发绀型先天性心脏病患儿改良体-肺动脉分流术中局部脑氧饱和度的变化

Changes of regional cerebral oxygen saturation in children with cyanotic congenital heart disease undergoing modified systemic-pulmonary artery shunt

目的探讨发绀型先天性心脏病患儿改良体-肺动脉分流术(MBTS)中局部脑氧饱和度(rScO_(2))的变化特征及相关因素。方法选择2019年1月至2020年12月于首都医科大学附属北京安贞医院择期行MBTS的发绀型先天性心脏病患儿42例。所有患儿术中均连续监测rScO_(2)及血流动力学相关参数,并分别于切皮前(T_(1))、打开心包(T_(2))、阻断术侧肺动脉5 min(T_(3))、人工血管通血3 min(T_(4))、术毕(T_(5))5个时点,记录rScO_(2)、脉搏血氧饱和度(SpO_(2))、呼气末二氧化碳分压(P_(ET)CO_(2))、收缩压、舒张压、心脏指数、脉压变异度等指标,并计算血管活性药物评分(VIS)。结果T_(3)时点rScO_(2)、SpO_(2)、P_(ET)CO_(2)均显著低于其他时点,T_(4)时点rScO_(2)显著高于T_(1)时点[(77±9)%比(75±9)%],T_(5)时点rScO_(2)[(74±8)%]显著低于T_(4)时点(均P<0.05)。T_(4)时点SpO_(2)显著高于T_(1)、T_(2)、T_(5)时点[(92±4)%比(86±6)%、(89±5)%、(88±5)%](均P<0.05)。T_(4)、T_(5)时点P_(ET)CO_(2)显著高于T_(1)、T_(2)时点,T_(3)时点收缩压低于T_(2)、T_(5)时点,T_(4)时点舒张压低于T_(1)、T_(2)、T_(5)时点,T_(4)时点心脏指数低于T_(1)、T_(2)时点,T_(5)时点脉压变异度低于其他各时点(均P<0.05)。VIS在T_(3)时点显著高于其他各时点(均P<0.05),在T_(4)、T_(5)时点开始降低,且两时点间差异有统计学意义,但T_(4)时点VIS仍高于T_(1)、T_(2)时点(均P<0.05)。rScO_(2)与SpO_(2)术中整体变化趋势有相关性(r=0.339,P=0.001);T_(4)时点rScO_(2)与P_(ET)CO_(2)、舒张压、VIS均有相关性(r=0.571、0.563、0.456,均P<0.05)。结论发绀型先天性心脏病患儿的发绀严重程度和MBTS术中阻断肺动脉是影响患儿rScO_(2)的重要因素;人工血管通血后,积极扩容并逐渐降低血管活性药物输注剂量,脑氧合明显改善;术毕不能盲目通过提高SpO_(2)增加rScO_(2)。

Objective To investigate the changes and related factors of regional cerebral oxygen saturation(rScO_(2))in children with cyanotic congenital heart disease undergoing modified systemic-pulmonary artery shunt(MBTS).Methods From January 2019 to December 2020,42 children with cyanotic congenital heart disease undergoing elective surgery in Beijing Anzhen Hospital,Capital Medical University were enrolled.The rScO_(2) and hemodynamic parameters of children were continuously monitored.The rScO_(2),pulse oxygen saturation(SpO_(2)),partial pressure of end-tidal carbon dioxide(PETCO_(2)),systolic blood pressure(SBP),diastolic blood pressure(DBP),cardiac index(CI),pulse pressure variation(PPV)were recorded before incision(T_(1)),at opening the pericardium(T_(2)),5 min after blocking pulmonary artery(T_(3)),3 min after the artificial vascular opened(T_(4))and the end of surgery(T_(5)),and the vasoactive-inotropic score(VIS)were calculated.Results The rScO_(2),SpO_(2),PETCO_(2)at T_(3)time point were significantly lower than those at other time points,rScO_(2) at T_(4) time point was higher than that at T_(1)time point[(77±9)%vs(75±9)%],and rScO_(2)at T_(5)time point[(74±8)%]was lower than that at T_(4)time point(all P<0.05).SpO_(2) at T_(4) time point was higher than that at T_(1),T_(2)and T_(5)time points[(92±4)%vs(86±6)%,(89±5)%,(88±5)%](all P<0.05).PETCO_(2)at T_(4),T_(5)time points were higher than that at T_(1) and T_(2) time points,SBP at T_(3)time point was lower than that at T_(2)and T_(5)time points,DBP at T_(4)time point was lower than that at T_(1),T_(2)and T_(5)time points,CI at T_(4)time point was lower than that at T_(1)and T_(2)time points,and PPV at T_(5)time point was lower than that at other time points(all P<0.05).VIS at T_(3)time point was higher than that at other time points(all P<0.05),that decreased at T_(4)and T_(5)time points,and there was significant difference between the two time points,but that at T_(4)time point was still higher than that at T_(1)and T_(2)time points(all P<0.05).The rScO_(2)was related to overall intraoperative trends in SpO_(2)(r=0.339,P=0.001).At T_(4)time point,rScO_(2)was related to PETCO_(2),DBP and VIS(r=0.571,0.563,0.456,all P<0.05).Conclusions The severity of cyanosis and pulmonary artery blocking during MBTS are the main factors affecting rScO_(2)in children with cyanotic congenital heart disease.After the artificial vascular opened,cerebral oxygenation was significantly improved by actively dilating the volume and gradually reducing the infusion dose of vasoactive drugs.After surgery,it is avoided increasing rScO_(2) by blindly increasing SpO_(2).