Gaies Michael G, Jeffries Howard E, Niebler Robert A, Pasquali Sara K, Donohue Janet E, Yu Sunkyung, Gall Christine, Rice Tom B, Thiagarajan Ravi R
1Department of Pediatrics and Communicable Diseases, Division of Cardiology, C.S. Mott Children's Hospital, University of Michigan Medical School, Ann Arbor, MI. 2Pediatric Cardiac Critical Care Consortium Data Coordinating Center, Michigan Congenital Heart Outcomes Research and Discovery Unit, Ann Arbor, MI. 3Department of Pediatrics, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA. 4Department of Pediatrics, Section of Critical Care, Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, WI. 5Virtual PICU Systems (VPS, LLC), Los Angeles, CA. 6Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA.
Pediatr Crit Care Med. 2014 Jul;15(6):529-37. doi: 10.1097/PCC.0000000000000153.
To empirically derive the optimal measure of pharmacologic cardiovascular support in infants undergoing cardiac surgery with bypass and to assess the association between this score and clinical outcomes in a multi-institutional cohort.
Prospective, multi-institutional cohort study.
Cardiac ICUs at four academic children's hospitals participating in the Pediatric Cardiac Critical Care Consortium during the study period.
Children younger than 1 year at the time of surgery treated postoperatively in the cardiac ICU.
None.
Three hundred ninety-one infants undergoing surgery with bypass were enrolled consecutively from November 2011 to April 2012. Hourly doses of all vasoactive agents were recorded for the first 48 hours after cardiac ICU admission. Multiple derivations of an inotropic score were tested, and maximum vasoactive-inotropic score in the first 24 hours was further analyzed for association with clinical outcomes. The primary composite "poor outcome" variable included at least one of mortality, mechanical circulatory support, cardiac arrest, renal replacement therapy, or neurologic injury. High vasoactive-inotropic score was empirically defined as more than or equal to 20. Multivariable logistic regression was performed controlling for center and patient characteristics. Patients with high vasoactive-inotropic score had significantly greater odds of a poor outcome (odds ratio, 6.5; 95% CI, 2.9-14.6), mortality (odds ratio, 13.2; 95% CI, 3.7-47.6), and prolonged time to first extubation and cardiac ICU length of stay compared with patients with low vasoactive-inotropic score. Stratified analyses by age (neonate vs infant) and surgical complexity (low vs high) showed similar associations with increased morbidity and mortality for patients with high vasoactive-inotropic score.
Maximum vasoactive-inotropic score calculated in the first 24 hours after cardiac ICU admission was strongly and significantly associated with morbidity and mortality in this multi-institutional cohort of infants undergoing cardiac surgery. Maximum vasoactive-inotropic score more than or equal to 20 predicts an increased likelihood of a poor composite clinical outcome. The findings were consistent in stratified analyses by age and surgical complexity.
通过实证得出体外循环心脏手术患儿的最佳药物性心血管支持测量方法，并评估该评分与多机构队列中临床结局之间的关联。
前瞻性多机构队列研究。
研究期间参与儿童心脏重症监护联盟的四家学术儿童医院的心脏重症监护病房。
心脏重症监护病房术后治疗的手术时年龄小于1岁的儿童。
无。
2011年11月至2012年4月连续纳入391例行体外循环手术的婴儿。记录心脏重症监护病房入院后前48小时所有血管活性药物的每小时剂量。对多种变力性评分推导方法进行了测试，并进一步分析了前24小时的最大血管活性-变力性评分与临床结局的关联。主要复合“不良结局”变量包括死亡、机械循环支持、心脏骤停、肾脏替代治疗或神经损伤中的至少一项。高血管活性-变力性评分经实证定义为大于或等于20。进行多变量逻辑回归分析，对中心和患者特征进行校正。与低血管活性-变力性评分的患者相比，高血管活性-变力性评分的患者出现不良结局（比值比，6.5；95%CI，2.9-14.6）、死亡（比值比，13.2；95%CI，3.7-47.6）以及首次拔管时间延长和心脏重症监护病房住院时间延长的几率显著更高。按年龄（新生儿与婴儿）和手术复杂性（低与高）进行分层分析显示，高血管活性-变力性评分的患者在发病率和死亡率增加方面具有相似的关联。
在这个接受心脏手术的多机构婴儿队列中，心脏重症监护病房入院后前24小时计算的最大血管活性-变力性评分与发病率和死亡率密切且显著相关。最大血管活性-变力性评分大于或等于20预示着不良复合临床结局的可能性增加。在按年龄和手术复杂性进行的分层分析中，研究结果一致。
