经肺热稀释法在婴幼儿先天性心脏病术后血流动力学监测中的临床应用
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摘要
目的：
通过临床应用经肺热稀释(Transpulmonary Thermodilution TPTD)法进行婴幼儿先天性心脏病(先心病)术后血流动力学监测：①验证婴幼儿先心病术后应用全心舒张末期容积指数(GEDVI)作为前负荷指标的有效性；②观察婴幼儿先心病术后早期(48小时内)心指数(CI)变化情况。探讨TPTD法在小儿先心术后血流动力学监护中的应用前景,为指导临床治疗提供更为可靠有力的依据。
对象和方法：
前瞻性研究,选取浙江大学附属儿童医院2009年8月-2010年4月期间心胸外科经体外循环进行心脏手术的3岁以下先心病患儿18例,排除股动脉穿刺和热稀释导管置入禁忌症,严重凝血功能异常,术后心内分流及严重心脏瓣膜功能不全。18例患儿中单纯室间隔缺损(VSD)6例,(VSD组)；室间隔缺损合并肺动脉高压(VSD+PH)6例,(VSD+PH组)；法洛氏四联症(TOF)6例,(TOF组)。术前经颈内静脉置入中心静脉导管,术中置入左房测压管以进行左房压力监测。术后经股动脉置入热稀释导管。在置入热稀释导管当时,术后4,8,12,24,48小时共6个时间点应用TPTD法进行血流动力学监测,每个时间点均测量3次,取平均值。
记录数据包括CI、SVI、GEDVI、LAP和CVP值。
统计学处理：
采用Microsoft Excel和SPSS16.0软件包进行统计处理,对所有数据进行正态性和方差齐性检验。数据符合正态性分布的以均数±标准差(x±s)表示,不符合正态性分布的以中位数±四分位间距表示(M±QD)；检验各时间点数据的趋势分布采用重复测量方差分析法；比较各组间和不同时点间数据的差异采用方差分析法,如变量偏态分布则作秩和检验；变量间的相关分析采用Pearson相关分析,并且用散点图表示数据的分布状态。P<0.05为差异具有显著性。
结果：
1.所有患儿均顺利出院,研究进行期间未发生因安置、撤除导管或导管留置而发生的出血、感染、心律失常、血栓、肢体缺血等并发症。
2.婴幼儿先心术后GEDVI与SVI显著相关,其相关性优于LAP与SVI的相关性,而CVP与SVI不相关。按病种分组后分析显示婴幼儿VSD术后GEDVI与SVI显著相关,优于LAP和CVP与SVI的相关性；婴幼儿VSD+PH术后GEDVI与SVI显著相关,优于LAP与SVI的相关性,而CVP与SVI不相关；婴幼儿TOF术后GEDVI与SVI显著相关,而CVP、LAP与SVI不相关。
3.婴幼儿先心病术后CI值在前12h内有逐渐降低趋势,术后12h相对最低,而在术后24h,48h时均较前有上升趋势,术后48小时CI值与术后0,4,8,12h时的CI值相比均有明显上升(P<0.05)。
4.按病种分组后CI变化：VSD组术后CI变化趋势不明显,各点间CI值均无明显差异；VSD+PH组CI值在前12h有下降趋势,术后12h时相对最低,术后24h,48h时较前有上升趋势,且术后48h时CI值显著高于术后12h时的CI值；在TOF组CI值术后8h、12h时相对最低,术后24h,48h时CI值较前有上升趋势,且术后48h时CI值明显高于术后前12小时的CI值。VSD组与TOF组比较,术后(0,4,8,12,24,48)h各点的CI值均显著高于TOF组(P<0.05)；与VSD+PH组比较,术后12h时CI值显著高于VSD+PH组(P<0.05)。VSD+PH组术后CI值高于TOF组,但仅术后8h时有统计学差异(P<0.05)。
结论：
1.婴幼儿先心术后GEDVI与SVI显著相关,无论在VSD、VSD+PH还是在TOF组其相关性均优于LAP. CVP, GEDVI能较CVP,LAP更能反映心脏前负荷指标。
2.婴幼儿先心术后采用TPTD法监测心脏前负荷、心功能等参数,可较准确反映循环功能变化。
Object:
Through the clinical application of transpulmonary thermodilution in infants after cardiac surgery with congenital heart disease①Ttry to validate GEDVI as cardiac preload in early period (in 48 hours) postoperative of congenital heart disease.②Observe the CI changes in early period (in 48 hours) postoperative of congenital heart disease, so as to guide a more reliable and effective clinical treatment.
