通过将治疗的主要重点从心输出量转移到灌注压来改善小儿心脏手术围手术期护理：β受体兴奋剂仍然需要吗？
Improvement in perioperative care in pediatric cardiac surgery by shifting the primary focus of treatment from cardiac output to perfusion pressure: Are beta stimulants still needed?
作者信息
Hosseinpour Amir-Reza, van Steenberghe Mathieu, Bernath Marc-André, Di Bernardo Stefano, Pérez Marie-Hélène, Longchamp David, Dolci Mirko, Boegli Yann, Sekarski Nicole, Orrit Javier, Hurni Michel, Prêtre René, Cotting Jacques
机构信息
Department of Cardiac Surgery, University Hospital of Vaud, Lausanne, Switzerland.
Department of Pediatric Anesthesiology, University Hospital of Vaud, Lausanne, Switzerland.
出版信息
Congenit Heart Dis. 2017 Sep;12(5):570-577. doi: 10.1111/chd.12485. Epub 2017 Jun 5.
OBJECTIVE
An important aspect of perioperative care in pediatric cardiac surgery is maintenance of optimal hemodynamic status using vasoactive/inotropic agents. Conventionally, this has focused on maintenance of cardiac output rather than perfusion pressure. However, this approach has been abandoned in our center in favor of one focusing primarily on perfusion pressure, which is presented here and compared to the conventional approach.
DESIGN
A retrospective study.
SETTING
Regional center for congenital heart disease. University Hospital of Lausanne, Switzerland.
PATIENTS
All patients with Aristotle risk score ≥8 that underwent surgery from 1996 to 2012 were included. Patients operated between 1996 and 2005 (Group 1: 206 patients) were treated according to the conventional approach. Patients operated between 2006 and 2012 (Group 2: 217 patients) were treated according to our new approach.
INTERVENTIONS
All patients had undergone surgery for correction or palliation of congenital cardiac defects.
OUTCOME MEASUREMENTS
Mortality, duration of ventilation and inotropic treatment, use of ECMO, and complications of poor peripheral perfusion (need for hemofiltration, laparotomy for enterocolitis, amputation).
RESULTS
The two groups were similar in age and complexity. Mortality was lower in group 2 (7.3% in group 1 vs 1.4% in group 2, P < .005). Ventilation times (hours) and number of days on inotropic/vasoactive treatment (all agents), expressed as median and interquartile range [Q1-Q3] were shorter in group 2: 69 [24-163] hours in group 1 vs 35 [22-120] hours in group 2 (P < .01) for ventilation, and 9 [3-5] days in group 1 vs 7 [2-5] days in group 2 (P < .05) for inotropic/vasoactive agents. There were no differences in ECMO usage or complications of peripheral perfusion.
CONCLUSIONS
Results in pediatric cardiac surgery may be improved by shifting the primary focus of perioperative care from cardiac output to perfusion pressure.
目的
小儿心脏手术围手术期护理的一个重要方面是使用血管活性/正性肌力药物维持最佳血流动力学状态。传统上，这主要侧重于维持心输出量而非灌注压。然而，我们中心已摒弃这种方法，转而采用主要侧重于灌注压的方法，本文将介绍该方法并与传统方法进行比较。
设计
一项回顾性研究。
地点
先天性心脏病区域中心。瑞士洛桑大学医院。
患者
纳入所有1996年至2012年接受手术且亚里士多德风险评分≥8的患者。1996年至2005年接受手术的患者（第1组：206例）采用传统方法治疗。2006年至2012年接受手术的患者（第2组：217例）采用我们的新方法治疗。
干预措施
所有患者均接受了先天性心脏缺陷矫正或姑息手术。
观察指标
死亡率、通气时间和正性肌力治疗时间、体外膜肺氧合（ECMO）的使用情况以及外周灌注不良的并发症（血液滤过需求、因坏死性小肠结肠炎行剖腹手术、截肢）。
结果
两组在年龄和病情复杂程度方面相似。第2组的死亡率较低（第1组为7.3%，第2组为1.4%，P＜0.005）。第2组的通气时间（小时）以及使用正性肌力/血管活性药物（所有药物）的天数，以中位数和四分位数间距[Q1-Q3]表示，均较短：通气方面，第1组为69[24-163]小时，第2组为35[22-120]小时（P＜0.01）；正性肌力/血管活性药物方面，第1组为9[3-5]天，第2组为7[2-]天（P＜0.05）。ECMO使用情况或外周灌注并发症方面无差异。
结论
将围手术期护理的主要重点从心输出量转移到灌注压，可能会改善小儿心脏手术的结果。
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