氧供导向的体外循环灌注策略预防患者心脏术后急性肾损伤的临床研究

A Clinical Study on the Prevention of Acute Kidney Injury after Cardiac Surgery by an Oxygen Delivery-Directed Perfusion Strategy during Cardiopulmonary Bypass

摘要: 目的：探讨氧供导向的体外循环灌注策略是否能降低患者心脏术后急性肾损伤的发生率。方法：选取2024年12月~2026年2月在重庆医科大学附属永川医院于浅低温体外循环下行心脏瓣膜置换手术的患者60名。根据体外循环管理方法分为传统灌注策略组(C组)和氧供导向灌注策略组(G组)，每组各30例。C组采用传统灌注策略，根据体表面积调整匹配泵流量。G组采用氧供导向的体外循环灌注策略，根据氧供指数(DO₂i)调整泵流量。比较两组术中灌注指标包括体外循环(CPB)时间、主动脉阻断时间、术中库存红细胞(PRBCs)输注率、体外循环中最低鼻咽膀胱温度、最低血红蛋白(Hb)浓度、最低氧供指数(DO₂i)、平均氧供指数(DO₂i)等方面。比较两组术后临床结局指标包括术后48小时急性肾损伤(AKI)发生率、术后机械通气时间、ICU停留时间、总住院时间、术后并发症发生率、术后30天死亡率等。记录两组麻醉诱导后(T1)、主动脉阻断后10 min (T2)、主动脉开放前10 min (T3)、CPB停机(T4)、回ICU即刻0 h (T5)、回ICU 6 h (T6)、回ICU 12 h (T7)、回ICU 24 h (T8)各时间点的乳酸水平。结果：两组的术中灌注指标比较，在最低DO₂i、平均DO₂i方面G组高于C组，差异有统计学意义(P < 0.05)，其余术中灌注指标两组无统计学差异(P > 0.05)。两组术后临床结局指标比较，C组术后48小时急性肾损伤(AKI)发生率高于G组(P < 0.05)，而术后机械通气时间、ICU停留时间、总住院时间、术后并发症发生率、术后30天死亡率等未呈现统计学差异(P > 0.05)。采用重复测量方差分析比较两组乳酸(Lac)水平，两组Lac水平主体间比较，T1~T8各时间点的Lac变化趋势大致一致，C组和G组比较差异无统计学意义(P > 0.05)；两组Lac水平主体内比较，T2~T3时点与同组T1时点无统计学差异(P > 0.05)，T4~T8时点与同组T1时点有统计学差异(P < 0.05)。结论：氧供导向的体外循环灌注策略能显著降低患者心脏术后急性肾损伤的发生率，更有利于患者的肾功能恢复。

Abstract: Objective: To investigate whether an oxygen delivery-directed perfusion strategy during cardiopulmonary bypass (CPB) can reduce the incidence of acute kidney injury (AKI) after cardiac surgery. Methods: A total of 60 patients who underwent cardiac valve replacement surgery under mild hypothermic CPB at the Yongchuan Hospital of Chongqing Medical University from December 2024 to February 2026 were selected. They were divided into two groups based on the CPB management method: the traditional perfusion strategy group (Group C) and the oxygen delivery-directed perfusion strategy group (Group G), with 30 cases in each group. Group C received traditional perfusion management, adjusting pump flow according to body surface area. Group G received an oxygen delivery-directed CPB perfusion strategy, adjusting pump flow based on the oxygen delivery index (DO₂i). Intraoperative perfusion parameters were compared between the two groups, including CPB time, aortic cross-clamp time, intraoperative packed red blood cells (PRBCs) transfusion rate, lowest nasopharyngeal and bladder temperature during CPB, lowest hemoglobin (Hb) concentration, lowest DO₂i, and mean DO₂i. Postoperative clinical outcomes were compared between the two groups, including the incidence of acute kidney injury (AKI) within 48 hours post-surgery, postoperative mechanical ventilation time, ICU stay length, total hospital stay length, postoperative complication rate, and 30-day postoperative mortality rate. Lactate levels were recorded at the following time points: After anesthesia induction (T1), 10 minutes after aortic cross-clamping (T2), 10 minutes before aortic declamping (T3), at CPB discontinuation (T4), immediately upon ICU admission at 0 h (T5), at 6 h (T6), 12 h (T7), and 24 h (T8) after ICU admission. Results: Comparison of intraoperative perfusion parameters showed that the lowest DO₂i and mean DO₂i were significantly higher in Group G than in Group C (P < 0.05). No statistcally significant differences were found in other intraoperative perfusion parameters between the two groups (P > 0.05). Regarding postoperative clinical outcomes, the incidence of AKI within 48 hours post-surgery was significantly higher in Group C than in Group G (P < 0.05). However, no statistcally significant differences were observed between the groups in terms of postoperative mechanical ventilation time, ICU stay length, total hospital stay length, postoperative complication rate, and 30-day postoperative mortality rate (P > 0.05). Repeated measures ANOVA was used to compare lactate (Lac) levels between the two groups. The between-group comparison showed that the trends in Lac levels from T1 to T8 were generally consistent, with no statistically significant difference between Group C and Group G (P > 0.05). The within-group comparison showed that Lac levels at T2~T3 were not statistcally significantly different from the T1 level within the same group (P > 0.05), while Lac levels at T4~T8 were statistcally significantly different from the T1 level within the same group (P < 0.05). Conclusion: The oxygen delivery-directed perfusion strategy during cardiopulmonary bypass significantly reduce the incidence of AKI after cardiac surgery, which is more beneficial for the recovery of patients’ renal function.