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中华妇幼临床医学杂志(电子版) ›› 2022, Vol. 18 ›› Issue (02) : 220 -227. doi: 10.3877/cma.j.issn.1673-5250.2022.02.014

论著

胸腔生物电阻抗法无创血流动力学监测对新生儿脓毒症患儿心功能障碍的预测价值
张慧平, 王金会, 李思袖, 杨雪峰, 唐小晶, 张海波, 朱巧棉, 梁若冰, 孙欢, 简茹, 刘建萍†()   
  1. 西安交通大学附属儿童医院新生儿重症监护室　710003
  • 收稿日期:2021-05-20 修回日期:2022-03-08 出版日期:2022-04-01
  • 通信作者: 刘建萍

Predictive value of non-invasive hemodynamic monitoring by bioelectrical impedance analysis in neonatal sepsis complicated with cardiac dysfunction

Huiping Zhang, Jinhui Wang, Sixiu Li, Xuefeng Yang, Xiaojing Tang, Haibo Zhang, Qiaomian Zhu, Ruobing Liang, Huan Sun, Ru Jian, Jianping Liu†()   

  1. Neonatal Intensive Care Unit, Affiliated Children′s Hospital of Xi′an Jiaotong University, Xi′an 710003, Shaanxi Province, China
  • Received:2021-05-20 Revised:2022-03-08 Published:2022-04-01
  • Corresponding author: Jianping Liu
  • Supported by:
    Natural Science Basic Research Project of Shaanxi Province(2020JM-651); Program of Affiliated Children′s Hospital of Xi′an Jiaotong University(2019A01, 2017A09)
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引用本文：

张慧平, 王金会, 李思袖, 杨雪峰, 唐小晶, 张海波, 朱巧棉, 梁若冰, 孙欢, 简茹, 刘建萍. 胸腔生物电阻抗法无创血流动力学监测对新生儿脓毒症患儿心功能障碍的预测价值[J/OL]. 中华妇幼临床医学杂志(电子版), 2022, 18(02): 220-227.

Huiping Zhang, Jinhui Wang, Sixiu Li, Xuefeng Yang, Xiaojing Tang, Haibo Zhang, Qiaomian Zhu, Ruobing Liang, Huan Sun, Ru Jian, Jianping Liu. Predictive value of non-invasive hemodynamic monitoring by bioelectrical impedance analysis in neonatal sepsis complicated with cardiac dysfunction[J/OL]. Chinese Journal of Obstetrics & Gynecology and Pediatrics(Electronic Edition), 2022, 18(02): 220-227.

目的

探讨胸腔生物电阻抗法无创血流动力学监测(NHM-BIA)预测新生儿脓毒症(NS)患儿心功能障碍(CD)的价值。

方法

选择2017年1月至2020年11月，西安交通大学附属儿童医院新生儿重症监护病房(NICU)收治的152例NS患儿为研究对象。采用回顾性研究方法，根据NS患儿是否并发CD，将其分为研究组(n＝53，并发CD)与对照组(n＝99，未并发CD)。对2组患儿性别、出生胎龄、出生体重、危重新生儿比例，血清N-末端脑利钠肽前体(NT-proBNP)、高敏肌钙蛋白(hs-cTn)，肌酸激酶同工酶MB(CK-MB)，心房、室内径及射血分数，以及心率、每搏输出量指数(SI)、心排血量(CO)、心指数、每搏输出量变异度(SVV)、校正流动时间(FTC)、外周血管阻力(SVR)、外周血管阻力指数(SVRI)、心肌收缩指数(ICON)、收缩时间比(STR)等NHM-BIA指标采用成组t检验、Mann-Whitney U检验与χ2检验进行统计学比较。对NS患儿并发CD的影响因素进行多因素非条件logistic回归分析。绘制NHM-BIA不同指标预测NS患儿并发CD的受试者工作特征(ROC)曲线，并计算曲线下面积(AUC)。根据约登指数最大原则，确定这些指标预测NS患儿并发CD的最佳临界值。本研究遵循的程序符合本院伦理委员会规定，通过本院伦理委员会审查，并获得批准(审批文号：20210034)。2组NS患儿性别构成比、出生胎龄、出生体重等一般临床资料比较，差异均无统计学意义(P>0.05)。

结果

①研究组患儿危重新生儿比例及血清NT-proBNP、hs-cTn水平，均显著高于对照组，并且差异均有统计学意义(P<0.05)。②研究组NS患儿心率、SVV、SVR、SVRI、STR，均显著高于对照组，而SI、心指数、FTC、ICON，均显著低于对照组，并且差异均有统计学意义(P<0.05)。③多因素非条件logistic回归分析结果显示，血清NT-proBNP、hs-cTn水平高，是NS患儿并发CD的独立危险因素(OR＝1.001、1.095，95%CI：1.000~1.001、1.047~1.146，P均<0.001)，而心指数高是NS患儿并发CD的独立保护因素(OR＝0.075，95%CI：0.022~0.253，P<0.001)。④血清NT-proBNP、hs-cTn水平与心指数及3项指标联合预测NS患儿并发CD的AUC分别为0.814(95%CI：0.734~0.894，P<0.001)，0.858(95%CI：0.784~0.931，P<0.001)，0.925(95%CI：0.784~0.931，P<0.001)，0.975(95%CI：0.942~1.000，P<0.001)。根据约登指数最大原则，血清NT-proBNP、hs-cTn水平与心指数预测NS患儿并发CD的最佳临界值依次为13 355 ng/L、74 ng/L、2.74 L/(min·m2)，此时血清NT-proBNP、hs-cTn水平与心指数及3项指标联合预测NS患儿并发CD的敏感度分别为77.4%、58.5%、84.9%、81.1%，特异度分别为73.6%、95.4%、93.1%、96.6%。

