≤1岁先天性心脏病患儿体外循环术后脑氧去饱和事件危险因素分析

doi:10.12372/jcp.2024.24e0252

摘要/Abstract

摘要：

目的探索≤1岁先天性心脏病（CHD）患儿术后脑氧去饱和事件（CDEs）发生现状及相关危险因素。方法回顾性分析2023年1至6月体外循环下行CHD矫治术的≤1岁患儿的临床资料，根据术后是否发生CDEs分为发生CDEs组和未发生CDEs组，比较两组间临床特征，分析与CDEs发生相关的影响因素。结果纳入397例行CHD矫治术的患儿，术后发生CDEs者67例（16.9%），男39例、女28例，中位年龄4.0（3.1~5.6）个月；未发生CDEs者330例（83.1%），男177例、女153例，中位年龄4.5（3.2~7.7）个月。二分类logistic回归分析结果显示，术后较高的外周血氧饱和度（SpO₂）和术中较高的红细胞比容（Hct）是CDEs发生的独立保护因素；较长的体外循环时间以及中、深度低温体外循环方案为CDEs发生的独立危险因素（P<0.05）。ROC曲线分析显示，术后SpO₂、术中Hct、体外循环时间对CDEs的发生均具有一定的预测价值（AUC>0.6，P<0.05）。结论 ≤1岁CHD患儿术后CDEs发生率较高，通过术后SpO₂、术中Hct、体外循环时间与体外循环方案可能预测该年龄段CHD患儿术后CDEs的发生。

关键词: 先天性心脏病, 体外循环, 脑保护

Abstract:

Objective To investigate the incidence of cerebral oxygen desaturation events (CDEs) and its related risk factors in infants under 1 year old with congenital heart disease (CHD) after surgery. Methods The clinical data of infants under 1 year old with CHD who underwent cardiopulmonary bypass surgery between January and June 2023 were retrospectively analyzed. According to whether CDEs occurred after surgery, the patients were divided into CDEs group and non-CDEs group. The clinical characteristics of the two groups were compared, and the influencing factors related to CDEs occurrence were analyzed. Results Among 397 infants who underwent CHD surgery, 67 infants (16.9%) developed CDEs after surgery, including 39 boys and 28 girls, with a median age of 4.0 (3.1-5.6) months. There were 330 patients (83.1%) without CDEs, 177 boys and 153 girls, with a median age of 4.5 (3.2-7.7) months. Binary logistic regression analysis showed that higher postoperative pulse oxygen saturation (SpO₂) and higher intraoperative hematocrit (Hct) were independent protective factors for CDEs, while prolonged cardiopulmonary bypass time and moderate to deep hypothermic circulatory arrest were independent risk factors for CDEs (P<0.05). ROC curve analysis showed that postoperative SpO₂, intraoperative Hct, and cardiopulmonary bypass time all had certain predictive value for the occurrence of CDEs (AUC>0.6, P<0.05). Conclusions The incidence of postoperative CDEs in CHD infants under 1 year old is higher. Postoperative SpO₂, intraoperative Hct, duration of cardiopulmonary bypass and cardiopulmonary bypass regimen may predict the incidence of postoperative CDEs in CHD patients in this age group.

Key words: congenital heart disease, cardiopulmonary bypass, cerebral protection

汪思园, 陈瑜, 孙梦莲, 何晓敏, 黄坚鹄, 沈南平. ≤1岁先天性心脏病患儿体外循环术后脑氧去饱和事件危险因素分析[J]. 临床儿科杂志, 2024, 42(10): 843-848.

WANG Siyuan, CHEN Yu, SUN Menglian, HE Xiaomin, HUANG Jianhu, SHEN Nanping. Risk factors of cerebral oxygen desaturation events after cardiopulmonary bypass in children with congenital heart disease under 1 year old[J]. Journal of Clinical Pediatrics, 2024, 42(10): 843-848.

