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中心静脉压峰值与体外循环心脏术后急性肾损伤的相关性
Peak Value of Central Venous Pressure and Acute Kidney Injury in Cardiac Patients After Cardiopulmonary Bypass Surgery
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摘要:目的 探究体外循环心脏手术(cardiopulmonary bypass surgery, CBS)后中心静脉压峰值(peak value of central venous pressure, CVPp)与急性肾损伤(acute kidney injury, AKI)的关系。方法 回顾性收集2016年5月1日至2018年5月1日北京协和医院重症医学科所有CBS患者的临床资料。记录转入ICU后即刻中心静脉压(central venous pressure, CVP)(CVP 0h)、6 h时CVP(CVP 6h), 转入ICU 48 h内CVPp(CVPp 48h), 以及转入ICU 48 h后AKI发生率及院内死亡率。采用受试者操作特征(receiver operating characteristic, ROC)曲线评估CVP相关指标预测CBS术后发生AKI的临床价值并确定最佳临界值; 采用单因素与多因素Logistic回归分析CBS术后发生AKI、院内死亡的危险因素。结果 共入选符合纳入和排除标准的CBS患者485例, AKI发生率为25.2%(122/485), 院内死亡率为2.5%(12/485)。ROC曲线分析显示, CVPp 48h预测CBS术后发生AKI的曲线下面积(area under the curve, AUC)为0.634(95% CI: 0.577~0.692, P＜0.001), 最佳临界值为14 mm Hg, 灵敏度为49.6%, 特异度为63.5%。多因素Logistic回归分析显示, 高血压(OR=2.505, 95% CI: 1.581~3.969, P＜0.001)、肺动脉高压(OR=2.552, 95% CI: 1.573~4.412, P＜0.001)、主动脉阻断时间延长(OR=1.009, 95% CI: 1.004~1.014, P=0.001)、CVPp 48h≥14 mm Hg(OR=1.613, 95% CI: 1.030~2.526, P=0.037)是CBS术后发生AKI的独立危险因素; CVPp 48h≥14 mm Hg是院内死亡的独立危险因素(OR=8.044, 95% CI: 1.579~40.979, P=0.012)。结论 CVPp 48h升高可能增加CBS术后AKI发生风险, 对其动态监测有助于AKI的预防和早期识别。Abstract:Objective To explore the relationship between the post-operative peak value of central venous pressure (CVPp) and the incidence of acute kidney injury (AKI) in patients who had undergone cardiopulmonary bypass surgery (CBS).Methods Clinical data were retrospectively collected from 1 May 2016 to 1 May 2018 from all patients undergoing CBS in the Department of Intensive Care Medicine, Peking Union Medical College Hospital. The CVP values immediately after transfer to ICU (CVP 0h) and at 6 h(CVP 6h), and CVPp within 48 h(CVPp 48h) of transfer to ICU, the incidence of AKI after 48 h of transfer to ICU and in-hospital mortality were recorded. The receiver operating characteristic (ROC) curve was used to evaluate the clinical value of CVP-related indicators in predicting AKI after CBS and determine the optimal threshold. The risk factors for AKI and in-hospital mortality after CBS were analysed using single factor and multifactorial Logistic regression.Results A total of 485 patients after CBS who met the inclusion and exclusion criteria were enrolled, with an incidence of AKI after 48 h of transfer to ICU of 25.2% (122/485) and an in-hospital mortality rate of 2.5% (12/485). The ROC curve analysis showed that the area under the curve (AUC) for CVPp 48h to predict AKI after CBS was 0.634 (95% CI: 0.577-0.692, P < 0.001), with an optimal threshold value of 14 mm Hg, sensitivity of 49.6% and specificity of 63.5%. Multifactorial logistic regression analysis showed that hypertension(OR=2.505, 95% CI: 1.581-3.969, P < 0.001), pulmonary hyperten-sion(OR=2.552, 95% CI: 1.573-4.412, P < 0.001), prolonged aortic block time(OR=1.009, 95% CI: 1.004-1.014, P=0.001), and CVPp 48h≥14 mm Hg(OR=1.613, 95% CI: 1.030-2.526, P=0.037) were independent risk factors for AKI after CBS; CVPp 48h≥14 mm Hg was an independent risk factor for in-hospital death(OR=8.044, 95% CI: 1.579-40.979, P=0.012).Conclusions CVPp 48h is associated with AKI in patients who have undergone CBS. The monitoring and management of CVP might be a way to improve the prognosis of these patients.
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