Patients and method:
Include criteria:infants(less than 3 years old)who underwent cardiac surgery with bypass for congenital heart disease in ZheJiang Univertisy affiliated children's hospitiabetween August 2009 and April 2010.Ruled out criteria:the femoral artery puncture or thermal dilution catheter insertion contraindications, cardiac shunt or severe cardiac valve insufficiency.18 cases were selected including simple ventricular septal defect (VSD) 6 cases (VSD group); ventricular septal defect with pulmonary hypertension (VSD+PH) 6 cases, (VSD+PH group); tetralogy of Fallot (TOF) 6 cases (TOF group).
Insert jugular central venous catheter preoperation; Place left atrium catheter intraoperation. When was transported to SICU, PiCCO thermodilution catheter was placed into femoral artery.Then use TPTD method Rapidly inject 3-5ml 4℃saline into the central venous catheter for three times and then write down the averaged indicates to record CI, GEDVI, meanwhile, recorded the LAP and CVP value at 6 interval times (0,4,8,12,24,48h) postoperation.
Statistical Analysis
All statistical analysis was computed by SPSS 16.0 software. All data are expressed as mean values standard deviations (mean±SD). All hemodynamic and volumetric data obtained were analyzed with analysis of variance for repeated measurements and LSD. Statistical significance was considered to be at P<0.05.
Results:
1. All of the 18 cases were discharged, did not occur complications such as bleeding, infection, arrhythmia, thrombosis, limb ischemia because of the catheter placement, removement or occurrence during the study period.
2. Infants with congenital heart disease in postoperative period GEDVI was significantly correlated with SVI, better than the correlation of LAP with SVI while CVP was significantly correlated with SVI. In VSD group GEDVI was significantly correlation with SVI, better than CVP, LAP. In VSD+PH group GEDVI was significantly correlated with SVI, better than the correlation of LAP with SVI while CVP was not significantly correlated with SVI. In TOF group GEDVI was significantly correlated with SVI, while CVP and LAP was not significantly correlated with SVI.
3. CI value in infants with congenital heart disease gradually decreased within the first 12 h postoperatively, and at the point of 24h,48h postoperatively it has upward trend compared with before, CI values of 48 postoperatively increased significantly compared to the CI values of 0,4h,8h,12h postoperatively. (P<0.05).
4. Grouped CI changes:CI values of VSD group is higher than VSD+PH group and the TOF group, all the time points of the CI values were significantly higher than the TOF group (P<0.05), and CI value of 12h postoperatively was significantly higher than the VSD+PH group (P<0.05). CI value of VSD+PH group was higher than the CI value of TOF group, but only the point of 8h postoperatively significant differences (P<0.05).In VSD group the CI value changed insignificantly by time. In the VSD+PH group,the CI value gradually decreased within the first 12 h postoperatively and 24,48h, it has upward trend compared with before.,and the CI value of 48h postoperatively increased significantly compared to 12h postoperatively (P<0.05).In the TOF group,CI value is the lowest at the 8 and 12 h postoperatively, and at the 24h and 48h, it has upward trend compared with before,CI values of 48h postoperatively increased significantly compared to the CI values of 0,4h,8h,12h postoperatively (P<0.05).
Conclusion:
1. In VSD group GEDVI was significantly correlated with SVI, better than CVP and LAP; In VSD+PH group GEDVI was significantly correlated with SVI, CVP and LAP was not correlated with SVI. than CVP, LAP.GEDVI was more accurately reflect cardiac preload.
2. Parameters monitored by TPTD can accurately reflects the circulation situation in infants with congenital heart after cardiac surgery.
