Song Young, Soh Sarah, Shim Jae-Kwang, Park Kyoung-Un, Kwak Young-Lan
Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seodaemun-gu, Seoul, Republic of Korea.
Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seodaemun-gu, Seoul, Republic of Korea.
PLoS One. 2017 Sep 19;12(9):e0184555. doi: 10.1371/journal.pone.0184555. eCollection 2017.
Hemodynamic management aims to provide adequate tissue perfusion, which is often altered during cardiac surgery with cardiopulmonary bypass (CPB). We evaluated whether skin perfusion pressure (SPP) can be used for monitoring of adequacy of tissue perfusion in patients undergoing valvular heart surgery. Seventy-two patients undergoing valve replacement were enrolled. SPP and serum lactate level were assessed after anaesthesia induction (baseline), during CPB, after CPB-off, end of surgery, arrival at intensive care unit, and postoperative 6 h. Lactate was further measured until postoperative 48 h. Association of SPP with lactate and 30-day morbidity comprising myocardial infarction, acute kidney injury, stroke, prolonged intubation, sternal infection, reoperation, and mortality was assessed. Among the lactate levels, postoperative 6 h peak value was most closely linked to composite of 30-day morbidity. The SPP value during CPB and its % change from the baseline value were significantly associated with the postoperative 6 h peak lactate (r = -0.26, P = 0.030 and r = 0.47, P = 0.001, respectively). Optimal cut-off of % decrease in SPP during CPB from baseline value for the postoperative 6 h hyperlactatemia was 48% (area under curve, 0.808; 95% confidence interval (CI), 0.652-0.963; P = 0.001). Decrease in SPP >48% during CPB from baseline value was associated with a 12.8-fold increased risk of composite endpoint of 30-day morbidity (95% CI, 1.48-111.42; P = 0.021) on multivariate logistic regression. Large decrease in SPP during CPB predicts postoperative 6 h hyperlactatemia and 30-day morbidity, which implicates a promising role of SPP monitoring in the achievement of optimal perfusion during CPB.
血流动力学管理旨在提供充足的组织灌注，而在体外循环（CPB）心脏手术期间组织灌注常常会发生改变。我们评估了皮肤灌注压（SPP）是否可用于监测心脏瓣膜手术患者的组织灌注充足情况。纳入了72例行瓣膜置换术的患者。在麻醉诱导后（基线）、CPB期间、CPB结束后、手术结束时、到达重症监护病房时以及术后6小时评估SPP和血清乳酸水平。术后48小时内进一步检测乳酸。评估SPP与乳酸以及包括心肌梗死、急性肾损伤、中风、长时间插管、胸骨感染、再次手术和死亡率在内的30天发病率之间的关联。在乳酸水平中，术后6小时峰值与30天发病率的综合指标关联最为密切。CPB期间的SPP值及其相对于基线值的变化百分比与术后6小时乳酸峰值显著相关（分别为r = -0.26，P = 0.030和r = 0.47，P = 0.001）。CPB期间相对于基线值SPP降低百分比对于术后6小时高乳酸血症的最佳截断值为48%（曲线下面积，0.808；95%置信区间（CI），0.652 - 0.963；P = 0.001）。CPB期间相对于基线值SPP降低>48%与30天发病率综合终点的风险增加12.8倍相关（95% CI，1.48 - 111.42；P = 0.021），多因素逻辑回归分析显示。CPB期间SPP大幅下降可预测术后6小时高乳酸血症和30天发病率，这表明SPP监测在CPB期间实现最佳灌注方面具有潜在作用。
