先天性心脏病术后婴儿血管活性药物评分与其预后的相关性研究

Vasoactive-inotropic score and correlation to prognosis in infants after cardiac surgery

目的:对体外循环下先天性心脏病术后围术期婴儿所用的血管活性药物进行评分,探讨其对患者预后结局的影响。方法:回顾性收集53例体外循环下行先天性心脏病手术的6月龄以下婴儿的临床资料,并对术后第1个24 h、第2个24 h血管活性药物评分(vasoactive-inotropic score,VIS)进行统计均值(mean,MEA)和最大值(maximum,MAX)[VIS(24MAX)、VIS(24MEA)、VIS(48MAX)、VIS(48MEA)],采用ROC曲线、t检验及卡方检验对血管活性药物评分和预后结局的相关性进行分析。结果:53例患儿中新生儿6例(6/53,11.32%);除房间隔缺损(atrial septal defect,ASD)、室间隔缺损(ventricular septal defect,VSD)之外复杂性先天性心脏病患儿11例(11/53,20.75%),包括完全性房室间隔缺损(complete atrioventricular septal defect,CAVC)1例、右室双出口(double outlet of right ventricle,DORV)1例、大动脉转位(translocation of great arteries,TGA)6例、肺动脉瓣闭锁(pulmonary valve atresia,PVA)1例、完全性肺静脉异位连接(total anomalous pulmonary venous connection,TAPVC)2例;死亡3例(3/53,5.66%);3种严重病情结局中缺氧缺血性脑损伤5例(5/53,9.43%),心肺复苏5例(5/53,9.43%),血液净化4例(4/53,7.56%);ROC曲线统计显示VIS(24MAX)分别对本组患儿严重病情结局和死亡的预后判断更准确(AUROC=0.938,P=0.000;AUROC=0.943,P=0.010),并计算出VIS(24MAX)对严重病情结局和死亡预测的最佳临界值均为19.5分(J=0.798,J=0.82);同时VIS(24MAXh)组[VIS(24MAX)≥19.5分]患儿的死亡率、严重病情结局比率及乳酸值均明显高于VIS(24MAXl)组[VIS(24MAX)<19.5分]患儿(25%&0%,χ2=6.688,P=0.01;66.67%&2.44%,χ2=22.799,P=0.000;5.68&1.67,t=3.329,P=0.006)且非死亡患儿中VIS(24MAXh)组患儿的机械通气时间和住重症监护室(intensive care unit,ICU)时间均显著高于VIS(24MAXl)组患儿(133.89&38.56,t=4.207,P=0.002;7.67&3.27,t=4.247,P=0.002)。结论:先天性心脏病术后小婴儿血管活性药物评分,尤其是术后第1个24 h内最大血管活性药物评分,对疾病严重程度及预后有较好的预判作用;其值越大,病情越严重,预后越差,死亡率越高。

Objective：To determine the association between vasoactive support and clinical outcome in infants after cardiac surgery.Methods：A retrospective chart review of 53 children （〈6 months of age） undergoing cardiac surgery with bypass was conducted. Vasoactive-inotropic seores（VIS） were calculated during the first 48 postoperative hours,and the maximum （MAX） and mean（MEA） scores in the first and second 24 postoperative hours[VIS（24MAX）,VIS（24MEA）,VIS（48MAX）, VIS （48MEA）] were also recorded. Chi-test,t-test,and ROC curves were performed for the association between VIS and the clinical outcomes. Results ： There were 6 cases of neonates （6/53, 11.32%）, 11 cases of complex congenital heart disease eliminated （atrial septal defect, ASD） and ventricular septal defect （VSD）（ 11/ 53,20.75%） [1 case of complete atrioventricular septal defect（CAVC）, 1 case of double outlet of fight ventricle（DORV）,6 cases of translocation of great arteries （TGA）, 1 case of pulmonary valve atresia （PVA）, 2 cases of total anomalous pulmonary venous connection （TAPVC）], 3 cases of death （3/53,5.66%）. Children who reached poor outcomes included 5 cases of neurologic injury （5/53,9.43 % ）, 5 cases of eardio-pulmonary resuscitation （5/53,9.43%） and 4 cases of hemodialysis （4/53,7.56%）. ROC analysis indicated that the VIS （24MAX） was strongly associated with poor outcomes and death （AUROC =0.938,P=0.000; AUROC =0.943,P=0.010）, and the cutoff points were 19.5 （J=0.798;J=0.82）. Children with high VIS[VIS （24MAX）I〉 19.5] had significantly higher odds of mortality （ 25% ＆ 0%, ）（2=6.688, P=0.O1 ） ,poor outcomes （66.67% ＆ 2.44%, ）（2=22.799, P=0.000）, lactate （ 5.68 ＆ 1.67, t=3.329, P=0.006）, prolonged time to first exudation（ 133.89 ＆ 38.56,t=4.207,P=0.002） and PICU length of stay （7.67 ＆ 3.27,t=4.247,P=0.002） com- pared with children with low VIS[VIS（24MAX）〈19.5]. Conclusion ：Maximum VIS calculated in the first 24 hours[VIS（24MAX）] after PICU admission is strongly and significantly associated with clinical outcomes in infants after cardiac surgery. The higher the VIS,the worse the illness, the poorer the prognosis, the higher the mortality.