协和医学杂志

2018, v.9(03) 228-233

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中心静脉氧饱和度替代混合静脉氧饱和度对先天性心脏病合并肺动脉高压术后的监护价值:多中心前瞻性研究
Monitoring Value of Central Venous Oxygen Saturation,the Substitute for Mixed Venous Oxygen Saturation,in Postoperative Care of Congenital Heart Disease with Pulmonary Arterial Hypertension: a Multicenter Prospective Study

胡帅;韩志岩;王晓建;韩京军;伍德强;张磊;林焰桂;梁建文;魏文斌;张文林;母存富;王义;李巅远;
HU Shuai;HAN Zhi-yan;WANG Xiao-jian;HAN Jing-jun;WU De-qiang;ZHANG Lei;LIN Yan-gui;LIANG Jian-wen;WEI Wen-bin;ZHANG Wen-lin;MU Cun-fu;WANG Yi;LI Dian-yuan;Department of Cardiovascular Surgery,Heart Center of Henan Provincial People's Hospital,Fuwai Central China Cardiovascular Hospital;Department of Anesthesiology,Fuwai Hospital,Chinese Academy of Medical Sciences & Peking Union Medical College;Thrombosis and Vascular Medicine Center,Fuwai Hospital,Chinese Academy of Medical Sciences & Peking Un

摘要(Abstract):

