张宏民;陈秀凯;王小亭;刘大为;柴文昭;
ZHANG Hongmin;CHEN Xiukai;WANG Xiaoting;LIU Dawei;CHAI Wenzhao;Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences &Peking Union Medical College;Pittsburgh Heart, Lung, Blood and Vascular Institute, University of Pittsburgh, School of Medicine;

• 1:中国医学科学院北京协和医院重症医学科
• 2:匹兹堡大学医学院匹兹堡心肺血液与血管研究所

摘要(Abstract)：

目的 探究体外循环心脏手术(cardiopulmonary bypass surgery, CBS)后中心静脉压峰值(peak value of central venous pressure, CVPp)与急性肾损伤(acute kidney injury, AKI)的关系。方法 回顾性收集2016年5月1日至2018年5月1日北京协和医院重症医学科所有CBS患者的临床资料。记录转入ICU后即刻中心静脉压(central venous pressure, CVP)(CVP 0h)、6 h时CVP(CVP 6h),转入ICU 48 h内CVPp(CVPp 48h),以及转入ICU 48 h后AKI发生率及院内死亡率。采用受试者操作特征(receiver operating characteristic, ROC)曲线评估CVP相关指标预测CBS术后发生AKI的临床价值并确定最佳临界值；采用单因素与多因素Logistic回归分析CBS术后发生AKI、院内死亡的危险因素。结果 共入选符合纳入和排除标准的CBS患者485例，AKI发生率为25.2%(122/485),院内死亡率为2.5%(12/485)。ROC曲线分析显示，CVPp 48h预测CBS术后发生AKI的曲线下面积(area under the curve, AUC)为0.634(95%CI:0.577～0.692,P<0.001),最佳临界值为14 mm Hg,灵敏度为49.6%,特异度为63.5%。多因素Logistic回归分析显示，高血压(OR=2.505, 95%CI:1.581～3.969,P<0.001)、肺动脉高压(OR=2.552, 95%CI:1.573～4.412,P<0.001)、主动脉阻断时间延长(OR=1.009, 95%CI:1.004～1.014,P=0.001)、CVPp 48h≥14 mm Hg(OR=1.613, 95%CI:1.030～2.526,P=0.037)是CBS术后发生AKI的独立危险因素；CVPp 48h≥14 mm Hg是院内死亡的独立危险因素(OR=8.044, 95%CI:1.579～40.979,P=0.012)。结论 CVPp 48h升高可能增加CBS术后AKI发生风险，对其动态监测有助于AKI的预防和早期识别。
Objective To explore the relationship between the post-operative peak value of central venous pressure(CVPp) and the incidence of acute kidney injury(AKI) in patients who had undergonecardiopulmonary bypass surgery(CBS). Methods Clinical data were retrospectively collected from 1 May 2016 to 1 May 2018 from all patients undergoing CBS in the Department of Intensive Care Medicine, Peking Union Medical College Hospital. The CVP values immediately after transfer to ICU(CVP 0 h) and at 6 h(CVP 6 h), and CVPp within 48 h(CVPp 48 h) of transfer to ICU, the incidence of AKI after 48 h of transfer to ICU and in-hospital mortality were recorded. The receiver operating characteristic(ROC) curve was used to evaluate the clinical value of CVP-related indicators in predicting AKI after CBS and determine the optimal threshold. The risk factors for AKI and in-hospital mortality after CBS were analysed using single factor and multifactorial Logistic regression. Results A total of 485 patients after CBS who met the inclusion and exclusion criteria were enrolled, with an incidence of AKI after 48 h of transfer to ICU of 25.2%(122/485) and an in-hospital mortality rate of 2.5%(12/485). The ROC curve analysis showed that the area under the curve(AUC) for CVPp 48 h to predict AKI after CBS was 0.634(95% CI: 0.577-0.692, P<0.001), with an optimal threshold value of 14 mm Hg, sensitivity of 49.6% and specificity of 63.5%. Multifactorial logistic regression analysis showed that hypertension(OR=2.505, 95% CI: 1.581-3.969,P<0.001), pulmonary hyperten-sion(OR=2.552, 95% CI: 1.573-4.412, P<0.001), prolonged aortic block time(OR=1.009, 95% CI: 1.004-1.014,P=0.001), and CVPp 48 h≥14 mm Hg(OR=1.613, 95% CI: 1.030-2.526,P=0.037) were independent risk factors for AKI after CBS; CVPp 48 h≥14 mm Hg was an independent risk factor for in-hospital death(OR=8.044, 95% CI: 1.579-40.979,P=0.012). Conclusions CVPp 48 h is associated with AKI in patients who have undergone CBS. The monitoring and management of CVP might be a way to improve the prognosis of these patients.

关键词(KeyWords)： 中心静脉压;心外手术;急性肾损伤;体外循环
central venous pressure;cardiac surgery;acute kidney injury;cardiopulmonary bypass

Abstract:

Keywords:

基金项目(Foundation): 中国医学科学院医学与健康科技创新工程(2020-I2M-C&T-B-045)~~

作者(Authors): 张宏民;陈秀凯;王小亭;刘大为;柴文昭;
ZHANG Hongmin;CHEN Xiukai;WANG Xiaoting;LIU Dawei;CHAI Wenzhao;Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences &Peking Union Medical College;Pittsburgh Heart, Lung, Blood and Vascular Institute, University of Pittsburgh, School of Medicine;

