全腔静脉肺动脉连接术后早期延迟恢复的危险因素

Risk factors associated with prolonged recovery after the total cavopulmonary connection

目的 探讨全腔静脉肺动脉连接（TCPC）术后早期延迟恢复的相关危险因素.方法 回顾性分析2013年1月至2014年3月上海儿童医学中心118例TCPC手术患儿的临床资料.剔除8例死亡及2例行TCPC管道拆除术病例,将术后呼吸机辅助时间或者胸腔引流管留置时间排在第75％位点以后的患儿定义为延迟恢复：正常恢复（正常）组65例,男39例,女26例,年龄3.1～4.8岁,中位年龄3.8岁;延迟恢复（延迟）组43例,男24例,女19例,年龄3.2～5.4岁,中位年龄4.0岁.比较正常组与延迟组患儿的一般资料、血流动力学、手术方式和辅助检查等资料.统计108例患儿手术后当天进入ICU至术后第3天凌晨7点所输注的血制品的容量总量,包括5％白蛋白、10％白蛋白、普通冰冻血浆和红细胞悬液,计算容量体质量比,容量体质量比排在第75％位点后的27例患儿纳入高血容量复苏组,其余81例均纳入低血容量复苏组,比较高、低血容量复苏组患儿围手术期资料.结果1 18例患儿手术体外循环47～ 410 min,平均（111.9±46.4） min;104例（88.1％）阻断主动脉下手术,14例（11.9％）平行循环下手术.术后早期死亡8例（6.8％）,均因严重低心排血量综合征继发多器官功能衰竭.延迟组术后中位呼吸机辅助通气时间、ICU滞留时间和胸腔引流管留置时间（24 h、6天和16天）较正常组（8.5h、3天和7天）明显延长.延迟组和正常组围手术期参数进行单因素logistic分析比较发现,导致术后早期延迟恢复的危险因素包括术前肺动脉平均压高（mPAP,P=0.022）,术前存在房室瓣反流（P=0.000）,体外循环时间长（TBT,P=0.044）,术后中心静脉压高（CVP,P=0.000）、谷草转氨酶升高（AST,P=0.001）、谷丙转氨酶升高（ALT,P=0.010）、N末端B型利钠肽原升高（NT-proBNP,P=0.000）、动脉血氧饱和度降低（SaO2,P=0.012）、正性肌力药物评分高（IS,P=0.001）,术后并发心律失常（P =0.000）、低心排血量综合征（P=0.000）、需腹膜透析（P=0.000）以及术后3天内高血容量复苏需求（P=0.000）.但过多因素logistic回归分析发现术后中心静脉压升高（OR1.446,95％CI1.113,1.879）及术后3天内高血容量复苏需求（OR 10.860,95％CI2.681,43.987）是TCPC术后早期延迟恢复的独立危险因素.结论 术后中心静脉压升高和术后3天内高血容量复苏需求是TCPC患儿术后早期延迟恢复的独立危险因素,有效预防及治疗,有助于患儿的尽早恢复.

Objective To study the risk factors of prolonged postoperative recovery after the total cavopulmonary connection（TCPC） in the current era.Methods Data on all patients admitted to the cardiac intensive care unit （CICU） after a TCPC between January 2013 and March 2014 were retrospectively analyzed.We excluded all patients who died and required TCPC takedown.The study cohort was further divided into a prolonged recovery group that included patients with 75% ile for duration of mechanical ventilation or pleural drainage,and a standard recovery group which included all other patients.A multivariable logistic regression model was used to compare demographic,anatomic,and physiological variables between the prolonged and standard recovery groups.Then,the cohort was separated into a high volume resuscitation group and a low volume resuscitation based on the 75% ile for volume resuscitation（ml/kg） administered on the first three days after the TCPC.Results Totally 118 TCPC operations were performed.Of the study population （n =118）,the median age was 3.8 years （3.1 to 4.8 years） and median weight was 14.8 kg（13.3 to 17.1 kg）.The most common diagnosis was double outlet of right ventricle （n =47,39.8%）.The extracardiac conduit fenestrated TCPC was the most common surgery（n =79,66.9%）.Within the study population,43 （39.8%） patients met criteria for prolonged recovery.Univariate risk factors for prolonged recovery included higher preoperative mPAP（P =0.022）,atrioventricular valve regurgitation （P =0.000）,longer total bypass time （P =0.044）,higher postoperative central venous pressure （P =0.000）,AST （P =0.001）,ALT （P =0.010）,NT-proBNP （P =0.000）,SaO2 （P =0.012）,I n-otropic score （P =0.001）,higher incidence of arrhythmia （P =0.000）,low cardiac output syndrome （P =0.000）,need for peritoneal dialysis （P =0.000）,and requirement for greater volume resuscitation during the 72 postoperative hours（75% for the entire group,P =0.000）.In a multivariable Logistic model,need for greater volume resuscitation （OR 10.860,95 % CI 2.681,43.987） and the higher postoperative central venous pressure （OR 1.446,95 % C I 1.113,1.879） were the only two independent risk factors for prolonged outcome after the TCPC.Conclusion The need for high volume expansion and higher central venous pressure were the risk factors of mediate prolonged recovery.