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Monitoring Value of Central Venous Oxygen Saturation, the Substitute for Mixed Venous Oxygen Saturation, in Postoperative Care of Congenital Heart Disease with Pulmonary Arterial Hypertension:a Multicenter Prospective Study
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摘要:
目的 探讨中心静脉氧饱和度(central venous oxygen saturation, ScvO2)与混合静脉氧饱和度(mixed venous oxygen saturation, SvO2)对先天性心脏病(congenital heart disease, CHD)合并肺动脉高压(pulmonary arterial hypertension, PAH)患者修补术后评估价值的一致性。 方法 本研究前瞻性选取2016年3月至2017年3月, 于河南省人民医院、北京阜外医院、广州中山大学第八附属医院及四川省广元市第一人民医院接受治疗且符合入选及排除标准的43例CHD-PAH患者, 分别于停体外循环后即刻及转入重症监护室后6、12、24、48 h等5个时间点, 同时测量ScvO2及SvO2, 并记录血流动力学参数、血红蛋白及乳酸等指标。采用Bland-Altman检验分析两个指标的一致性, 采用线性回归分析两指标偏倚的相关影响因素。 结果 ScvO2和SvO2的总体相关系数R2=0.369, 体外循环后即刻R2=0.515, 入重症监护室后6、12、24、48 h的R2分别为0.375、0.605、0.712、0.252。Bland-Altman检验显示ScvO2与SvO2的偏倚(△ScvO2﹣SvO2)为-1.3%, 一致性区间(limits of agreement, LOA)为(-17.0%, 14.4%)。总体上氧摄取率(oxygen extraction rate, O2ER)(R2=0.030, P < 0.05)、肺动脉收缩压(R2=0.030, P < 0.05)和心率(R2=0.032, P < 0.05)对△ScvO2-SvO2的影响较小; 当ScvO2 < 70%时, O2ER(R2=0.203, P < 0.01)、肺动脉收缩压(R2=0.110, P < 0.01)、心率(R2=0.150, P < 0.01)对△ScvO2-SvO2的影响则较大, 此时ScvO2有低估SvO2的趋势, 而当ScvO2 ≥ 70%时, ScvO2会高估SvO2。机械通气期间ScvO2与SvO2的偏倚为-1.3%, LOA为(-16.1%, 13.5%), △ScvO2-SvO2的影响因素为O2ER(R2=0.122, P < 0.01);撤机后ScvO2与SvO2的偏倚为-1.3%, LOA为(-19.5%, 16.8%), △ScvO2-SvO2的影响因素为O2ER(R2=0.320, P < 0.01)和动脉氧饱和度(R2=0.320, P < 0.01)。 结论 CHD-PAH患者术后监护中ScvO2不能替代SvO2的评估价值。当ScvO2 ≥ 70%时, 宜同时监测ScvO2与SvO2以排除低灌注状态。 Abstract:Objective This study aimed to investigate the agreement of central venous oxygen saturation (ScvO2) with mixed venous oxygen saturation (SvO2) in postoperative care of congenital heart disease (CHD)with pulmonary arterial hypertension (PAH). Methods Forty-three patients undergoing CHD-PAH repairing surgery were prospectively selected from Henan Provincial People's Hospital, Fuwai Hospital, the Eighth Affiliated Hospital of Sun Yat-sen University, and the First People's Hospital of Guanyuang from March 2016 to March 2017. Data of ScvO2 and SvO2 were synchronously collected after cardiopulmonary bypass (CPB), and 6, 12, 24, and 48 hours after admission to the intensive care unit. In addition, hemodynamic parameters, hemoglobin, and arterial lactate were recorded. Data were analyzed by Bland-Altman test and linear regression analysis. Results The overall R2 of ScvO2 to SvO2 for the pooled measurements was 0.369. R2 of post-CPB, 6, 12, 24, 48 hours after admission to the intensive care unit were 0.515, 0.375, 0.605, 0.712, and 0.252, respectively. Bland-Altman test for ScvO2 and SvO2 showed that the mean bias was -1.3% and limits of agreement (LOA) were -17.0% to 14.4%. In general, the influences of oxygen extraction rate (O2ER) (R2=0.030, P < 0.05), pulmonary artery systolic pressure (SPAP) (R2=0.030, P < 0.05), and heart rate (HR) (R2=0.032, P < 0.05) on △ScvO2-SvO2 were relatively small; when ScvO2 was < 70%, the influences of O2ER (R2=0.203, P < 0.01), SPAP (R2=0.110, P < 0.01), and HR (R2=0.150, P < 0.01) were much greater, and ScvO2 would underestimate SvO2; ScvO2 might overestimate SvO2 when ≥ 70%. Bland-Altman test indicated during mechanical ventilation the mean bias of ScvO2 and SvO2 (△ScvO2-SvO2) was -1.3% and LOA were -16.1% to 13.5%, the only factor influencing △ScvO2-SvO2 was O2ER (R2=0.122, P < 0.01); without mechanical ventilation, the mean bias was -1.3% and LOA were -19.5% to 16.8%, and the influence on △ScvO2-SvO2 were O2ER (R2=0.320, P < 0.01) and arterial oxygen saturation (R2=0.320, P < 0.01). Conclusions ScvO2 cannot replace SvO2 in postoperative care for patients with CHD-PAH. ScvO2 and SvO2 should be monitored respectively to exclude the hypo-perfusion state when ScvO2 ≥ 70%. -
图 1 CHD-PAH患者术后48 h内各监测时间点的ScvO2和SvO2
CHD:先天性心脏病; PAH:肺动脉高压; ScvO2:中心静脉氧饱和度; SvO2:混合静脉氧饱和度
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