结论

NHM-BIA可有效监测NS合并CD患儿的血流动力学改变。心指数联合血清NT-proBNP、hs-cTn对NS患儿并发CD有较高预测价值。

关键词: 脓毒症, 心功能障碍, 血流动力学, 无创血流动力学监测, 胸腔生物电阻抗法, 利钠肽，脑, 肌钙蛋白, 婴儿，新生
Objective

To explore value of non-invasive hemodynamic monitoring by bioelectrical impedance analysis (NHM-BIA) in predicting neonatal sepsis (NS) complicated with cardiac dysfunction (CD).

Methods

A total of 152 children with NS who were admitted to neonatal intensive care unit (NICU) of Affiliated Children′s Hospital of Xi′an Jiaotong University from January 2017 to November 2020 were selected as research subjects. They were divided into study group (n=53, complicated with CD) and control group (n=99, without CD) according to whether they were complicated with CD or not by retrospective analysis method. The gender, gestational age at birth, weight at birth, proportion of critically ill neonates, serum N-terminal pro-brain natriuretic peptide (NT-proBNP), high sensitive cardiac troponin (hs-cTn), and creatine kinase isoenzyme MB (CK-MB), atrial and ventricular diameter and ejection fraction, as well as heart rate, stroke volume index (SI), cardiac output (CO), cardiac index, stroke volume variability (SVV), flow time of corrected (FTC), systemic vascular resistance (SVR), systemic vascular resistance index (SVRI), index of contractility (ICON), systolic time ratio (STR) of two groups were compared by independent-samples t test, Mann-Whitney U test and chi-square test. Multivariate unconditional logistic regression analysis was used to analyze the influencing factors of NS complicated with CD in neonates. Receiver operating characteristics (ROC) curves of different indexes of NHM-BIA to predict NS complicated with CD were drawn, and area under the curve (AUC) was calculated. According to principle of maximum Youden index, the best critical value of different indexes for predicting NS complicated with CD were determined. The procedures followed in this study met the standards formulated by the Ethics Review Committee of Affiliated Children′s Hospital of Xi′an Jiaotong University and has been approved by it (Approval No. 20210034). There were no significant differences in general clinical data of neonates with NS between two groups, such as gender composition ratio, gestational age and weight at birth (P>0.05).

Results

①The proportion of critically ill neonates and serum levels of NT-proBNP and hs-cTn in study group were significantly higher than those in control group, and the differences were statistically significant (P<0.05). ②Heart rate, SVV, SVR, SVRI and STR of neonates with NS in study group were significantly higher than those in control group, while SI, cardiac index, FTC, and ICON were significantly lower than those in control group, and all differences were statistically significant (P<0.05). ③Multivariate unconditional logistic regression analysis showed that high serum levels of NT-proBNP and hs-cTn were independent risk factors for NS neonates complicated with CD (OR=1.001, 1.095; 95%CI: 1.000-1.001, 1.047-1.146, all P<0.001), while high cardiac index was an independent protective factor for NS neonates complicated with CD (OR=0.075, 95%CI: 0.022-0.253, P<0.001). ④AUC of serum levels of NT-proBNP and hs-cTn, cardiac index and three indexes combined to predict of NS neonates complicated with CD were 0.814 (95%CI: 0.734-0.894, P<0.001), 0.858 (95%CI: 0.784-0.931, P<0.001), 0.925 (95%CI: 0.784-0.931, P<0.001), and 0.975 (95%CI: 0.942-1.000, P<0.001), respectively. According to principle of maximum Youden index, the best critical values of serum levels of NT-proBNP and hs-cTn and cardiac index for predicting CD in neonates with NS were 13 355 ng/L, 74 ng/L, and 2.74 L/(min·m2), the sensitivities of serum levels of NT-proBNP and hs-cTn, cardiac index and three indexes combined were 77.4%, 58.5%, 84.9%, and 81.1%, respectively, and the specificities were 73.6%, 95.4%, 93.1%, and 96.6%, respectively.

Conclusions

NHM-BIA can effectively monitor hemodynamic changes in neonates with NS complicated with CD. Cardiac index combined with serum levels of NT-proBNP and hs-cTn has high predictive value in NS neonates complicated with CD.

