Department of Anesthesiology, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine & National Children's Medical Center (Shanghai), 1678 Dongfang Road, Shanghai 200127, China.
Pediatric Clinical Pharmacology Laboratory, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine & National Children's Medical Center (Shanghai), Shanghai, China.
Biomed Res Int. 2020 Nov 7;2020:2595960. doi: 10.1155/2020/2595960. eCollection 2020.
Fontan operation is a palliative medical procedure performed on children with single-ventricle defects. As postoperative success of the procedure largely depends on the preload volume, it is necessary to maintain an appropriate pressure gradient between the systemic vein and the left atrium to ensure the effective volume of systemic circulation. However, there is a lack of effective indexes to evaluate fluid responsiveness in Fontan patients. Stroke volume variation (SVV) is a dynamic hemodynamic parameter based on cardiopulmonary interaction in mechanical ventilation. This study is aimed at validating the sensitivity and specificity of SVV and central venous pressure (CVP) in assessing the fluid responsiveness of Fontan patients.
Sixty-four children with single ventricle who underwent modified Fontan operation between May 2018 and January 2020 were included in this study. Patients were administered 10 ml·kg albumin for fluid challenge within 10 min after cardiopulmonary bypass. Before and after fluid challenge, the invasive arterial pressure module was connected to MostCare™ equipment to collect the cardiac index (CI) and SVV dynamically in a time window of 30 s at a frequency of 1000 Hz. According to the range of CI change, patients with ΔCI ≥ 15% were classified into the responder (R) group and those with ΔCI < 15% into the nonresponder (NR) group. Using SVV and CVP as indicators, the receiver operating characteristic (ROC) curve of the patients was established, and the area under curve (AUC), diagnostic threshold, sensitivity, and specificity were calculated.
The SVV values were 16.28% (25th and 75th percentiles 14.17%-19.24%) and 13.68% (25th and 75th percentiles 12.90%-15.89%) before and after fluid challenge treatment in responders, respectively, and the values were 18.60 ± 1.83 mmHg before and 20.20 ± 2.39 mmHg for CVP after treatment. The AUC of SVV was 0.74 (95% confidence interval (CI) 0.54-0.94, < 0.05), and the cutoff value was 16%, offering a sensitivity of 50% and a specificity of 91.7%. Meanwhile, the AUC of CVP was 0.70 (95% CI 0.50-0.92, > 0.05), and the cutoff value was 19.5 mmHg, offering a sensitivity of 58% and a specificity of 76%.
SVV exhibited a good predictive value for fluid responsiveness in pediatric Fontan patients. Appropriate fluid therapy according to SVV could improve the cardiac function of such patients. . This study was registered in Chinese Clinical Trail Registry on Jan 26, 2018. Registration number is ChiCTR1800014654. Registry URL is http://www.chictr.org.cn/showproj.aspx?proj=25019. This observational prospective study was approved by the Local Ethics Committee of Shanghai Children's Medical Center affiliated to Shanghai Jiao Tong University (SCMCIRB-K2017035).
Fontan 手术是一种针对单心室缺陷儿童的姑息性医疗程序。由于该手术的术后成功率在很大程度上取决于前负荷容量，因此有必要在体静脉和左心房之间保持适当的压力梯度，以确保全身循环的有效容量。然而，目前缺乏评估 Fontan 患者液体反应性的有效指标。每搏变异度（SVV）是一种基于机械通气中心肺相互作用的动态血流动力学参数。本研究旨在验证 SVV 和中心静脉压（CVP）在评估 Fontan 患者液体反应性方面的敏感性和特异性。
本研究纳入了 2018 年 5 月至 2020 年 1 月期间接受改良 Fontan 手术的 64 例单心室儿童。患者在体外循环后 10 分钟内接受 10ml·kg 白蛋白的液体冲击。在液体冲击前后，将有创动脉压力模块连接到 MostCare™设备上，以在 1000Hz 的频率下在 30s 的时间窗口内动态收集心指数（CI）和 SVV。根据 CI 变化范围，将 CI 变化≥15%的患者分为反应者（R）组和 CI 变化<15%的非反应者（NR）组。使用 SVV 和 CVP 作为指标，为患者绘制 ROC 曲线，并计算曲线下面积（AUC）、诊断阈值、灵敏度和特异性。
反应者的 SVV 值分别为 16.28%（25%和 75%分别为 14.17%-19.24%）和 13.68%（25%和 75%分别为 12.90%-15.89%），治疗前后 CVP 值分别为 18.60±1.83mmHg 和 20.20±2.39mmHg。SVV 的 AUC 为 0.74（95%置信区间（CI）为 0.54-0.94， <0.05），截断值为 16%，灵敏度为 50%，特异性为 91.7%。同时，CVP 的 AUC 为 0.70（95%CI 为 0.50-0.92， >0.05），截断值为 19.5mmHg，灵敏度为 58%，特异性为 76%。
SVV 对儿科 Fontan 患者的液体反应性具有良好的预测价值。根据 SVV 进行适当的液体治疗可以改善此类患者的心脏功能。
本研究于 2018 年 1 月 26 日在中国临床试验注册中心注册。注册号为 ChiCTR1800014654。注册网址为 http://www.chictr.org.cn/showproj.aspx?proj=25019。本观察性前瞻性研究得到了上海交通大学附属上海儿童医学中心地方伦理委员会的批准（SCMCIRB-K2017035）。
