NT-proBNP达峰时间对儿童先天性心脏病术后早期预后的预测价值

目的 探讨血清氨基末端脑钠肽前体(N-terminal pro-brain natriuretic peptide,NT-proBNP)的变化,对先天性心脏病患儿术后早期预后的预测价值.方法 选择2014年6-12月在全身麻醉、体外循环下行先天性心脏病手术415例患儿,在术前及术后早期(1、12、36、60 h和1周)测定NT-proBNP,并收集一般临床资料.各时间点NT-proBNP的比较采用配对t检验及重复测量数据的方差分析,使用ROC曲线评价NT-proBNP预测机械通气时间＞48 h、术后ICU停留时间＞3 d、血管活性药物使用时间＞3 d的诊断效能,总体诊断效能用ROC曲线下面积(AUC)及95％可信区间表示.结果 全组平均NT-proBNP达峰时间为术后12h.其中296例NT-proBNP在术后12h内达到峰值(12h内达峰组),其余119例均在12h后达到峰值(12 h后达峰组).12h内达峰组术后机械通气时间为(29.19±33.34)h,12h后达峰组为(49.16±85.85)h,组间比较,差异有统计学意义(t=2.465,P=0.015).12h内达峰组ICU停留时间为(3.69±2.73)d,12 h后达峰组为(5.57±5.64)d,组间比较,差异有统计学意义(t=3.479,P=0.001).12h内达峰组血管活性药物使用时间＞3 d比例为35.8％(106/296),12 h后达峰组为52.9％(63/119),组间比较,差异有统计学意义(x2=10.318,P=0.002).通过ROC曲线计算术后12 h NT-proBNP预测机械通气时间＞48 h的曲线下面积(AUC)为80.1％(95％可信区间75.0％～85.1％),最佳界值为7 708.71 pg/ml,灵敏度为65.1％,特异度为81.8％.术后12 h NT-proBNP预测血管活性药物使用时间＞3 d的AUC为78.4％(95％可信区间为73.9％～82.9％),最佳界值为6 145.67 pg/ml,灵敏度为82.5％,特异度为62.7％.术后12hNT-proBNP预测术后ICU停留时间＞3 d的AUC为77.5％(95％可信区间为73.0％～82.1％),最佳界值为4 981.77 pg/ml,灵敏度为68.7％,特异度为76.4％.结论 血清NT-proBNP是小儿先天性心脏病术后估测早期预后的一个敏感指标,在协助判断先天性心脏病术后患儿机械通气时间、血管活性药物使用时间、ICU停留时间方面有一定的临床应用价值.

Predictive values of N-terminal pro-brain natriuretic peptide after congenital heart disease surgery in children

Objective To explore the potential associations between NT-proBNP level and outcomes in patients with cardiopulmonary bypass (CPB).Methods A total of 415 children undergoing surgery for congenital heart disease were enrolled.Their clinical data were collected and NT-proBNP levels measured during preoperative and early postoperative periods (1,12,36,60 hours and 1 week).Paired t-test and repeated measures analysis of variance (ANOVA) were used for comparing the NT-proBNP levels at different timepoints.Receiver operating characteristic (ROC) curves were adopted to evaluate the diagnostic efficiency of NT-proBNP for predicting the time of mechanical ventilation＞48 h,postoperative intensive care unit (ICU) stay＞ 3 days and vasoactive drug use＞3 days.General diagnostic efficiency was presented as area under an ROC curve (AUC) and 95％ confidence interval (95％CI).Results The levels of NT-proBNP peaked at 12 h postoperation for 296 patients.And the remaining 119 patients peaked later than 12 h.The difference in time of mechanical ventilation postoperation between the groups of NT-proBNP-Peak (within 12 h postoperation) (29.19 ± 33.34) h and NT-proBNP-Peak (after 12 h postoperation)(49.16 ± 85.85 h) was statistically significant (t =2.465,P =0.015).The percentage of vasoactive drug use＞3 days was 35.8％ (106/296) in group of NT-proBNP-Peak (within 12 h postoperation) and was 52.9％ (63/119) in group of later than 12 h postoperation.And the inter-group difference reached statistical significance (x2 =10.318,P =0.002).12 h NT-proBNP levels of ＞7 708.71 pg/ml predicted mechanical ventilation beyond 48h showed AUC of 80.1 ％ (95％ CI:75.0％ ～ 85.1％) with a sensitivity of 65.1％ and a specificity of 81.8％.12 h NT-proBNP levels of ＞ 6 145.67 pg/ml predicted using inotropic therapy beyond 72 h showed AUC of 78.4％ (95 ％CI:73.9％～82.9％) with a sensitivity of 82.5％ and a specificity of 62.7％.In addition,12 h NT-proBNP levels of ＞ 4 981.77 pg/ml predicted ICU stay beyond 72 h showed AUC of 77.5 ％ (95 ％ CI:73.0 ％ ～ 82.1％) with a sensitivity of 68.7％ and a specificity of 76.4％.Conclusions Plasma level of NT-proBNP might be a prognostic indicator during ICU for pediatric surgical patients of congenital heart disease.