通过临床应用经肺热稀释(Transpulmonary Thermodilution TPTD)法进行婴幼儿先天性心脏病(先心病)术后血流动力学监测：①验证婴幼儿先心病术后应用全心舒张末期容积指数(GEDVI)作为前负荷指标的有效性；②观察婴幼儿先心病术后早期(48小时内)心指数(CI)变化情况。探讨TPTD法在小儿先心术后血流动力学监护中的应用前景,为指导临床治疗提供更为可靠有力的依据。
对象和方法：
前瞻性研究,选取浙江大学附属儿童医院2009年8月-2010年4月期间心胸外科经体外循环进行心脏手术的3岁以下先心病患儿18例,排除股动脉穿刺和热稀释导管置入禁忌症,严重凝血功能异常,术后心内分流及严重心脏瓣膜功能不全。18例患儿中单纯室间隔缺损(VSD)6例,(VSD组)；室间隔缺损合并肺动脉高压(VSD+PH)6例,(VSD+PH组)；法洛氏四联症(TOF)6例,(TOF组)。术前经颈内静脉置入中心静脉导管,术中置入左房测压管以进行左房压力监测。术后经股动脉置入热稀释导管。在置入热稀释导管当时,术后4,8,12,24,48小时共6个时间点应用TPTD法进行血流动力学监测,每个时间点均测量3次,取平均值。
记录数据包括CI、SVI、GEDVI、LAP和CVP值。
统计学处理：
采用Microsoft Excel和SPSS16.0软件包进行统计处理,对所有数据进行正态性和方差齐性检验。数据符合正态性分布的以均数±标准差(x±s)表示,不符合正态性分布的以中位数±四分位间距表示(M±QD)；检验各时间点数据的趋势分布采用重复测量方差分析法；比较各组间和不同时点间数据的差异采用方差分析法,如变量偏态分布则作秩和检验；变量间的相关分析采用Pearson相关分析,并且用散点图表示数据的分布状态。P<0.05为差异具有显著性。
结果：
1.所有患儿均顺利出院,研究进行期间未发生因安置、撤除导管或导管留置而发生的出血、感染、心律失常、血栓、肢体缺血等并发症。
2.婴幼儿先心术后GEDVI与SVI显著相关,其相关性优于LAP与SVI的相关性,而CVP与SVI不相关。按病种分组后分析显示婴幼儿VSD术后GEDVI与SVI显著相关,优于LAP和CVP与SVI的相关性；婴幼儿VSD+PH术后GEDVI与SVI显著相关,优于LAP与SVI的相关性,而CVP与SVI不相关；婴幼儿TOF术后GEDVI与SVI显著相关,而CVP、LAP与SVI不相关。
3.婴幼儿先心病术后CI值在前12h内有逐渐降低趋势,术后12h相对最低,而在术后24h,48h时均较前有上升趋势,术后48小时CI值与术后0,4,8,12h时的CI值相比均有明显上升(P<0.05)。
4.按病种分组后CI变化：VSD组术后CI变化趋势不明显,各点间CI值均无明显差异；VSD+PH组CI值在前12h有下降趋势,术后12h时相对最低,术后24h,48h时较前有上升趋势,且术后48h时CI值显著高于术后12h时的CI值；在TOF组CI值术后8h、12h时相对最低,术后24h,48h时CI值较前有上升趋势,且术后48h时CI值明显高于术后前12小时的CI值。VSD组与TOF组比较,术后(0,4,8,12,24,48)h各点的CI值均显著高于TOF组(P<0.05)；与VSD+PH组比较,术后12h时CI值显著高于VSD+PH组(P<0.05)。VSD+PH组术后CI值高于TOF组,但仅术后8h时有统计学差异(P<0.05)。
结论：
1.婴幼儿先心术后GEDVI与SVI显著相关,无论在VSD、VSD+PH还是在TOF组其相关性均优于LAP. CVP, GEDVI能较CVP,LAP更能反映心脏前负荷指标。
2.婴幼儿先心术后采用TPTD法监测心脏前负荷、心功能等参数,可较准确反映循环功能变化。
Object:
Through the clinical application of transpulmonary thermodilution in infants after cardiac surgery with congenital heart disease①Ttry to validate GEDVI as cardiac preload in early period (in 48 hours) postoperative of congenital heart disease.②Observe the CI changes in early period (in 48 hours) postoperative of congenital heart disease, so as to guide a more reliable and effective clinical treatment.
Patients and method:
Include criteria:infants(less than 3 years old)who underwent cardiac surgery with bypass for congenital heart disease in ZheJiang Univertisy affiliated children's hospitiabetween August 2009 and April 2010.Ruled out criteria:the femoral artery puncture or thermal dilution catheter insertion contraindications, cardiac shunt or severe cardiac valve insufficiency.18 cases were selected including simple ventricular septal defect (VSD) 6 cases (VSD group); ventricular septal defect with pulmonary hypertension (VSD+PH) 6 cases, (VSD+PH group); tetralogy of Fallot (TOF) 6 cases (TOF group).
Insert jugular central venous catheter preoperation; Place left atrium catheter intraoperation. When was transported to SICU, PiCCO thermodilution catheter was placed into femoral artery.Then use TPTD method Rapidly inject 3-5ml 4℃saline into the central venous catheter for three times and then write down the averaged indicates to record CI, GEDVI, meanwhile, recorded the LAP and CVP value at 6 interval times (0,4,8,12,24,48h) postoperation.
Statistical Analysis
All statistical analysis was computed by SPSS 16.0 software. All data are expressed as mean values standard deviations (mean±SD). All hemodynamic and volumetric data obtained were analyzed with analysis of variance for repeated measurements and LSD. Statistical significance was considered to be at P<0.05.
