日本小児循環器学会雑誌 第26巻 第1号（57-64） 2010年
Anthony F. Rossi1)，Robert L. Hannan2)，Redmond P. Burke2)
1) Department of Cardiology,Cardiac Intensive Care Unit，2) Department of Cardiac Surgery, ，Miami Children’s Hospital, Miami, FL, USA
Objective: Goal directed therapy (GDT) has been proven to reduce morbidity and mortality in critical illness. Point of care testing (POCT) allows rapid turn around time (TAT) of critical data, yet data suggesting improved outcomes is very limited.
Design: Beginning July 2001, POCT in the form of the i-STAT handheld analyzer was integrated in the management of patients after congenital heart surgery at Miami Children’s Hospital. Blood lactate measurements were performed serially for 24 hours after surgery. Based on a lactate value, medical therapy was escalated, diminished or left unchanged after surgery. Outcome data was collected prospectively for later review. Mortality at 30 days after surgery was compared for patients undergoing a GDT protocol to a group of historical cohorts. The operative risk for all operations was determined using the Risk Adjustment for Congenital Heart Surgery-1 (RACHS) scoring system.
Setting: A 16 bed cardiac intensive care unit located in a 268 bed free standing pediatric hospital.
Patients: Outcomes of all patients undergoing congenital heart surgery from July 2001 through September 2008 (Group B) were compared to historical controls in our institution from June 1995 through June 2001 (Group A). There were 1,656 patients in Group A and 1,919 patients in Group B. Patients in Group B were smaller and younger than those in Group A (median weight 6.2 vs. 8 kg., p<0.001; median age 161 vs. 327 days, p<0.001). Measurements and results: The 30 day mortality was lower for Group B as compared to Group A (2.2 % vs. 6.2%, p<0.001). Significant reduction in mortality between Group B and Group A was noted in neonates (4.3% vs. 12%, p=0.001) and infants (1.3% vs. 2.6%, p=0.01). Patients undergoing the highest risk operations (RACHS-1 groups 5+6) had a 70% reduction in mortality when comparing Group B to Group A, (9% vs. 30%, p=0.001), with a smaller but statistically significant difference in mortality for those patients undergoing lower risk operations (RACHS-1 groups 1 and 2, Group B 0.5% vs. Group A 1.5%, p<0.01). Conclusions: The combination of GDT and POCT significantly reduced mortality in patients undergoing congenital heart surgery. This improvement is greatest in the youngest patients and those undergoing higher risk surgeries.
Anthony F. Rossi, MD, Director, Cardiac Intensive Care Unit Miami Children’s Hospital, 3200 S.W. 60 Court, Miami, FL 33135, USA firstname.lastname@example.org