参考文献(References)：

• [1] Uchino S,Kellum JA,Bellomo R,et al.Acute renal failure in critically ill patients:a multinational,multicenter study[J].JAMA,2005,29:813- 818.
• [2] Lassnigg A,Schmidlin D,Mouhieddine M,et al.Minimal changes of serum creatinine predict prognosis in patients after cardiothoracic surgery:a prospective cohort study[J].J Am Soc Nephrol,2004,15:1597- 1605.
• [3] Loef BG,Epema AH,Smilde TD,et al.Immediate postoperative renal function deterioration in cardiac surgical patients predicts in-hospital mortality and long-term survival[J].J Am Soc Nephrol,2005,16:195- 200.
• [4] Burns KE,Chu MW,Novick RJ,et al.Perioperative N-acetylcysteine to prevent renal dysfunction in high-risk patients undergoing cabg surgery:a randomized controlled trial[J].JAMA,2005,294:342- 350.
• [5] Magder S.Understanding central venous pressure:not a preload index?[J].Curr Opin Crit Care,2015,21:369- 375.
• [6] De Backer D,Vincent JL.Should we measure the central venous pressure to guide fluid management?Ten answers to 10 questions[J].Crit Care,2018,22:43.
• [7] Honore PM,Jacobs R,Hendrickx I,et al.Prevention and treatment of sepsis-induced acute kidney injury:an update[J].Ann Intensive Care,2015,5:51.
• [8] Chen X,Wang X,Honore PM,et al.Renal failure in critically ill patients,beware of applying (central venous) pressure on the kidney[J].Ann Intensive Care,2018,8:91.
• [9] Spiegel R,Teeter W,Sullivan S,et al.The use of venous Doppler to predict adverse kidney events in a general ICU cohort[J].Crit Care,2020,24:615.
• [10] Williams JB,Peterson ED,Wojdyla D,et al.Central venous pressure after coronary artery bypass surgery:does it predict postoperative mortality or renal failure?[J].J Crit Care,2014,29:1006- 1010.
• [11] Gambardella I,Gaudino M,Ronco C,et al.Congestive kidney failure in cardiac surgery:the relationship between central venous pressure and acute kidney injury[J].Interact Cardiovasc Thorac Surg,2016,23:800- 805.
• [12] Yang Y,Ma J,Zhao L.High central venous pressure is associated with acute kidney injury and mortality in patients underwent cardiopulmonary bypass surgery[J].J Crit Care,2018,48:211- 215.
• [13] Wang XT,Chen H,Liu DW,et al.The correlation between CVP-derived parameters and the prognosis of critically ill patients[J].J Crit Care,2017,40:257- 264.
• [14] Kellum JA,Lameire N.Diagnosis,evaluation,and management of acute kidney injury:a KDIGO summary (Part 1)[J].Crit Care,2013,17:204.
• [15] Prowle JR,Forni LG,Bell M,et al.Postoperative acute kidney injury in adult non-cardiac surgery:joint consensus report of the Acute Disease Quality Initiative and PeriOperative Quality Initiative[J].Nat Rev Nephrol,2021,17:605- 618.
• [16] Palomba H,de Castro I,Neto AL,et al.Acute kidney injury prediction following elective cardiac surgery:AKICS Score[J].Kidney Int,2007,72:624- 631.
• [17] Choi SJ,Ha EJ,Jhang WK,et al.Elevated central venous pressure is associated with increased mortality in pediatric septic shock patients[J].BMC Pediatr,2018,18:58.
• [18] Wang XT,Yao B,Liu DW,et al.Central Venous Pressure Dropped Early is Associated with Organ Function and Prognosis in Septic Shock Patients:A Retrospective Observa-tional Study[J].Shock,2015,44:426- 430.
• [19] Guyton AC.Determination of cardiac output by equating venous return curves with cardiac response curves[J].Physiol Rev,1955,3:123- 129.
• [20] Berlin DA,Bakker J.Starling curves and central venous pressure[J].Crit Care,2015,19:55.
• [21] Boyd JH,Forbes J,Nakada TA,et al.Fluid resuscitation in septic shock:a positive fluid balance and elevated central venous pressure are associated with increased mortality[J].Crit Care Med,2011,39:259- 265.
• [22] Denault AY,Couture P,Beaulieu Y,et al.Right Ventricu-lar Depression After Cardiopulmonary Bypass for Valvular Surgery[J].J Cardiothorac Vasc Anesth,2015,29:836- 844.
• [23] Vonk-Noordegraaf A,Haddad F,Chin KM,et al.Right heart adaptation to pulmonary arterial hypertension:physiology and pathobiology[J].J Am Coll Cardiol,2013,62:D22-D33.
• [24] Hrymak C,Strumpher J,Jacobsohn E.Acute Right Ventricle Failure in the Intensive Care Unit:Assessment and Management[J].Can J Cardiol,2017,33:61- 71.
• [25] Zhang H,Wang X,Chen X,et al.Tricuspid annular plane systolic excursion and central venous pressure in mechani-cally ventilated critically ill patients[J].Cardiovasc Ultrasound,2018,16:11.
• [26] Vellinga NA,Ince C,Boerma EC.Elevated central venous pressure is associated with impairment of microcirculatory blood flow in sepsis:a hypothesis generating post hoc analysis[J].BMC Anesthesiol,2013,13:17.
• [27] Mullens W,Abrahams Z,Francis GS,et al.Importance of venous congestion for worsening of renal function in advanced decompensated heart failure[J].J Am Coll Cardiol,2009,53:589- 596.
• [28] Royster RL.Myocardial dysfunction following cardiopulmonary bypass:recovery patterns,predictors of inotropic need,theoretical concepts of inotropic administration[J].J Cardiothorac Vasc Anesth,1993,7:19- 25.