Liu Hong, Zheng Si-Qiang, Zeng Zhi-Hua, Liu Zhi-Gang, Liu Xiao-Cheng, Shao Yong-Feng
Department of Cardiovascular Surgery, the First Affiliated Hospital of Nanjing Medical University, Nanjing, P.R. China.
Department of Cardiovascular Surgery, Graduate School, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P.R. China.
Shock. 2020 Jul;54(1):21-29. doi: 10.1097/SHK.0000000000001475.
Little is known regarding precise estimates of the association between perfusate oxygenation (PpO2) and acute lung injury (ALI) following tetralogy of Fallot repair. The objective is to investigate PpO2 and the risk of ALI following tetralogy of Fallot repair in pediatric patients.
We conducted a nested case-control study within a prospective Chinese TedaICH cohort including 134 ALI patients aged 1 month to 18 years undergoing complete repair of tetralogy of Fallot, and each was matched to two controls. We selected the highest PpO2 during aortic crossclamp as the exposure. Conditional logistic regression was used to quantify the association between PpO2 and overall ALI risk by covariates of interest. We identified and integrated the risk covariates to build ALI nomograms and internally validated the nomograms using bootstrapping.
After adjusting for covariates, continuously and categorically higher PpO2 values were associated with ALI risk (all P < 0.05), especially for those with a z-score of pulmonary annulus < -4.0 (P = 0.002), McGoon ratio < 1.5 (P = 0.029), and major aortopulmonary collateral arteries (P = 0.005), despite no statistical heterogeneity (all P interaction >0.05). Younger age, lower oxyhemoglobin saturation, untreated minor aortopulmonary collateral arteries, transannular patch, larger transpulmonary gradient, major transfusion, and longer cardiopulmonary bypass time were independent risk factors for ALI (all P < 0.05). Combining the PpO2 nomogram provided further risk discriminative information on ALI diagnosis compared with the covariate-based nomogram alone in the training cohort (AUC 0.865, 95% CI [0.828-0.903] vs. 0.869 [0.832-0.906], respectively) with no statistical significance (P = 0.445).
The findings suggested an association between high PpO2 and ALI risk, and more importance should be attached to independent risk factors for ALI.
关于法洛四联症修复术后灌注液氧合（PpO2）与急性肺损伤（ALI）之间关联的精确估计所知甚少。本研究旨在调查小儿法洛四联症修复术后的PpO2及ALI风险。
我们在中国泰达国际心血管病医院前瞻性队列中进行了一项巢式病例对照研究，纳入134例年龄在1个月至18岁之间接受法洛四联症完全修复术的ALI患者，每例患者匹配两名对照。我们选择主动脉交叉钳夹期间的最高PpO2作为暴露因素。采用条件逻辑回归，通过感兴趣的协变量来量化PpO2与总体ALI风险之间的关联。我们识别并整合风险协变量以构建ALI列线图，并使用自抽样法对列线图进行内部验证。
在对协变量进行调整后，持续且分类的较高PpO2值与ALI风险相关（所有P<0.05），特别是对于那些肺动脉环z评分<-4.0（P=0.002）、麦戈恩比率<1.5（P=0.029）以及存在主要主肺动脉侧支血管的患者（P=0.005），尽管无统计学异质性（所有P交互作用>0.05）。年龄较小、氧合血红蛋白饱和度较低、未处理的次要主肺动脉侧支血管、跨环补片、较大的跨肺压差、大量输血以及较长的体外循环时间是ALI的独立危险因素（所有P<0.05）。与仅基于协变量的列线图相比，在训练队列中，结合PpO2列线图为ALI诊断提供了更多的风险判别信息（分别为AUC 0.865，95%CI[0.828-0.903]与0.869[0.832-0.906]），但无统计学意义（P=0.445）。
研究结果提示高PpO2与ALI风险之间存在关联，且应更加重视ALI的独立危险因素。
