Division of Pediatric Cardiology, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, USA.
Arkansas Children's Research Institute, Little Rock, AR, USA.
J Intensive Care Med. 2019 Nov-Dec;34(11-12):917-923. doi: 10.1177/0885066617728494. Epub 2017 Aug 29.
Nitric oxide is utilized after pediatric cardiac surgery as an off-label medication without much evidence, is expensive, and varies among centers of varying surgical volume. The objective of our study was to describe the spectrum of nitric oxide utilization and to evaluate the effect of nitric oxide utilization on outcomes among patients cared for in centers of varying surgical volume using Pediatric Health Information system.
Patients aged ≤18 years undergoing heart surgery were included (2004-2015). Multivariable mixed-effects logistic regression models were fitted to evaluate association of center volume with odds of nitric oxide utilization among patients undergoing heart operations. Centers were classified into 3 volume categories based on tertiles of number of cardiopulmonary bypass cases performed (low volume: 34 792 patients, 21 centers; medium volume: 38 362 patients, 13 centers; high volume: 30 560 patients, 7 centers).
A total of 103 714 patients from 41 hospitals were included. Of these, 15 708 (15.1%) patients received nitric oxide after cardiac surgery. Of the patients receiving nitric oxide, only 3936 (25.1%) patients were associated with a diagnosis of pulmonary hypertension. In adjusted models, low- and medium-volume centers were associated with higher nitric oxide utilization after heart operations as compared to high-volume centers (low vs high, odds ratio [OR]: 1.48, 95% confidence interval [CI]: 1.38-1.60; medium vs high, OR: 1.33, 95% CI: 1.26-1.41). Despite higher nitric oxide utilization, the mortality was worse among patients treated in low- and medium-volume centers, as compared to high-volume centers (low vs high, OR: 1.42, 95% CI: 1.26-1.60; medium vs high, OR: 1.14, 95% CI: 1.04-1.25).
This study demonstrates variation in nitric oxide utilization after heart operations among centers of varying surgical volume. Further, it raises questions on the benefit of nitric oxide administration after pediatric cardiac surgery.
一氧化氮在儿科心脏手术后被用作未经证实的标签外药物，价格昂贵，且在不同手术量的中心之间存在差异。本研究的目的是描述一氧化氮使用的范围，并使用儿科健康信息系统评估在不同手术量中心接受治疗的患者中使用一氧化氮对结局的影响。
纳入年龄≤18 岁接受心脏手术的患者（2004-2015 年）。采用多变量混合效应逻辑回归模型评估中心容量与心脏手术后接受一氧化氮治疗的患者使用一氧化氮的可能性之间的关系。根据体外循环例数的三分位值将中心分为 3 个容量类别（低容量：34792 例，21 个中心；中容量：38362 例，13 个中心；高容量：30560 例，7 个中心）。
共纳入 41 家医院的 103714 名患者。其中，15708 名（15.1%）患者在心脏手术后接受了一氧化氮治疗。在接受一氧化氮治疗的患者中，只有 3936 名（25.1%）患者被诊断为肺动脉高压。在调整后的模型中，与高容量中心相比，低容量和中容量中心的心脏手术后一氧化氮使用率更高（低容量与高容量相比，比值比[OR]：1.48，95%置信区间[CI]：1.38-1.60；中容量与高容量相比，OR：1.33，95%CI：1.26-1.41）。尽管一氧化氮使用率较高，但与高容量中心相比，低容量和中容量中心的死亡率更高（低容量与高容量相比，OR：1.42，95%CI：1.26-1.60；中容量与高容量相比，OR：1.14，95%CI：1.04-1.25）。
本研究表明，不同手术量中心的心脏手术后一氧化氮使用存在差异。此外，这引发了对儿科心脏手术后使用一氧化氮的益处的质疑。