目的探讨中心静脉氧饱和度(central venous oxygen saturation,ScvO_2)与混合静脉氧饱和度(mixed venous oxygen saturation,SvO_2)对先天性心脏病(congenital heart disease,CHD)合并肺动脉高压(pulmonary arterial hypertension,PAH)患者修补术后评估价值的一致性。方法本研究前瞻性选取2016年3月至2017年3月,于河南省人民医院、北京阜外医院、广州中山大学第八附属医院及四川省广元市第一人民医院接受治疗且符合入选及排除标准的43例CHD-PAH患者,分别于停体外循环后即刻及转入重症监护室后6、12、24、48 h等5个时间点,同时测量ScvO_2及SvO_2,并记录血流动力学参数、血红蛋白及乳酸等指标。采用Bland-Altman检验分析两个指标的一致性,采用线性回归分析两指标偏倚的相关影响因素。结果 ScvO_2和SvO_2的总体相关系数R~2=0.369,体外循环后即刻R~2=0.515,入重症监护室后6、12、24、48 h的R~2分别为0.375、0.605、0.712、0.252。Bland-Altman检验显示ScvO_2与SvO_2的偏倚(△ScvO_2﹣SvO_2)为-1.3%,一致性区间(limits of agreement,LOA)为(-17.0%,14.4%)。总体上氧摄取率(oxygen extraction rate,O2ER)(R~2=0.030,P<0.05)、肺动脉收缩压(R~2=0.030,P<0.05)和心率(R~2=0.032,P<0.05)对△ScvO_2-SvO_2的影响较小;当ScvO_2<70%时,O2ER(R~2=0.203,P<0.01)、肺动脉收缩压(R~2=0.110,P<0.01)、心率(R~2=0.150,P<0.01)对△ScvO_2-SvO_2的影响则较大,此时ScvO_2有低估SvO_2的趋势,而当ScvO_2≥70%时,ScvO_2会高估SvO_2。机械通气期间ScvO_2与SvO_2的偏倚为-1.3%,LOA为(-16.1%,13.5%),△ScvO_2-SvO_2的影响因素为O2ER(R~2=0.122,P<0.01);撤机后ScvO_2与SvO_2的偏倚为-1.3%,LOA为(-19.5%,16.8%),△ScvO_2-SvO_2的影响因素为O2ER(R~2=0.320,P<0.01)和动脉氧饱和度(R~2=0.320,P<0.01)。结论CHD-PAH患者术后监护中ScvO_2不能替代SvO_2的评估价值。当ScvO_2≥70%时,宜同时监测ScvO_2与SvO_2以排除低灌注状态。
Objective This study aimed to investigate the agreement of central venous oxygen saturation( ScvO_2) with mixed venous oxygen saturation( SvO_2) in postoperative care of congenital heart disease( CHD)with pulmonary arterial hypertension( PAH). Methods Forty-three patients undergoing CHD-PAH repairing surgery were prospectively selected from Henan Provincial People's Hospital, Fuwai Hospital, the Eighth Affiliated Hospital of Sun Yat-sen University,and the First People's Hospital of Guanyuang from March 2016 to March 2017. Data of ScvO_2 and SvO_2 were synchronously collected after cardiopulmonary bypass( CPB),and 6,12,24,and 48 hours after admission to the intensive care unit. In addition,hemodynamic parameters,hemoglobin,and arterial lactate were recorded. Data were analyzed by Bland-Altman test and linear regression analysis.Results The overall R~2 of ScvO_2 to SvO_2 for the pooled measurements was 0. 369. R~2 of post-CPB,6,12,24,48 hours after admission to the intensive care unit were 0. 515,0. 375,0. 605,0. 712,and 0. 252,respectively.Bland-Altman test for ScvO_2 and SvO_2 showed that the mean bias was-1. 3% and limits of agreement( LOA)were-17. 0% to 14. 4%. In general,the influences of oxygen extraction rate(O_2 ER)( R~2= 0. 030,P<0. 05),pulmonary artery systolic pressure( SPAP)( R~2= 0. 030,P < 0. 05),and heart rate( HR)( R~2= 0. 032,P <0. 05) on △ScvO_2-SvO_2 were relatively small; when ScvO_2 was <70%,the influences ofO_2 ER( R~2= 0. 203,P<0. 01),SPAP( R~2= 0. 110,P<0. 01),and HR( R~2= 0. 150,P < 0. 01) were much greater,and ScvO_2 would underestimate SvO_2; ScvO_2 might overestimate SvO_2 when ≥ 70%. Bland-Altman test indicated during mechanical ventilation the mean bias of ScvO_2 and SvO_2( △ScvO_2-SvO_2) was-1. 3% and LOA were-16. 1%to 13. 5%,the only factor influencing △ScvO_2-SvO_2 wasO_2 ER( R~2= 0. 122,P < 0. 01); without mechanical ventilation,the mean bias was-1. 3% and LOA were-19. 5% to 16. 8%,and the influence on △ScvO_2-SvO_2 wereO_2 ER( R~2= 0. 320,P<0. 01) and arterial oxygen saturation( R~2= 0. 320,P<0. 01). Conclusions ScvO_2 cannot replace SvO_2 in postoperative care for patients with CHD-PAH. ScvO_2 and SvO_2 should be monitored respectively to exclude the hypo-perfusion state when ScvO_2≥70%.

关键词(KeyWords): 中心静脉氧饱和度;混合静脉氧饱和度;先天性心脏病;肺动脉高压;术后监护
central venous oxygen saturation;mixed venous oxygen saturation;congenital heart disease;pulmonary arterial hypertension;postoperative care

Abstract:

Keywords:

基金项目(Foundation): 深圳市医疗卫生三名工程项目(SZSM201502001)

作者(Author): 胡帅;韩志岩;王晓建;韩京军;伍德强;张磊;林焰桂;梁建文;魏文斌;张文林;母存富;王义;李巅远;
HU Shuai;HAN Zhi-yan;WANG Xiao-jian;HAN Jing-jun;WU De-qiang;ZHANG Lei;LIN Yan-gui;LIANG Jian-wen;WEI Wen-bin;ZHANG Wen-lin;MU Cun-fu;WANG Yi;LI Dian-yuan;Department of Cardiovascular Surgery,Heart Center of Henan Provincial People's Hospital,Fuwai Central China Cardiovascular Hospital;Department of Anesthesiology,Fuwai Hospital,Chinese Academy of Medical Sciences & Peking Union Medical College;Thrombosis and Vascular Medicine Center,Fuwai Hospital,Chinese Academy of Medical Sciences & Peking Un

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