Key words: Sepsis, Cardiac dysfunction, Hemodynamics, Non-invasive hemodynamic monitoring, Bioelectrical impedance analysis, Natriuretic peptide, brain, Troponin, Infant, newborn
表1 2组NS患儿相关临床资料比较
组别 例数 性别[例数(%)] 出生胎龄(周，±s) 出生体重(kg，±s) 危重新生儿[例数(%)] WBC[×109/L，M(P25~P75)] PLT[×109/L，M(P25~P75)] 血清CRP[×109/L，M(P25~P75)]
男 女
研究组 53 39(73.6) 14(26.4) 35.7±1.1 2.52±0.64 50(94.3) 7.4(7.1~8.1) 188.0(118.4~237.6) 6.7(3.6~21.5)
对照组 99 60(60.6) 39(39.4) 35.4±1.2 2.54±0.81 60(60.6) 7.5(7.2~8.2) 195.0(123.6~284.2) 6.8(2.7~22.4)
检验值   χ2＝2.560 t＝-0.147 t＝-0.448 χ2＝6.216 Z＝-0.320 Z＝-0.883 Z＝-0.253
P值   0.110 0.883 0.655 0.013 0.749 0.377 0.800
组别 例数 血清hs-cTn(ng/L，±s) 血清NT-proBNP(ng/L，±s) 血清CK-MB(mmol/L，±s) UCG(±s)
左心室内径(mm) 左心房内径(mm) 右心室内径(mm) 右心房内径(mm) 射血分数(%)
研究组 53 74.5±27.3 12 234.0±4 894.1 142.7±35.2 13.7±2.3 10.1±1.6 8.8±2.3 14.45±3.05 60.5±9.3
对照组 99 40.8±13.3 7 969.0±2 777.8 137.4±31.6 14.4±2.7 10.8±1.9 8.6±1.8 15.05±2.36 66.6±3.7
检验值   t＝9.522 t＝8.011 t＝1.558 t＝1.392 t＝1.416 t＝1.039 t＝0.801 t＝0.637
P值   <0.001 <0.001 0.122 0.167 0.160 0.301 0.425 0.525
表2 2组NS患儿NHM-BIA指标比较(±s)
组别 例数 心率(次/min) SI[L/(min·m2)] 心指数[L/(min·m2)] SVV(%) FTC(ms) SVR(dyn·s/cm5) SVRI[dyn·s/(cm5·m2)] ICON STR
研究组 53 150.5±18.9 16.7±2.3 2.4±0.6 26.7±3.3 168.6±23.0 8 237.2±725.4 1 938.5±274.9 52.7±9.2 0.67±0.16
对照组 99 144.1±16.3 24.7±2.3 3.6±0.7 15.8±2.3 248.5±23.3 6 463.4±536.3 1 145.6±227.6 74.8±14.4 0.46±0.09
t值   2.140 -19.158 -10.198 22.917 -19.799 10.452 18.457 -10.450 13.897
P值   0.034 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001
表3 NS患儿并发CD影响因素的多因素非条件logistic回归分析结果
影响因素 B SE Wald值 P值 OR值 OR值95%CI
血清NT-proBNP水平 <0.001 <0.001 13.582 <0.001 1.001 1.000~1.001
血清hs-cTn水平 0.091 0.023 15.458 <0.001 1.095 1.047~1.146
心指数 -2.592 0.621 17.417 <0.001 0.075 0.022~0.253
心率 0.035 0.021 2.661 0.103 1.036 0.993~1.080
SI -0.376 0.335 1.261 0.262 0.687 0.356~1.324
SVV -0.702 1.508 0.217 0.642 0.496 0.026~9.517
FTC 5.257 9.977 0.278 0.598 19.811 0.001~5.960
SVR 2.826 2.145 1.735 0.188 16.872 0.252~11.32
SVRI -0.015 0.026 0.323 0.570 0.985 0.936~1.037
ICON -0.002 0.011 0.039 0.843 0.998 0.976~1.020
STR -1.537 3.054 0.253 0.615 0.215 0.001~54.321
常数项 -6.244 3.512 3.162 0.075 0.002 —
图1 血清NT-proBNP、hs-cTn水平与心指数及3项指标联合预测NS患儿并发CD的ROC曲线注：NT-proBNP为脑利钠肽前体，hs-cTn为高敏肌钙蛋白，NS为新生儿脓毒症，CD为心功能障碍。ROC曲线为受试者工作特征曲线
表4 血清NT-proBNP、hs-cTn水平与心指数及3项指标联合预测NS患儿并发CD的ROC曲线分析结果
指标 AUC AUC 95%CI P值 最佳临界值 敏感度(%) 特异度(%) 约登指数
血清NT-proBNP水平(ng/L) 0.814 0.734~0.894 <0.001 13 355 77.4 73.6 0.510
血清hs-cTn水平(ng/L) 0.858 0.784~0.931 <0.001 74 58.5 95.4 0.539
心指数[L/(min·m2)] 0.925 0.877~0.973 <0.001 2.74 84.9 93.1 0.780
上述3项指标联合 0.975 0.942~1.000 <0.001 — 81.1 96.6 0.777
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