婴幼儿体外循环中动静脉血气分析参数对术后急性肾损伤的评估价值分析

Value of arterial and venous blood gas parameters during cardiopulmonary bypass in evaluating postoperative acute kidney injury in infants

摘要:

目的 探讨婴幼儿体外循环中动静脉血气分析参数对术后急性肾损伤（PO-AKI）的评估价值。方法 选取2022年6月—2024年6月于徐州医科大学附属徐州儿童医院的进行心脏手术的108例婴幼儿作为研究对象。所有患儿在体外循环下接受手术，且接受动静脉血气分析，术后依据改良儿童肾脏疾病风险分级诊断标准，将患儿分为PO-AKI组和非PO-AKI组，比较两组患儿临床相关资料，分析动静脉血气分析参数对患儿PO-AKI的评估价值。结果 两组患儿性别构成、年龄、体重、美国麻醉医师学会分级、术前左室射血分数、术前血红蛋白、术前肺动脉高压占比和体外循环中最低血红蛋白水平比较，差异均无统计学意义（P >0.05）。PO-AKI组患儿体外循环时间、主动脉阻断时间均长于非PO-AKI组（P <0.05），阻断30 min 静脉-动脉二氧化碳分压差（Pv-aCO₂）、阻断30 min Pv-aCO₂/Pv-aCO₂与动静脉氧含量差（Ca-vO₂）、阻断45 min Pv-aCO₂和阻断45 min Pv-aCO₂/Ca-vO₂水平均高于非PO-AKI组（P <0.05）。多因素一般Logistic回归分析结果显示：阻断30 min Pv-aCO₂水平高［O^R=2.447（95% CI：1.176，5.094）］、阻断30 min Pv-aCO₂/Ca-vO₂水平高［O^R=2.627（95% CI：2.627，5.566）］、阻断45 min Pv-aCO₂水平高［O^R=2.394（95% CI：1.102，5.203）］和阻断45 min Pv-aCO₂/Ca-vO₂水平高［O^R=2.790（95% CI：1.254，6.207）］均为患儿心脏手术后发生PO-AKI的危险因素（P <0.05）。绘制受试者工作特征曲线分析结果显示，阻断30 min Pv-aCO₂评估的敏感性、特异性分别为85.71%（95% CI：0.791，0.923）、43.68%（95% CI：0.343，0.530）；阻断30 min Pv-aCO₂/Ca-vO₂评估的敏感性、特异性分别为76.19%（95% CI：0.682，0.842）、74.71%（95% CI：0.665，0.829）；阻断45 min Pv-aCO₂评估的敏感性、特异性分别为85.71%（95% CI：0.791，0.923）、58.62%（95% CI：0.493，0.679）；阻断45 min Pv-aCO₂/Ca-vO₂评估敏感性、特异性分别为57.14%（95% CI：0.478，0.665）、94.25%（95% CI：0.899，0.986）；联合评估的敏感性、特异性分别为80.95%（95% CI：0.735，0.884）、87.36%（95% CI：0.811，0.936）。阻断30 min Pv-aCO₂、阻断30 min Pv-aCO₂/Ca-vO₂的曲线下面积分别为0.637（95% CI：0.592，0.774）、0.817（95% CI：0.713，0.885），阻断45 min Pv-aCO₂、阻断45 min Pv-aCO₂/Ca-vO₂的曲线下面积分别为0.724（95% CI：0.629，0.805）、0.765（95% CI：0.673，0.841），联合评估的曲线下面积为0.915（95% CI：0.845，0.960），高于其他单一评估。结论 心脏手术中PO-AKI发婴幼儿体外循环中存在Pv-aCO₂、Pv-aCO₂/Ca-vO₂的升高表现，且上述参数指标为PO-AKI的影响因素，上述指标联合对婴幼儿心脏PO-AKI具有最佳的评估价值。

Abstract:

Objective To analyze the value of arterial and venous blood gas parameters during cardiopulmonary bypass in evaluating postoperative acute kidney injury (PO-AKI) in infants.Methods A total of 108 infants who underwent cardiac surgery under cardiopulmonary bypass in our hospital between June 2022 and June 2024 were selected as the subjects. Arterial and venous blood gas analyses were performed. After surgery, the children were divided into the PO-AKI group and the non-PO-AKI group based on the modified risk classification criteria for pediatric kidney diseases. Relevant clinical characteristics of the two groups were compared, and the value of arterial and venous blood gas parameters in evaluating PO-AKI was analyzed.Results There were no statistically significant differences between the two groups in terms of sex distribution, age, body weight, American Society of Anesthesiologists (ASA) classification, preoperative left ventricular ejection fraction, preoperative hemoglobin level, proportion of pulmonary hypertension, or the lowest hemoglobin level during cardiopulmonary bypass (P > 0.05). The cardiopulmonary bypass time and aortic cross-clamp time were longer in the PO-AKI group than in the non-PO-AKI group (P < 0.05). At 30 minutes after aortic cross-clamping, the venous-arterial carbon dioxide partial pressure difference (Pv-aCO₂) and the ratio of Pv-aCO₂ to the arteriovenous oxygen difference (Ca-vO₂) were significantly higher in the PO-AKI group compared with the non-PO-AKI group (P < 0.05). Similarly, at 45 minutes after aortic cross-clamping, both Pv-aCO₂ and Pv-aCO₂/Ca-vO₂ were higher in the PO-AKI group (P < 0.05). Multivariable logistic regression analysis showed that higher Pv-aCO₂ at 30 minutes after aortic cross-clamping [O^R = 2.447 (95% CI: 1.176, 5.094) ], higher Pv-aCO₂/Ca-vO₂ at 30 minutes after aortic cross-clamping [O^R = 2.627 (95% CI: 1.239, 5.566) ], higher Pv-aCO₂ level at 45 minutes [O^R = 2.394 (95% CI: 1.102, 5.203) ], and higher Pv-aCO₂/Ca-vO₂ ratio at 45 minutes [O^R = 2.790 (95% CI: 1.254, 6.207) ] were all independent risk factors for postoperative acute kidney injury (PO-AKI) in children after cardiac surgery (P < 0.05). Receiver operating characteristic (ROC) curve analysis showed that the sensitivity and specificity of Pv-aCO₂ at 30 minutes after aortic cross-clamping were 85.71% (95% CI: 0.791, 0.923) and 43.68% (95% CI: 0.343, 0.530), respectively; those of Pv-aCO₂/Ca-vO₂ at 30 minutes after aortic cross-clamping were 76.19% (95% CI: 0.682, 0.842) and 74.71% (95% CI: 0.665, 0.829); those of Pv-aCO₂ at 45 minutes after aortic cross-clamping were 85.71% (95% CI: 0.791, 0.923) and 58.62% (95% CI: 0.493, 0.679); and those of Pv-aCO₂/Ca-vO₂ at 45 minutes after aortic cross-clamping were 57.14% (95% CI: 0.478, 0.665) and 94.25% (95% CI: 0.899, 0.986). Combined evaluation yielded a sensitivity of 80.95% (95% CI: 0.735, 0.884) and specificity of 87.36% (95% CI: 0.811, 0.936). The areas under the ROC curves (AUCs) for Pv-aCO₂ and Pv-aCO₂/Ca-vO₂ at 30 minutes after aortic cross-clamping were 0.637 (95% CI: 0.592, 0.774) and 0.817 (95% CI: 0.713, 0.885); those at 45 minutes after aortic cross-clamping were 0.724 (95% CI: 0.629, 0.805) and 0.765 (95% CI: 0.673, 0.841), respectively. The combined evaluation achieved the highest AUC of 0.915 (95% CI: 0.845, 0.960), outperforming each single indicator.Conclusion Pv-aCO₂ and Pv-aCO₂/Ca-vO₂ are increased during cardiopulmonary bypass in infants with PO-AKI. Both parameters are significant risk factors for PO-AKI, and their combined assessment provides the highest predictive value for evaluating PO-AKI in infants undergoing cardiac surgery.