Results:
1. All of the 18 cases were discharged, did not occur complications such as bleeding, infection, arrhythmia, thrombosis, limb ischemia because of the catheter placement, removement or occurrence during the study period.
2. Infants with congenital heart disease in postoperative period GEDVI was significantly correlated with SVI, better than the correlation of LAP with SVI while CVP was significantly correlated with SVI. In VSD group GEDVI was significantly correlation with SVI, better than CVP, LAP. In VSD+PH group GEDVI was significantly correlated with SVI, better than the correlation of LAP with SVI while CVP was not significantly correlated with SVI. In TOF group GEDVI was significantly correlated with SVI, while CVP and LAP was not significantly correlated with SVI.
3. CI value in infants with congenital heart disease gradually decreased within the first 12 h postoperatively, and at the point of 24h,48h postoperatively it has upward trend compared with before, CI values of 48 postoperatively increased significantly compared to the CI values of 0,4h,8h,12h postoperatively. (P<0.05).
4. Grouped CI changes:CI values of VSD group is higher than VSD+PH group and the TOF group, all the time points of the CI values were significantly higher than the TOF group (P<0.05), and CI value of 12h postoperatively was significantly higher than the VSD+PH group (P<0.05). CI value of VSD+PH group was higher than the CI value of TOF group, but only the point of 8h postoperatively significant differences (P<0.05).In VSD group the CI value changed insignificantly by time. In the VSD+PH group,the CI value gradually decreased within the first 12 h postoperatively and 24,48h, it has upward trend compared with before.,and the CI value of 48h postoperatively increased significantly compared to 12h postoperatively (P<0.05).In the TOF group,CI value is the lowest at the 8 and 12 h postoperatively, and at the 24h and 48h, it has upward trend compared with before,CI values of 48h postoperatively increased significantly compared to the CI values of 0,4h,8h,12h postoperatively (P<0.05).
Conclusion:
1. In VSD group GEDVI was significantly correlated with SVI, better than CVP and LAP; In VSD+PH group GEDVI was significantly correlated with SVI, CVP and LAP was not correlated with SVI. than CVP, LAP.GEDVI was more accurately reflect cardiac preload.
2. Parameters monitored by TPTD can accurately reflects the circulation situation in infants with congenital heart after cardiac surgery.
引文
[1]Palmieri TL. The inventors of the SwanGanz catheter:H. J. C. Swan and Willian Ganz[J]. Curr Surg,2002,60(3):351-352.
[2]Elliaott CG Zimmerman GA,Clammer TP. Complications of pulmonary artery catheterzation n the care of critically ill patients. A prospective study[J]. Chest, 1979,76(6):647-652.
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[12]Buhre W, Bendyk K, Weyland A et al. Assessment of intrathoracic blood volume. Thermo-dye dilution technique vs single thermodilution technique [J]. Anaesthesist, 1998;47(1):51-53.
[13]Shane Tibby,. Transpulmonary thermodilution:Finally, a gold standard for pediatric cardiac output measurement[J]. Pediatr Crit Care Med 2008 Vol.9. No. 3:341-342.
[14]Newman EV, Merrel M, Genecin A, et al. The dye dilution method for describingthe central circulation:an analysis of factors shading the time-concentration curves [J]. Circulation 1951;4:735-746.
[15]Bindels AJ, van der Hoeven JG, Graafland AD, et al. Relationships between volume and pressure measurements and stroke volume in critically ill patients[J]. Crit Care,2000;4:193-199.
[16]Michard F, Alaya S,Zarka V et al. Global end-diastolic volume as an indiicator of cardiac preload in patients with septic shock[J]. Chest 2003,124:1900-1908.
[17]Mahajan A, Shabanie A, Turner J, et al. Pulse Contour Analysis for Cardiac Output Monitoring in Cardiac Surgery for Congenital Heart Disease[J]. Anesth Analg,2003:97:1283-1288.
[18]Corrado C, Riccardo L, Sebastian C; Relationship between global end-diastolic volume and cardiac output in critically ill infants and children[J]. Crit Care Med 2008 Vol.36. No.3:928-932.
[19]Luecke T, Roth H, Hemnann P, et al. Assessment of cardiac preload and left ventricular function under increasing levels of positive end-expiratory pressure[J]. Intensive Care Med,2004;30:119-126.
[20]Hofer CK, Furrer L, Matter-Ensner S, et al. Volumetric preload measurement by thermodilution:a comparison with transoesophageal echocardiography[J]. Br J Anaesth,2005;94:748-755
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