Neunhoeffer Felix, Hofbeck Michael, Schlensak Christian, Schuhmann Martin Ulrich, Michel Jörg
Department of Pediatric Cardiology, Pulmology and Pediatric Intensive Care Medicine, University Children's Hospital Tübingen, Hoppe-Seyler-Str. 1, 72076, Tuebingen, Germany.
Department of Thoracic and Cardiovascular Surgery, University Hospital Tübingen, Hoppe-Seyler-Str. 1, 72076, Tuebingen, Germany.
Pediatr Cardiol. 2018 Dec;39(8):1681-1687. doi: 10.1007/s00246-018-1952-2. Epub 2018 Aug 25.
Optimizing oxygen delivery to the brain is one of the main goals in children with congenital heart defects after surgery. It has been shown that cerebral oxygen saturation (cSO2) is depressed within the first day after neonatal cardiopulmonary bypass surgery. However, peri-operative cerebral oxygen metabolism has not yet been assessed in previous studies. The aim of this study was to describe the peri-operative changes in cerebral oxygen metabolism in neonates with congenital heart defects following cardiopulmonary bypass surgery. Prospective observational cohort study. PICU of a tertiary referral center. Fourteen neonates with hypoplastic left heart syndrome (HLHS) undergoing Norwood procedure and 14 neonates with transposition of great arteries (TGA) undergoing arterial switch operation (ASO) were enrolled. Pediatric heart surgery. We measured non-invasively regional cSO2 and microperfusion (rcFlow) using tissue spectrometry and laser Doppler flowmetry before and after surgery. Cerebral fractional tissue oxygen extraction (cFTOE), the arterio-cerebral difference in oxygen content (acDO2) and approximated cerebral metabolic rate of oxygen (aCMRO2) were calculated. According to the postsurgical hemodynamics, arterial saturation (aSO2) normalized immediately after surgery in the TGA group, whereas HLHS patients still were cyanotic. cSO2 significantly increased in TGA group over 48 h after ASO (p = 0.004) and was significantly higher compared to HLHS group after Norwood procedure. cFTOE as a risk marker for brain injury was elevated before surgery (TGA group 0.37 ± 0.10, HLHS group 0.42 ± 0.12) and showed a slight decrease after ASO (p = 0.35) but significantly decreased in patients after Norwood procedure (p = 0.02). Preo-peratively, acDO2 was significantly higher in patients with HLHS compared to patients with TGA (7.7 ± 2.5 vs. 5.2 ± 1.6 ml/dl, p = 0.005), but normalized in the posto-perative course. Before surgery, the aCMRO2 was slightly higher in the HLHS group (5.1 ± 1.5 vs. 3.9 ± 2.5 AU, p = 0.14), but significantly decreased after Norwood procedure (- 1.6 AU, p = 0.009). There was no difference in rcFlow between both groups and between the points in time prior and after surgery. Neonates undergoing cardiac surgery suffer from peri-operative changes in hemodynamics and cerebral hypoxemic stress. The cerebral oxygen metabolism seems to be more affected in cyanotic children with functionally univentricular hearts compared to post-operative acyanotic patients. Additional stress factors must be avoided to achieve the best possible neurological outcome.
优化脑氧输送是先天性心脏病患儿术后的主要目标之一。研究表明，新生儿体外循环心脏手术后第一天脑氧饱和度（cSO2）会降低。然而，以往研究尚未评估围手术期脑氧代谢情况。本研究旨在描述先天性心脏病新生儿体外循环心脏手术后围手术期脑氧代谢的变化。前瞻性观察队列研究。一家三级转诊中心的儿科重症监护病房。纳入14例接受诺伍德手术的左心发育不全综合征（HLHS）新生儿和14例接受动脉调转术（ASO）的大动脉转位（TGA）新生儿。小儿心脏手术。我们在手术前后使用组织光谱分析和激光多普勒血流仪无创测量局部cSO2和微灌注（rcFlow）。计算脑分数组织氧摄取率（cFTOE）、动脉血与脑的氧含量差值（acDO2）以及近似的脑氧代谢率（aCMRO2）。根据术后血流动力学情况，TGA组术后动脉血氧饱和度（aSO2）立即恢复正常，而HLHS患儿仍有青紫。TGA组在ASO术后48小时内cSO2显著升高（p = 0.004），且与诺伍德手术后的HLHS组相比显著更高。cFTOE作为脑损伤的风险标志物，术前升高（TGA组0.37±0.10，HLHS组0.42±0.12），ASO术后略有下降（p = 0.35），但诺伍德手术后患者显著下降（p = 0.02）。术前，HLHS患者的acDO2显著高于TGA患者（7.7±2.5 vs. 5.2±1.6 ml/dl，p = 0.005），但术后恢复正常。术前，HLHS组的aCMRO2略高（5.1±1.5 vs. 3.9±2.5 AU，p = 0.14），但诺伍德手术后显著下降（-1.6 AU，p = 0.009）。两组之间以及手术前后各时间点的rcFlow均无差异。接受心脏手术的新生儿在围手术期会出现血流动力学变化和脑缺氧应激。与术后无青紫的患儿相比，功能性单心室的青紫患儿的脑氧代谢似乎受影响更大。必须避免额外的应激因素以实现最佳的神经学预后。
