脉搏指示连续心排血量法测定婴幼儿心内直视围手术期血流动力学变化的临床意义

Clinical significance of pulse indicator continuous cardiac output in pediatric patients undergoing open-heart surgery

目的临床应用脉搏指示连续心排血量法(PiCCO),初步研究和探索婴幼儿三种常见先天性心脏病(简称先心病)[室间隔缺损(VSD)、室间隔缺损合并肺动脉高压(PH)、法洛四联症(TOF)]患者围手术期心排血量、血管内容量、血管外肺水、肺血管通透性等血流动力学参数,为进一步提高危重先心病的手术成功率提供更为客观、直接的依据。方法前瞻性连续选取浙江大学附属儿童医院2010年8月至2011年6月经体外循环心内直视根治手术的0～3岁先心病患儿30例为研究对象。其中TOF10例,VSD10例,VSD+PH10例。连续测定和记录所有患儿术后0h、4h、8h、12h、24h、48h、72h的血流动力学变化,包括心指数(CI)、全心舒张末期容积指数(GEDVI)、血管外肺水指数(EVLWI)、肺血管通透性指数(PVPI)等。抽血检测术前、术后4h、24h、48h、72h的血浆CK-MB活性、CK-MB质量、肌钙蛋白水平,同时监测和记录左心房压(LAP)、中心静脉压(CVP)、平均肺动脉压(mPAP)、肺血管阻力指数(PVRI)、血管活性药评分、血乳酸和PaO2/FiO2。结果 (1)30例患儿中男18例,女12例,VSD、VSD+PH、TOF患者各10例,均顺利出院。(2)三组患者围手术期CK-MB活性、CK-MB质量、肌钙蛋白均于CPB术后4h达到最高值,后逐渐下降恢复。(3)三组患者术后8～12hCI相对最低,但与术后0h比较无统计学差异,VSD+PH组和TOF组术后48hCI值均较术后0h显著上升(P<0.05)。TOF组患者在术后各时点的CI均低于VSD组(P<0.05)和VSD+PH组(P<0.05)。(4)所有3组患者术后各时点的mPAP和PVRI与术前比较均无统计学差异;组间比较显示VSD+PH组患者术前和术后的mPAP和PVRI均显著高于VSD组和TOF组同时点的水平(P<0.05)。(5)TOF组、VSD+PH组患者术后早期GEDVI均显著低于VSD组(P<0.05)。与术后0h相比,VSD组患者术后12h的GEDVI显著增加恢复(P<0.05),TOF组术后24h的GEDVI开始显著增加(P<0.05),VSD+PH组患者GEDVI于术后48h显著增加恢复(P<0.05)。(6)组间比较显示术后48h时,VSD+PH组EVLWI显著高于TOF组(P<0.05),而TOF组EVLWI显著高于VSD组(P<0.05);VSD组术后24h和48h的PVPI显著低于VSD+PH组和TOF组(P<0.05)。结论微创的PiCCO法揭示了三种先心病心内直视根治术后的详细的血流动力学特征,包括CI、GEDVI、EVLW、SVRI、PVRI等参数,具有指导临床正确判断和有效治疗的意义。

Objective To evaluate the clinical significance of PiCCO in pediatric patients with three different types of congenital heart disease[tetralogy of Fallot(TOF),ventricular septal defect(VSD),VSD+pulmonary hypertension(PH)]after open-heart surgery.Methods From August 2010 to June 2011,30 patients of 0-3 years old who underwent open-heart surgery were prospectively included in this study.There were 10 cases with tetralogy of Fallot,10 cases with VSD and pulmonary hypertension,and 10 cases with VSD without pulmonary hypertension.PiCCO analyzer continuously measured hemodynamic data on 0 h,4 h,8 h,12 h,24 h,48 h,72 h after operation,including cardiac index(CI),global end-diastolic volume index(GEDVI),extra vascular lung water index(EVLWI)etc;LAP,CVP,PAP,PVRI,inotropic score,plasma lactate levels and PaO2/FiO2 were also measured and recorded;Plasma CK-MB activity,CK-MB mass,troponin were tested before surgery,and on 4 h,24 h,48 h,72 h after surgery.Results(1)There were 10 patients each in VSD,VSD+PH and TOF group.(2)At the time of 4 h after surgery,the CK-MB activity,CK-MB mass,troponin levels get the highest value,and than gradually reduced.(3)The cardiac index in all patients decreased significantly to the lowest nadir on 8-12 h after surgery,but not significant compare to 0 h postoperative.CI in VSD+PH and TOF group was significantly improved on 48 h after surgery compare to 0 h postoperative.The CI of TOF group was significantly lower than the VSD and the VSD+PH group at all the time postoperative.(4)VSD+PH group of patients had significantly higher mPAP and PVRI than that of VSD and TOF group,while the mPAP and PVRI of TOF group showed no significant difference with the VSD group.(5)GEDVI was significantly lower in TOF and VSD+PH group than VSD group during the early postoperative period.(6)The EVLWI was significantly higher in VSD+PH group than TOF group at 48 h after surgery,whereas it was significantly higher in TOF group than VSD group.Conclusions The use of PiCCO in pediatric patients after openheart surgery in this study reveal a continuous detailed data such as CI,GEDVI,EVLW,SVRI and PVRI,which were not clear in 3 different types of congenital hearty diseases to guide accurate diagnose and treatment.