Gupta Bhawna, Dodge-Khatami Ali, Tucker Juan, Taylor Mary B, Maposa Douglas, Urencio Miguel, Salazar Jorge D
Division of Cardiothoracic Surgery, The Children's Heart Center, The University of Mississippi Medical Center, Jackson, Mississippi, USA.
Divisions of Pediatric Critical Care and Pediatric Cardiology, The Children's Heart Center, The University of Mississippi Medical Center, Jackson, Mississippi, USA.
Transl Pediatr. 2016 Jul;5(3):114-124. doi: 10.21037/tp.2016.06.03.
Antegrade cerebral perfusion (ACP) typically is used with deep hypothermia for cerebral protection during aortic arch reconstructions. The impact of ACP on cerebral oxygenation and serum creatinine at a more tepid 25 °C was studied in newborns and children.
Between 2010 and 2014, 61 newborns and children (<5 years old) underwent aortic arch reconstruction using moderate hypothermia (25.0±0.9 °C) with ACP and a pH-stat blood gas management strategy. These included 44% Norwood-type operations, 30% isolated arch reconstructions, and 26% arch reconstructions with other major procedures. Median patient age at surgery was 9 days (range, 3 days-4.7 years). Cerebral oxygenation (NIRS) was monitored continuously perioperatively for 120 hours. Serum creatinine was monitored daily.
Median cardiopulmonary bypass (CPB) and cross clamp times were 181 minutes (range, 82-652 minutes) and 72 minutes (range, 10-364 minutes), respectively. ACP was performed at a mean flow rate of 46±6 mL/min/kg for a median of 48 minutes (range, 10-123 minutes). Cerebral and somatic NIRS were preserved intraoperatively and remained at baseline postoperatively during the first 120 hours. Peak postoperative serum creatinine levels averaged 0.7±0.3 mg/dL for all patients. There were 4 (6.6%) discharge mortalities. Six patients (9.8%) required ECMO support. Median postoperative length of hospital and intensive care unit (ICU) stay were 16 days(range, 4-104 days) and 9 days (range, 1-104 days), respectively. Two patients (3.3%) received short-term peritoneal dialysis for fluid removal, and none required hemodialysis. Three patients (4.9%) had an isolated seizure which resolved with medical therapy, and none had a neurologic deficit or stroke.
ACP at 25 °C preserved perioperative cerebral oxygenation and serum creatinine for newborns and children undergoing arch reconstruction. Early outcomes are encouraging, and additional study is warranted to assess the impact on late outcomes.
在主动脉弓重建术中，顺行性脑灌注（ACP）通常与深度低温联合使用以保护大脑。本研究在新生儿和儿童中探讨了在更温和的25℃时，ACP对脑氧合和血清肌酐的影响。
2010年至2014年期间，61例新生儿和儿童（<5岁）接受了主动脉弓重建术，采用中度低温（25.0±0.9℃）联合ACP及pH稳态血气管理策略。其中包括44%的诺伍德式手术、30%的单纯主动脉弓重建术以及26%的主动脉弓重建联合其他主要手术。手术时患者的中位年龄为9天（范围：3天至4.7岁）。围手术期连续120小时监测脑氧合（近红外光谱法，NIRS）。每日监测血清肌酐。
体外循环（CPB）和主动脉阻断时间的中位数分别为181分钟（范围：82至652分钟）和72分钟（范围：10至364分钟）。ACP的平均流速为46±6 mL/（min·kg），中位持续时间为48分钟（范围：10至123分钟）。术中脑和躯体的NIRS得以维持，术后120小时内保持在基线水平。所有患者术后血清肌酐峰值平均为0.7±0.3mg/dL。有4例（6.6%）患者出院时死亡。6例（9.8%）患者需要体外膜肺氧合（ECMO）支持。术后住院时间和重症监护病房（ICU）住院时间的中位数分别为16天（范围：4至104天）和9天（范围：1至104天）。2例（3.3%）患者接受短期腹膜透析以清除液体，无人需要血液透析。3例（4.9%）患者出现孤立性癫痫发作，经药物治疗后缓解，无人有神经功能缺损或中风。
对于接受主动脉弓重建术的新生儿和儿童，25℃的ACP可维持围手术期脑氧合和血清肌酐水平。早期结果令人鼓舞，有必要进一步研究以评估其对远期结果 的影响。
