压力记录分析指标预测婴幼儿肝移植术中心肌损伤的准确性

Accuracy of PRAM in predicting myocardial injury during pediatric liver transplantation in infants

目的评价压力记录分析(PRAM)指标预测婴幼儿肝移植术中心肌损伤的准确性。方法选取2019年1月至2019年12月本院亲体肝移植术婴幼儿115例,使用PRAM/Mostcare监测设备连续监测血流动力学指标。记录供肝冷缺血时间、手术时间、无肝期时间、术中输液量、出血量、红细胞和新鲜冰冻血浆用量、血管活性药使用情况。于手术开始(T_0)、无肝期30 min(T_1)、门静脉开放后即刻(T_2)、新肝期60 min(T_3)和术毕(T_4)时记录HR、MAP、CI、外周血管阻力指数(SVRI)、等容收缩期心室内压力最大上升速率(dp/dtmax)、心动周期效率(CCE)以及手术开始后单位时间(每小时)内各指标最大变化值(△maxMAP、△maxHR、△max CI、△max SRVI、△max dp/dtmax、△maxCCE)。以术毕血清cT_nI浓度≥0.04μg/L作为心肌损伤的诊断标准,将患儿分为心肌损伤组及无心肌损伤组。采用多因素logistic回归分析,评估各指标与心肌损伤的关系,采用受试者工作特征(ROC)曲线计算各指标预测术中心肌损伤的准确性。结果心肌损伤组32例,无心肌损伤组83例,心肌损伤发生率27.8%。与无心肌损伤组比较,心肌损伤组无肝期时间延长,术中输液量增多,血管活性药使用率升高,T_1时HR和SVRI升高,CCE降低,T_2时dp/dtmax降低,△maxMAP、△maxCI、△maxdpt/dtmax和△maxCCE升高(P<0.05)。多因素logistic回归分析结果显示,dp/dtmax、△maxdp/dtmax、CCE、△maxCCE与心肌损伤有关(P<0.01)。CCE预测术中心肌损伤的ROC曲线下面积为0.73,最佳临界值为-0.80,灵敏度0.70,特异度0.64。结论PRAM可以用于婴幼儿肝移植术中血流动力学监测,其监测的CCE(无肝期30 min时)预测术中心肌损伤的准确性较高。

Objective To evaluate the accuracy of pressure recording analytical method(PRAM)in predicting myocardial injury during pediatric liver transplantation in infants.Methods One hundred and fifteen infants who underwent autologous liver transplantation from January 2019 to December 2019 in T_ianjin First Central Hospital were collected.T_he PRAM/Mostcare monitoring equipment was used to monitor the hemodynamic parameters.T_he cold ischemic time of the donor liver,operation time,anhepatic period,the amount of intraoperative fluid infused,amount of bleeding,amount of red blood cells and fresh frozen plasma,and use of vasoactive drugs were recorded.Heart rate(HR),mean arterial pressure(MAP),cardiac index(CI),peripheral vascular resistance index(SVRI),the maximum rate of increase in ventricular pressure(dp/dtmax)during the isovolumic contraction period,cardiac cycle efficiency(CCE),and the maximum change value of each index(△maxMAP,△maxHR,△max CI,△max SRVI,△max dp/dtmax,△maxCCE)per unit time(per hour)were recorded at the start of surgery(T_0),at 30 min of anhepatic phase(T_1),immediately after portal vein opening(T_2),60 min of neohepatic phase(T_3),and at the end of operation(T_4).T_he serum troponin I(cT_nI)concentration≥0.04μg/L at the end of operation was concidered as the diagnostic criteria for myocardial injury,and the pediatric patients were divided into myocardial injury group and non-myocardial injury group.Multivariate logistic regression analysis was used to evaluate the relationship between each index and myocardial injury.T_he receiver operating characteristic curve(ROC)was used to calculate the accuracy of each index in predicting introperative myocardial injury.Results T_here were 32 cases in myocardial injury group and 83 cases in non-myocardial injury group,and the incidence of myocardial injury was 27.8%.Compared with non-myocardial injury group,the anhepatic phase was significantly prolonged,the amount of intraoperative fluid infused was increased,and the requirement for vasoactive drugs was increased,HR and SVRI were and CCE was decreased at T_1,and dp/dtmax was decreased and△maxMAP,△maxCI,△maxdpt/dtmax and△maxCCE were increased at T_2 in myocardial injury group.T_he results of multivariate logistic regression analysis showed that dp/dtmax,△maxdp/dtmax,CCE,and△maxCCE were associated with myocardial injury(P<0.01).T_he area under the ROC curve of CCE in predicting intraoperative myocardial injury was 0.73,the optimal cutoff value was-0.80,sensitivity 0.70,and specificity 0.64.Conclusion PRAM can be used to monitor hemodynamics during liver transplantation in infants,and the CCE monitored(at 30 min of anhepatic phase)produces higher accuracy in predicting intraoperative myocardial injury.