Hoffman George M, Scott John P, Stuth Eckehard A
Division of Pediatric Cardiac Anesthesia, Children's Hospital of Wisconsin Herma Heart Institute, Milwaukee, WI, United States.
Division of Pediatric Cardiac Critical Care, Children's Hospital of Wisconsin Herma Heart Institute, Milwaukee, WI, United States.
Front Pediatr. 2022 Feb 11;10:762739. doi: 10.3389/fped.2022.762739. eCollection 2022.
Neonates undergoing the Norwood procedure for hypoplastic left heart syndrome are at higher risk of impaired systemic oxygen delivery with resultant brain, kidney, and intestinal ischemic injury, shock, and death. Complex developmental, anatomic, and treatment-related influences on cerebral and renal-somatic circulations make individualized treatment strategies physiologically attractive. Monitoring cerebral and renal circulations with near infrared spectroscopy can help drive rational therapeutic interventions. The primary aim of this study was to describe the differential effects of carbon dioxide tension on cerebral and renal circulations in neonates after the Norwood procedure. Using a prospectively-maintained database of postoperative physiologic and hemodynamic parameters, we analyzed the relationship between postoperative arterial carbon dioxide tension and tissue oxygen saturation and arteriovenous saturation difference in cerebral and renal regions, applying univariate and multivariate multilevel mixed regression techniques. Results were available from 7,644 h of data in 178 patients. Increases in arterial carbon dioxide tension were associated with increased cerebral and decreased renal oxygen saturation. Differential changes in arteriovenous saturation difference explained these effects. The cerebral circulation showed more carbon dioxide sensitivity in the early postoperative period, while sensitivity in the renal circulation increased over time. Multivariate models supported the univariate findings and defined complex time-dependent interactions presented graphically. The cerebral and renal circulations may compete for blood flow with critical limitations of cardiac output. The cerebral and renal-somatic beds have different circulatory control mechanisms that can be manipulated to change the distribution of cardiac output by altering the arterial carbon dioxide tension. Monitoring cerebral and renal circulations with near infrared spectroscopy can provide rational physiologic targets for individualized treatment.
接受诺伍德手术治疗左心发育不全综合征的新生儿，发生全身氧输送受损并导致脑、肾和肠道缺血性损伤、休克及死亡的风险更高。大脑和肾-体循环受到复杂的发育、解剖及与治疗相关的影响，这使得个体化治疗策略在生理上颇具吸引力。利用近红外光谱监测脑循环和肾循环有助于推动合理的治疗干预。本研究的主要目的是描述诺伍德手术后新生儿二氧化碳分压对脑循环和肾循环的不同影响。我们使用一个前瞻性维护的术后生理和血流动力学参数数据库，应用单变量和多变量多层次混合回归技术，分析术后动脉二氧化碳分压与脑区和肾区组织氧饱和度及动静脉饱和度差之间的关系。178例患者的7644小时数据可供分析。动脉二氧化碳分压升高与脑氧饱和度升高和肾氧饱和度降低相关。动静脉饱和度差的差异变化解释了这些影响。脑循环在术后早期对二氧化碳更敏感，而肾循环的敏感性随时间增加。多变量模型支持单变量研究结果，并以图形方式定义了复杂的时间依赖性相互作用。脑循环和肾循环可能在心脏输出量严重受限的情况下争夺血流。脑和肾-体床具有不同的循环控制机制，可通过改变动脉二氧化碳分压来操纵这些机制，以改变心脏输出量的分布。利用近红外光谱监测脑循环和肾循环可为个体化治疗提供合理的生理靶点。
