国际麻醉学与复苏杂志   2018, Issue (7): 0-0
    
婴幼儿法洛四联症根治术中脑氧饱和度的变化特征
潘守东, 韩丁, 欧阳川, 罗毅, 李稼1()
1.首都儿科研究所附属儿童医院
The characteristics of regional cerebral oxygen saturation in infants and toddlers undergoing surgical repair of tetralogy of Fallot
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摘要：

目的：在法洛四联症（tetralogy of Fallot，TOF）婴幼儿双心室矫治术中通过近红外光谱技术（near-infrared spectroscopy，NIRS）研究脑氧饱和度（regional cerebral oxygen saturation，rScO2）的变化特征及其相关因素。 方法：选择6个月～3岁择期在体外循环（cardiopulmonary bypass，CPB）下行TOF根治术的患儿38例，年龄1.1±0.8岁，体重8.9±2.5 kg。全麻诱导气管插管后，持续使用Fore-sight（CASMED，美国）连续监测右侧额部区域rScO2。所有患儿均行桡动脉穿刺置管，连接MostCare（PRAM）监测仪，监测血流动力学指标。在切皮前（T1）、切开心包（T2）、CPB全流量（T3）、CPB减流量（T4）、CPB结束（T5）、改良超滤结束（T6）和术毕（T7）7个时点记录rScO2和体温（T），在T1、T2、T5～T7 5个时点记录SpO2、HR、SBP、DBP、心指数（CI）、体循环阻力指数（SVRI）、每搏量指数（SVI）、脉压变异度（PPV）和压力升支最大斜率（dp/dt）等指标。分析rScO2的变化特征及与其它观察指标的相关性。 结果：与T1相比（72%±6%），rScO2在T2～T4时点无明显变化（P ＞ 0.05），T5时点降低（67±8%，P ＜ 0.05），T6时点（76%±7%）升高（P ＜ 0.05），T7（74%±7%）与T6时点差异无统计学意义（P ＞ 0.05）。与T1相比，T5时点SBP、DBP、CI、SVI、dp/dt降低，SpO2、HR、SVRI、PPV升高（P ＜ 0.05）。与T5相比，T6、T7时点SBP、DBP、CI、SVI、dp/dt升高，PPV降低（P ＜ 0.05）。rScO2仅在T1、T2和T7时点与SpO2呈正相关（r = 0.41、0.65、0.49，P ＜ 0.05），在T2时点与CI呈正相关（r = 0.35，P ＜ 0.05），在T1、T2、T4～T7时点均与患儿年龄呈正相关（r = 0.34～0.58，P ＜ 0.05）。T5～T7时点rScO2均与T4时点rScO2呈正相关（r＝ 0.86、0.71、0.45，P ＜ 0.05）。 结论：在婴幼儿法洛四联症根治术中,脑氧饱和度维持相对稳定，并与年龄呈正相关；脱离体外循环时易发生脑氧饱和度降低，改良超滤后脑氧饱和度随着血流动力学的改善而明显改善；体外循环结束后各时点的脑氧饱和度水平与体外循环结束前减流量时的脑氧饱和度呈正相关。
关键词： 先天性心脏病，法洛四联症 脑氧饱和度 血流动力学 婴儿
Abstract:

Objective To investigate the characteristics and related factors of regional cerebral oxygen saturation （rScO2） using near-infrared spectroscopy (NIRS) in infants and toddlers undergoing complete surgical repair of tetralogy of Fallot (TOF). Method Thirty-eight children aged 6 months to 3 years old undergoing complete surgical repair of TOF with cardiopulmonary bypass (CPB) were enrolled. The rScO2 on the right forehead was monitored with Fore-sight（CASMED, USA）after induction of anesthesia and tracheal intubation. The radial artery was catheterized and connected to the MostCare (PRAM) to monitor the hemodynamic parameters. The rScO2, T, SpO2, HR, SBP, DBP, CI, SVRI, SVI, PPV, and dp/dt were recorded before incision (T1), at opening the pericardium (T2), total volume of CPB (T3), reducing flow of CPB (T4),termination of CPB（T5）, termination of modified ultrafiltration (T6) and the end of the surgery (T7). Results As compared to the rScO2 at T1 (72%±6%), the rScO2 at T2-T4 maintained stable (P ＞ 0.05), while decreased at T5 (67±8%, P ＜ 0.05), and increased at T6 (76%±7%, P ＜ 0.05). The rScO2 at T7 (74%±7%) was similar to that at T6 (P ＞ 0.05). The SBP, DBP, CI, SVI and dp/dt decreased, while SpO2, HR, SVRI and PPV increased at T5 compared to that at T1 (P ＜ 0.05). The SBP, DBP, CI, SVI and dp/dt increased, while PPV decreased at T6 and T7, compared to that at T5 (P ＜ 0.05). The rScO2 significantly related to SpO2 only at T1, T2 and T7 (r = 0.41, 0.65, and 0.49, respectively，P ＜ 0.05), and related to CI only at T2 (r = 0.35，P ＜ 0.05), while significantly related to the age at T1, T2, and T4～T7 (r = 0.34～0.58，P ＜ 0.05）. The rScO2 at T5-T7 were significantly related to that at T4 (r＝ 0.86、0.71、0.45, respectively, P ＜ 0.05). Conclusion The regional cerebral oxygen saturation maintains relatively stable in infants and toddlers undergoing complete surgical repair of tetralogy of Fallot, and significantly related to the age of the child. Immediately after the termination of cardiopulmonary bypass, the regional cerebral oxygen saturation tends to decrease, while improves with the hemodynamics after the modified ultrafiltration. The level of the cerebral oxygen saturation after cardiopulmonary bypass is related to that at reducing flow of cardiopulmonary bypass.
Key words: Congenital heart disease, Tetralogy of Fallot; Cerebral oxygen saturation; Hemodynamics; Infant