先天性心脏病体外循环术后合并急性肾损伤患儿的临床特点及预后分析

Clinical characteristics and prognostic analysis of children with congenital heart disease complicated by postoperative acute kidney injury

摘要:

目的 分析体外循环（CPB）手术后合并急性肾损伤（AKI）的先天性心脏病患儿围术期临床资料，探讨有无改善预后的可调节因素。方法 针对小儿先心病CPB手术后48 h内发生AKI的118例患者进行回顾性分析。结果 118例中手术后48 h后死亡的18例。与存活组相比，死亡组术前的紫绀型心脏病所占比例、先天性心脏病手术风险评估共识评分均较高；术中CPB时间和升主动脉阻断时间、采用全晶体液进行心肌保护的比例、术中平均血糖均较高；术后48 h内正性肌力药物分值（IS）、术后肌酐值、3级AKI所占比例、采用肾脏替代疗法进行治疗的比例、红细胞或其它血制品输注数量均较高，差异均具有统计学意义（P < 0.05）。术后死亡率随着术中平均血糖升高而增加，有线性关联（P < 0.05）。术中平均血糖 > 8.3 mmol/L的患儿累积生存率和平均生存期均低于血糖 ≤ 8.3 mmol/L者（P < 0.05）。结论 先天性心脏病CPB术后合并AKI患儿的术中血糖水平与预后相关，术中严格控制血糖上升对改善CPB术后AKI患儿的预后有积极作用。

Abstract:

Objective To analyze the perioperative clinical data of children with congenital heart disease complicated by acute kidney injury (AKI) after cardiopulmonary bypass (CPB) surgery, and to explore potential factors influencing the prognosis. Methods A retrospective analysis was performed among 118 children with congenital heart disease who developed AKI within 48 hours after CPB surgery. Results In the 118 patients, 18 died after 48 hours of surgery. Compared with the survivors, the dead children had significantly higher incidence of cyanotic disease and Risk Adjustment for Congenital Heart Surgery-1 (RACHS-1) scores before surgery; during surgery, the dead children had significantly longer CPB time and aortic cross-clamping time, a significantly higher proportion of patients receiving crystalloid solution for myocardial protection, and a significantly higher mean blood glucose level. Within 48 hours after surgery, the dead children had significantly higher positive inotropic drug scores, significantly higher creatinine values, a significantly higher incidence of stage 3 AKI, a significantly higher proportion of patients receiving renal replacement the, and significantly higher usage of blood products (P < 0.05). The mortality rate of the patients increased with increased intraoperative blood glucose levels (P < 0.05). Patients with intraoperative blood glucose levels > 8.3 mmol/L had a significantly lower postoperative cumulative survival rate and a significantly shorter mean survival time than those with blood glucose levels ≤ 8.3 mmol/L (P < 0.05). Conclusions Intraoperative blood glucose levels are associated with the prognosis in children with congenital heart disease complicated by AKI after CPB surgery. Maintaining good intraoperative blood glucose control can improve the prognosis of the children.