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目的 探讨血管加压素在儿童复杂右心畸形体外循环术后高危血管麻痹风险人群中的最佳应用时机，评价早期应用是否优于传统应用。方法 前瞻性纳入对象为本院小儿外科中心自2023年1月至12月年龄在1月至14岁之间行体外循环手术的高危血管麻痹风险复杂右心畸形患儿[中重度法洛四联症(TOF)或TOF型右室双出口、肺动脉闭锁/室间隔缺损]，按照血管加压素启用时机随机分为早期使用组和传统使用组。早期使用组在返回监护室即刻完成外周血管阻力指数(SVRI)测量后即启动使用。传统使用组必须满足血管活性药物评分≥20分、2 h内补充等张液体≥30 mL/kg并且通过超声评估除外残余解剖畸形和严重心功能低下(左室射血分数≤40%)的情况下仍然存在低血压状态，才开始启用。比较两组主要临床结果(呼吸机时间和ICU时间)及相关临床并发症的差异。结果 169例患儿纳入最终数据统计，早期使用组102例，传统使用组67例。传统使用组在血管加压素使用前血管张力低下状态更明显，其SVRI为(899.7±283.1)dyn/(s·cm5·m2)低于早期使用组(1 012.7±282.8)dyn/(s·cm5·m2)(P=0.009)。早期使用组呼吸机时间明显短于传统使用组[24(19,43)h vs. 39(21,71)h,P=0.012]约15 h;ICU时间也明显短于传统使用组[4(3,7)d vs. 5.5(4,13.6)d,P=0.031]，约1.5 d。血流动力学方面，早期使用组达到目标循环和实现负平衡所需时间均更短。两组术后均无死亡事件发生，相关并发症未见明显差异(心律失常发生率、胸腹腔积液发生率、急性肾损伤及肾替代治疗发生率)，所有患者均顺利出院。结论 儿童复杂右心畸形体外循环术后，血管加压素作为血管麻痹的一线治疗药物，早期应用优于传统时机应用。可以实现更稳定的血流动力学，更快达到目标循环和实现负平衡，从而带来更短的呼吸机时间和ICU时间，同时不增加相关并发症。SVRI监测可以作为儿童血管麻痹诊断的一项重要参考，具有很好的指导作用。
Abstract：Objective To explore the optimal timing of vasopressin initiation for children with complex right heart malformation at high risk of vasoplegia after cardiopulmonary bypass: traditional use or early administration? Methods Children aged 1 month to 14 years with complex right heart malformations at high risk of vasoplegia after cardiopulmonary bypass at our pediatric cardiac center from January 1 st to December 31 st, 2023 were prospectively enrolled in this study. The main types of the diseases included moderate to severe Tetralogy of Fallot(TOF), double outlet of the right ventricle with pulmonary stenosis(DORV/PS, TOF type), pulmonary atresia with ventricular septal defect(PAA/VSD). Patients were randomly divided into the early initiation group and the traditional initiation group based on the timing of vasopressin administration. In the early initiation group, vasopressin was given immediately upon return to the intensive care unit(ICU) after completing the systemic vascular resistance index(SVRI) measurement. In the traditional initiation group, vasopressin was given only if the following criteria were all met: vasoactive-inotropic score ≥20, ≥30 mL/kg of isotonic fluid resuscitation administered within 2 hours, and persistent hypotension despite ultrasound evaluation ruling out significant residual anatomical defects and severe ventricular dysfunction(Left Ventricular Ejection Fraction ≤ 40%).The primary clinical outcomes(duration of mechanical ventilation and ICU length of stay) and the related clinical complications were compared between the two groups. Results A total of 169 pediatric patients were included in the final analysis: 102 in the early initiation group and 67 in the traditional initiation group. The traditional initiation group exhibited a more pronounced state of vasoplegia prior to vasopressor initiation, with a significantly lower SVRI(899.7 ± 283.1 dyn/s·cm-5·m-2) compared to the early initiation group(1012.7 ± 282.8 dyn/s·cm-5·m-2; P = 0.009). The early initiation group had a significantly shorter duration of mechanical ventilation [24(19, 43) hours vs. 39(21, 71) hours, P = 0.012] with a reduction of approximately 15 hours. Additionally, the ICU stay was significantly shorter with a reduction of approximately 1.5 days [4(3, 7) days vs. 5.5(4, 13.6) days, P = 0.031]. In terms of hemodynamics, the early initiation group took less time to achieve target circulation and negative fluid balance. There were no deaths in either group, and there was no significant difference in the incidence of associated complications(arrhythmia, pleural effusion, acute kidney injury and renal replacement therapy), and all patients were successfully discharged. Conclusion Early initiation of vasopressin is superior to traditional use in vasoplegic shock for pediatric patients with complex right heart malformations after cardiopulmonary bypass. More stable hemodynamics, faster attainment of target circulation and negative fluid balance can be achieved, resulting in shorter duration of ventilator support and ICU stay without increasing associated complications. SVRI monitoring can be used as an important reference for the diagnosis of vasoplegia in children and has a good guiding role.
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基本信息:
DOI：10.13498/j.cnki.chin.j.ecls.2025.05.03
中图分类号:R726.5
引用信息:
[1]鲁中原,王澎,李宸钰,等.儿童复杂右心畸形体外循环术后血管加压素应用时机研究[J].中国体外生命支持,2025,23(05):388-393.DOI:10.13498/j.cnki.chin.j.ecls.2025.05.03.
基金信息:
高水平医院临床科研项目（2022-GSP-QN-13）;高水平医院临床科研项目（2022-GSP-GG-32）
2025-10-28
2025-10-28