图/表 4

表1

≤1岁CHD患儿体外循环术后发生与未发生CDEs组临床资料比较"

项目	未发生CDEs组(n=330)	发生CDEs组(n=67)	统计量	P
年龄[M(P₂₅~P₇₅)]/月	4.5(3.2~7.7)	4.0(3.1~5.6)	Z=2.68	0.007
男[n(%)]	177(53.6)	39(58.2)	χ²=0.47	0.493
体重($\bar{x}±s$)/kg	6.5±2.1	5.7±1.7	t=2.89	0.004
身高($\bar{x}±s$)/cm	63.5±7.1	59.5±7.9	t=4.14	<0.001
体表面积($\bar{x}±s$)/m²	0.34±0.06	0.30±0.06	t=3.53	<0.001
早产儿[n(%)]	23(7.0)	5(7.5)	χ²=0.00	1.000
ABC评分[M(P₂₅~P₇₅)]/分	6.5(5.5~7.5)	7.5(6.5~9.5)	Z=4.42	<0.001
ASA分级[n(%)]			－	0.740¹⁾
1级	0(0.0)	0(0.0)
2级	3(0.9)	0(0.0)
3级	287(83.9)	57(85.1)
4级	40(15.2)	10(14.9)
手术体位[n(%)]			χ²=9.91	0.002
正卧位	297(90.0)	51(76.1)
侧卧位	33(10.0)	16(23.9)
体外循环方案[n(%)]			χ²=23.07	<0.001
常温、浅低温	301(91.2)	48(71.6)
中、深低温	29(8.8)	19(28.4)
术中进行≥2次阻断[n(%)]	4(1.2)	5(7.5)	χ²=9.82	0.009
术前SBP($\bar{x}±s$)/mmHg	85.5±16.5	81.5±16.6	t=0.75	0.454
术前DBP($\bar{x}±s$)/mmHg	59.6±15.3	59.6±13.4	t=0.01	0.994
术前SpO₂($\bar{x}±s$)/%	97.5±1.7	97.4±1.5	t=0.49	0.624
术前心率($\bar{x}±s$)/次·min^-1	125.5±19.5	125.9±19.6	t=1.68	0.093
术前Hct($\bar{x}±s$)/%	30.7±3.9	27.9±4.2	t=5.24	<0.001
术前CrSO₂($\bar{x}±s$)/%	70.3±8.3	66.8±9.1	t=0.94	0.355
术后SBP($\bar{x}±s$)/mmHg	83.4±16.5	82.7±16.6	t=0.31	0.753
术后DBP($\bar{x}±s$)/mmHg	52.4±8.6	50.3±8.5	t=1.85	0.066
术后SpO₂[M(P₂₅~P₇₅)]/%	100.0(98.0~100.0)	98.0(85.0~99.0)	Z=3.24	0.001
术后心率($\bar{x}±s$)/次·min^-1	132.8±17.7	139.9±18.6	t=2.98	0.003
术中Hct($\bar{x}±s$)/%	26.6±2.5	24.3±1.7	t=7.44	<0.001
手术时间[M(P₂₅~P₇₅)]/min	157.0(140.0~179.0)	184.0(158.0~213.0)	Z=5.05	<0.001
术中阻断时间[M(P₂₅~P₇₅)]/min	35.0(26.0~47.8)	46.0(34.0~66.5)	Z=4.22	<0.001
体外循环时间[M(P₂₅~P₇₅)]/min	65.0(51.0~87.0)	90.0(67.0~120.0)	Z=5.18	<0.001

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因素	偏回归系数	标准误	χ²值	P	OR(95%CI)
术后SpO₂	－0.29	0.08	13.40	<0.001	0.75(0.64~0.88)
术中Hct	－0.10	0.04	6.30	0.012	0.90(0.83~0.98)
体外循环时间	0.01	0.01	3.98	0.046	1.01(1.00~1.02)
体外循环方案为中、深低温	1.48	0.25	34.40	<0.001	4.41(2.68~7.23)
常量	22.13	7.74	8.19	0.040	－

因素	最佳阈值	AUC(95%CI)	P	灵敏度/%	特异度/%	约登指数
术后SpO₂/%	96	0.66(0.58~0.75)	0.003	23.9	96.7	0.22
术中Hct/%	25	0.76(0.69~0.82)	<0.001	50.7	78.8	0.30
体外循环时间/min	80	0.70(0.63~0.77)	<0.001	62.7	69.4	0.32
联合预测因子	0.18	0.82(0.76~0.88)	<0.001	73.1	80.0	0.53