的一致性界限为-3.5-6.0 mm Hg。MAP数据70对测量值,桡动脉的MAP（MAPra）值平均为（82.3±13.4）mm Hg,胫前动脉MAP（MAPta）值平均为（82.2±13.1）mm Hg;平均偏差为0.04 mm Hg,95%的一致性界限为-5.7-5.8 mm Hg。体外循环期间MAP（MAP-CPB）数据100对测量值,体外循环期间的基于桡动脉的MAP（MAP-CPBra）值平均为（61.1±11.1）mm Hg,体外循环期间的基于胫前动脉的MAP（MAP-CPBta）值平均为（60.4±11.4）mm Hg;平均偏差为0.68 mm Hg,95%的一致性界限为-8.8-10.2 mm Hg。两种方法同步采集的数据百分误差：CPB前SBP为24.8%、DBP为7.8%、MAP为7.0%,CPB期间MAP为15.5%。结论胫前动脉与桡动脉监测动脉血压有较好的一致性,在临床上尤其在CPB期间可以部分替代桡动脉观察血流动力学指标。

Objective To analyze and practice the feasibility of the tibial artery puncture, and determine the consistency of the tibial artery（TA） blood pressures and the radial artery（RA） blood pressure in patients undergoing cardiopulmonary bypass（CPB）. Methods From June to August 2014, in Nanjing Hospital Affiliated to Nanjing Medical University, 12 patients scheduled for valve replacement requiring CPB were selected. Catheters were placed in both the TA and RA at the same time for each patient, intravenous compound anesthesia was used for inducting and maintaining anesthesia, systolicarterial blood pressure（SBP）, and diastolic arterial blood pressure（DBP）, mean arterial blood pressure（MAP） were recorded. Two states of blood pressure were monitored at before anesthesia（T1）, 2 min（T2）, 5 min（T3）after intubation of anesthesia, 1 min（T4）, 3 min（T5） after administration of 50 μg phenylephrine, 1 min（T6）, 3 min（T7）after administration of 100 μg phenylephrine, a series of 10 paired BP measurements（RA and TA） were recorded every5 minutes after initiation of CPB（T8-17）, a total of 17 points of arterial blood pressure data were collected. All the data were compared by Bland-Altman analysis. Results At last, the effective cases were 10. 70 pairs of SBP values were compared, SBPramean was（121.8±20.1） mm Hg, SBPtamean was（134.9±22.7） mm Hg; mean bias was-13.1 mm Hg, and limit of agreement-44.9-18.7 mm Hg. 70 pairs of DBP values were compared： DBPramean was（62.1±12.6） mm Hg, DBPtamean was（60.8 ±12.7） mm Hg;mean bias was 1.3 mm Hg, and limit of agreement-3.5-6.0 mm Hg. 70 pairs of MAP values were compared： MAPramean was（82.3±13.4） mm Hg, MAPtamean was（82.2± 13.1） mm Hg; mean bias was 0.04 mm Hg, and limit of agreement-5.7-5.8 mm Hg.100 pairs of MAP-CPB values during CPB were compared： MAP-CPBramean was（61.1 ±11.1） mm Hg, MAP-CPBta mean was（60.4±11.4） mm Hg; mean bias was 0.68 mm Hg, and limit of agreement-8.8-10.2 mm Hg. Percent error of data from the two methods of synchronization： before CPB, SBP was 24.8%, DBP was 7.8%, MAP was 7.0%; during CPB, MAP was 15.5%. Conclusion The tibial artery blood pressures has well consistency with the radial artery blood pressures in patients undergoing CPB, In clinic, especially during CPB it can partly replace radial artery to observe hemodynamic indexes.