目的: 在小儿开颅癫痫病灶切除术中连续监测每搏量变异(stroke volume variation, SVV)、脉压变异(pulse pressure variation, PPV)和脉搏容积变异(plethysmographic variability index, PVI)3项心脏前负荷动态指标,评价这些常用动态指标的一致性,探索三者之间是否可以互换,以简化临床决策过程。方法: 30例行择期开颅癫痫病灶切除术的0 ~ 14岁患儿术中常规监测SVV、PPV和PVI, 根据上述指标和动脉收缩压实施目标导向液体管理。所有数据对分为6个阶段,每个阶段选取3 ~ 8个数据对,用Bland-Altman法分析数据对数值的一致性,用四象限图和极图分析数据对的同向变化趋势。结果: 患儿术中动脉收缩压为 (94±19) mmHg,平均SVV、PPV和PVI分别为8%±2%、10%±3%和15%±7%,共分析834个数据对。Bland-Altman分析显示SVV-PPV的平均偏倚为-2.3,一致限为-6.0 ~ 1.5,误差百分比为26%。SVV-PVI和PPV-PVI的平均偏倚分别为-7.5和-5.0,一致限分别为-22.7 ~ 7.8和-20.5 ~ 10.5,误差百分比分别为54%和43%。四象限图分析中3项指标变化的符合率分别为ΔSVV-ΔPPV 88.6%、ΔSVV-ΔPVI 50.1%、ΔPPV-ΔPVI 50.4%。<3岁者PPV-SVV符合率高于≥ 3岁者(92.7%与84.2%)。极坐标图分析中SVV-PPV变化的角符合率为86.6%,基于动脉压力波形的指标(SVV和PPV)与PVI变化符合率较差(分别为29.1%和29.9%)。结论: 小儿开颅术中SVV和PPV变化趋势一致性较高,尤其<3岁者,二者可以互换,无需额外使用SVV监测设备;但基于动脉压力波形的指标(SVV和PPV)与PVI之间变化趋势的一致性较差,不能互换。联合PPV和PVI用于监测心脏前负荷可能有助于提高小儿术中补液反应性的预测值。

Objective: To compare well-known preload dynamic parameters intraoperatively including stroke volume variation (SVV), pulse pressure variation (PPV), and plethysmographic variability index (PVI) in children who underwent craniotomy for epileptogenic lesion excision. Methods: A total of 30 children aged 0 to 14 years undergoing craniotomy for intracranial epileptogenic lesion excision were enrolled. During surgery, we measured PPV, SVV (measured by the Flotrac/Vigileo device), and PVI (measured by the Masimo Radical-7 monitor) simultaneously and continuously. Preload dynamic parameter measurements were collected at predefined steps: after induction of anesthesia, during opening the skull, intraoperative electroencephalogram monitoring, excision of epileptogenic lesion, skull closure, at the end of the operation. After exclusion of outliers, agreement among SVV, PPV, and PVI was assessed using repeated measures of Bland-Altman approach. The 4-quadrant and polar plot techniques were used to assess the trending ability among the changes in the three parameters. Results: The mean SVV, PPV, and PVI were 8%±2%, 10%±3%, and 15%±7%, respectively during surgery. We analyzed a total of 834 paired measurements (3 to 8 data sets for each phase per patient). Repeated measures Bland-Altman analysis identified a bias of -2.3 and 95% confidence intervals between -1.9 and -2.7 (95% limits of agreement between -6.0 and 1.5) between PPV and SVV, showing significant correlation at all periods. The bias between PPV and PVI was -5.0 with 95% limits of agreement between -20.5 and 10.5, and that between SVV and PVI was -7.5 with 95% limits of agreement between -22.7 and 7.8, both not showing significant correlation. Reflected by 4-quadrant plots, the con-cordance rates showing the trending ability between the changes in PPV and SVV, PPV and PVI, SVV and PVI were 88.6%, 50.4%, and 50.1%, respectively. The concordance rate between PPV and SVV was higher (92.7%) in children aged less than 3 years compared with those aged 3 and more than 3 years. The mean angular bias, radial limits of agreement, and angular concordance rate in the polar analysis were not clinically acceptable in the changes between arterial pressure waveform-based parameters and volume-based PVI (PPV vs. PVI: angular mean bias 8.4°, angular concordance rate 29.9%; SVV vs. PVI: angular mean bias 2.4°, angular concordance rate 29.1%). There was a high concordance between the two arterial pressure waveform-based parameters reflected by the polar plot (angular mean bias -0.22°, angular concordance rate 86.6%). Conclusion: PPV can be viewed as a surrogate for SVV, especially in children aged less than 3 years. The agreement between arterial pressure waveform-based preload parameters (PPV and SVV) and PVI is poor and these two should not be considered interchangeable. Attempt to combine PVI and PPV for improving the anesthesiologist’s ability to monitor cardiac preload in major pediatric surgery is warranted.