文章摘要
控制性低中心静脉压对心肺转流心脏手术中静脉淤血和术后急性肾损伤的影响
Effect of controlled low central venous pressure on venous congestion and postoperative acute kidney injury in cardiac surgery under cardiopulmonary bypass
  
DOI：10.12089/jca.2024.08.004
中文关键词: 急性肾损伤  控制性低中心静脉压  静脉淤血  心肺转流  心脏手术
英文关键词: Acute kidney injury  Controlled low central venous pressure  Venous congestion  Cardiopulmonary bypass  Cardiac surgery
基金项目:南京市卫生科技发展专项资金项目（YKK22109）
作者单位E-mail
刘佳聪 210006,南京医科大学附属南京医院,南京市第一医院麻醉疼痛与围术期医学科  
胡兰鑫 210006,南京医科大学附属南京医院,南京市第一医院麻醉疼痛与围术期医学科  
陈利海 210006,南京医科大学附属南京医院,南京市第一医院麻醉疼痛与围术期医学科  
程怡 中国药科大学理学院  
史宏伟 210006,南京医科大学附属南京医院,南京市第一医院麻醉疼痛与围术期医学科  
赵雅梅 210006,南京医科大学附属南京医院,南京市第一医院麻醉疼痛与围术期医学科  
葛亚力 210006,南京医科大学附属南京医院,南京市第一医院麻醉疼痛与围术期医学科 ge_yl@163.com 
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中文摘要:
      
目的：探讨控制性低中心静脉压（CLCVP）对心肺转流（CPB）心脏手术中静脉淤血和术后急性肾损伤（AKI）的影响。
方法：选择择期拟于全麻CPB下行心脏手术的患者137例，男73例，女64例，年龄18～70岁，BMI 20～28 kg/m2，ASA Ⅱ或Ⅲ级。采用随机数字表法将患者分为两组: 控制性低中心静脉压组（CL组，n=68）和对照组（C组，n=69）。CL组在CPB停机后20 min，通过泵注硝酸甘油应用CLCVP将CVP 降低至10 mmHg以下，直至手术结束，必要时应用去甲肾上腺素维持MAP≥65 mmHg。C组采用标准化麻醉管理。分别在麻醉诱导前、术后12 h采集尿液标本检测肾损伤分子-1（KIM-1）浓度。分别在麻醉诱导前、术后2 h采集尿液标本检测中性粒细胞明胶酶相关脂质运载蛋白（NGAL）浓度。使用CVP高于10、12、16、20 mmHg的累计时间和时间加权平均CVP评估静脉淤血。记录术后AKI发生情况、2期及以上AKI发生情况、肾脏替代治疗（CRRT）、术后低心排综合征（LCOS）发生情况、到达ICU时心脏术后急性肾功能不全（AKICS）评分、住院死亡情况、ICU停留时间和术后住院时间。
结果：与C组比较，CPB后CL组CVP高于10、12、16、20 mmHg的累计时间明显缩短，时间加权平均CVP明显降低（P<0.05）。术后CL组发生AKI 9例（13.2%），C组15例（21.7%），两组差异无统计学意义。CL组发生2期及以上的AKI 1例（1.5%），C组2例（2.9%），C组有1例需行CRRT。与C组比较，CL组术后12 h KIM-1浓度和术后2 h NGAL浓度明显降低（P<0.05）。两组LCOS、AKICS评分、住院死亡率、ICU住院时间和术后住院时间差异无统计学意义。
结论：在心肺转流心脏手术中应用控制性低中心静脉压通过减轻静脉淤血，减少术后肾损伤的发生，具有一定的肾脏保护作用。
英文摘要:
      
Objective: To explore the effect of controlled low central venous pressure (CLCVP) on venous congestion and postoperative acute kidney injury (AKI) in cardiac surgery under cardiopulmonary bypass (CPB).
Methods: A total of 137 patients scheduled for elective cardiac surgery under general anesthesia with CPB were selected, including 73 males and 64 females, aged 18 to 70 years, with a BMI of 20 to 28 kg/m2, and ASA physical status Ⅱ or Ⅲ. The patients were randomly assigned into two groups: the controlled low central venous pressure group (group CL, n = 68) and the control group (group C, n = 69). In group CL, CLCVP was applied by pumping nitroglycerin to reduce CVP to below 10 mmHg after 20 minutes of CPB cessation until the end of surgery. If necessary, norepinephrine was applied to maintain MAP ≥ 65 mmHg. Patients in group C received standardized anesthesia management. Urine samples were collected before anesthesia induction and 12 hours postoperatively to detect the concentration of kidney injury molecule-1 (KIM-1). Urine samples were also collected before anesthesia induction and 2 hours postoperatively to detect the concentration of neutrophil gelatinase-associated lipocalin (NGAL). Cumulative time above 10, 12, 16, and 20 mmHg and time-weighted average CVP were used to assess venous congestion. The occurrence of postoperative AKI, stage 2 or above AKI, renal replacement therapy (CRRT), postoperative low cardiac output syndrome (LCOS), acute kidney injury following cardiac surgery (AKICS) score when arriving in ICU, in-hospital mortality, ICU stay, and postoperative hospital stay were recorded.
Results: Compared with group C, the cumulative time of CVP above 10, 12, 16, and 20 mmHg after CPB in group CL was significantly shorter, and the time-weighted average CVP was significantly lower (P < 0.05). AKI occurred in 9 patients (13.2%) in group CL and 15 patients (21.7%) in group C postoperatively, and there was no significant difference between the two groups. One case (1.5%) of stage 2 or above AKI occurred in group CL and 2 patients (2.9%) in group C, with one patient in group C requiring CRRT. Compared with group C, the concentrations of KIM-1 at 12 hours postoperatively and NGAL at 2 hours postoperatively were significantly lower in group CL (P < 0.05). There were no statistically significant differences between the two groups in LCOS, AKICS score, in-hospital mortality, ICU stay, and postoperative hospital stay.
Conclusion: Controlled low central venous pressure in cardiac surgery under cardiopulmonary bypass can reduce venous congestion and decrease the occurrence of postoperative renal injury, thereby exerting a certain renal protective effect.
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