Duke T, Butt W, South M, Karl T R
Department of Paediatrics, Royal Children's Hospital, Parkville, Victoria, Australia.
J Thorac Cardiovasc Surg. 1997 Dec;114(6):1042-52. doi: 10.1016/S0022-5223(97)70018-7.
The purpose of this study was to determine the physiologic variables that predict major adverse events in children in the intensive care unit after cardiac operations.
A cohort observational study was conducted. At the time of admission to the intensive care unit and 4, 8, 12, and 24 hours later the following variables were recorded: mean arterial pressure, heart rate, cardiac index, oxygen delivery, mixed venous oxygen saturation, base deficit, blood lactate, gastric intramucosal pH, carbon dioxide difference (the difference between arterial carbon dioxide tension and gastric intraluminal carbon dioxide tension), and toe-core temperature gradient. Major adverse events were prospectively identified as cardiac arrest, need for emergency chest opening, development of multiple organ failure, and death.
Ninety children were included in the study; 12 had major adverse events and there were 4 deaths. Blood lactate level, mean arterial pressure, and duration of cardiopulmonary bypass were the only significant, independent predictors of major adverse events when measured at the time of admission to the intensive care unit. The odds ratio (95% confidence intervals) for major adverse events if a lactate level was greater than 4.5 mmol/L was 5.1 (1.2 to 21.1), for admission hypotension 2.3 (0.5 to 9.8), and for a cardiopulmonary bypass time greater than 150 minutes 13.7 (3.3 to 57.2). Four hours after admission lactate and carbon dioxide difference, and 8 hours after admission lactate and base deficit, were independently significant predictors. The odds ratios for major adverse events if the blood lactate level was greater than 4 mmol/L at 4 and 8 hours were 8.3 (1.8 to 38.4) and 9.3 (1.9 to 44.3), respectively. At no time in the first 24 hours were cardiac output, oxygen delivery, mixed venous oxygen saturation, toe-core temperature gradient, or heart rate significant predictors of major adverse events.
In the context of our current treatment strategies, the duration of cardiopulmonary bypass and blood lactate level, measured in the early postoperative period, were the best predictors of impending major adverse events.
本研究旨在确定预测心脏手术后重症监护病房儿童发生主要不良事件的生理变量。
进行了一项队列观察性研究。在重症监护病房入院时以及入院后4、8、12和24小时记录以下变量：平均动脉压、心率、心脏指数、氧输送、混合静脉血氧饱和度、碱缺失、血乳酸、胃黏膜内pH值、二氧化碳差值（动脉血二氧化碳分压与胃腔内二氧化碳分压之间的差值）以及趾-核心温度梯度。主要不良事件被前瞻性地确定为心脏骤停、急诊开胸需求、多器官功能衰竭的发生以及死亡。
90名儿童纳入研究；12名发生主要不良事件，4例死亡。在重症监护病房入院时测量，血乳酸水平、平均动脉压和体外循环持续时间是主要不良事件仅有的显著、独立预测因素。如果乳酸水平大于4.5 mmol/L，发生主要不良事件的比值比（95%置信区间）为5.1（1.2至21.1），入院时低血压为2.3（0.5至9.8），体外循环时间大于150分钟为13.7（3.3至57.2）。入院后4小时乳酸和二氧化碳差值，以及入院后8小时乳酸和碱缺失是独立的显著预测因素。如果在4小时和8小时血乳酸水平大于4 mmol/L，发生主要不良事件的比值比分别为8.3（1.8至38.4）和9.3（1.9至44.3）。在术后最初24小时内，心输出量、氧输送、混合静脉血氧饱和度、趾-核心温度梯度或心率均不是主要不良事件的显著预测因素。
在我们当前的治疗策略背景下，术后早期测量的体外循环持续时间和血乳酸水平是即将发生主要不良事件的最佳预测因素。
