Development and internal validation of an early postoperative nomogram for predicting prolonged intensive care unit stay after primary complete repair of tetralogy of Fallot in children

Rao Min; Zhu Junming; Lü Xiangni

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Development and internal validation of an early postoperative nomogram for predicting prolonged intensive care unit stay after primary complete repair of tetralogy of Fallot in children

更新时间：2026-10-23

- Development and internal validation of an early postoperative nomogram for predicting prolonged intensive care unit stay after primary complete repair of tetralogy of Fallot in children
- Journal of Chongqing Medical University Pages: 1-9(2026)
- 作者机构：
  
  空军军医大学第一附属医院心血管外科，西安 710032
- 作者简介：
- 基金信息：
- DOI：
  CLC： R114
- Received：14 July 2026，
  
  Revised：2026-09-17，
  
  Accepted：20 September 2026，
  
  Published：23 October 2026
- 稿件说明：
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Rao Min,Zhu Junming,Lü Xiangni.Development and internal validation of an early postoperative nomogram for predicting prolonged intensive care unit stay after primary complete repair of tetralogy of Fallot in children[J].Journal of Chongqing Medical University,
DOI：

Rao Min,Zhu Junming,Lü Xiangni.Development and internal validation of an early postoperative nomogram for predicting prolonged intensive care unit stay after primary complete repair of tetralogy of Fallot in children[J].Journal of Chongqing Medical University, DOI：10.13406/j.cnki.cyxb..

摘要

目的

探讨法洛四联症（tetralogy of Fallot，TOF）患儿一期根治术后重症监护室（intensive care unit，ICU）延长滞留的预测因素，并建立ICU入室时的术后早期风险预测模型。

方法

采用单中心回顾性队列设计，连续筛选研究期间接受TOF外科治疗的患儿783例，排除不符合纳入标准或符合排除标准者343例及术后ICU滞留时间或住院结局无法确认者19例，最终纳入421例。参考既往研究并结合本中心术后ICU管理流程，将术后ICU滞留时间≥72 h预先定义为主要结局；次要结局包括ICU滞留时间≥96 h和住院期间死亡，并以“住院期间死亡或ICU滞留时间≥72 h”作为敏感性分析的复合结局。预测时点设定为患儿完成手术并进入ICU时。将10个预先设定的候选预测变量同时纳入L

惩罚logistic回归，惩罚参数通过交叉验证确定，并根据惩罚后系数和重新校准截距绘制nomogram。采用5次重复嵌套5折交叉验证和500次bootstrap评价模型的判别能力、总体预测误差及校准表现。

结果

421例患儿中，142例发生ICU延长滞留，发生率为33.7%。L

惩罚logistic回归显示，手术时体重增加与ICU延长滞留概率降低相关［比值比（odds ratio，OR）=0.83，95%置信区间（confidence interval，CI）为0.73~0.95］；到达手术室前已行气管插管［

=2.36，95%CI=1.18~4.88］、体外循环时间延长［每增加10 min，

=1.12，95%CI=1.03~1.22］、ICU入室乳酸升高［每增加1 mmol/L，

=1.41，95%CI=1.08~1.88］、ICU入室血管活性药物–正性肌力药物评分升高［每增加5分，

=1.72，95%CI=1.23~2.52］及离开手术室前经食管超声心动图评估的残余病变等级升高［每升高1级，

=1.29，95%CI=1.02~1.63］与ICU延长滞留概率升高相关。模型表观受试者工作特征曲线下面积（area under the receiver operating characteristic curve，AUC）为0.736；重复嵌套交叉验证AUC为0.707（95%CI=0.653~0.759），Brier评分为0.196，校准截距为0.036（95%CI=-0.263~0.366），校准斜率为1.057（95%CI=0.750~1.425）。敏感性复合结局模型的重复嵌套交叉验证AUC为0.701（95%CI=0.647~0.754）。

结论

基于ICU入室时可获得的信息建立的L

惩罚logistic回归模型在内部验证中显示出中等判别能力，但仍存在不确定性。该模型应定位为探索性的ICU入室时术后早期风险预测工具。由于预测时点为ICU入室时，该模型不能支持术前决策或术前ICU资源安排；在完成独立时间验证或外部验证前，也不应据此调整监护强度或作出临床决策。

Abstract

Objective

To investigate predictors of prolonged intensive care unit（ICU） stay after primary complete repair of tetralogy of Fallot in children and develop an early postoperative risk prediction model for use at ICU admission.

Methods

This single-center retrospective cohort study consecutively screened 783 children who underwent surgical treatment for tetralogy of Fallot during the study period. Of these，343 were excluded because they did not meet the inclusion criteria or met the exclusion criteria，and 19 were excluded because their postoperative ICU stay or in-hospital outcome could not be ascertained. The final analysis included 421 children. Based on previous studies and the postoperative ICU management pathway at our center，an ICU stay of ≥72 h was prespecified as the primary outcome. Secondary outcomes included an ICU stay of ≥96 h and in-hospital mortality. A composite outcome of in-hospital mortality or an ICU stay of ≥72 h was evaluated in a sensitivity analysis. The prediction time point was defined as ICU admission after completion of surgery. Ten prespecified candidate predictors were simultaneously entered into an L

-penalized logistic regression model，with the penalty parameter selected by cross-validation. A nomogram was constructed using the penalized coefficients and recalibration intercept. Model discrimination，overall prediction error，and calibration were evaluated using five repeated runs of nested five-fold cross-validation and 500 bootstrap resamples.

Results

Of the 421 children，142 experienced a prolonged ICU stay，corresponding to an incidence of 33.7%. L

-penalized logistic regression showed that greater weight at surgery was associated with a lower probability of prolonged ICU stay（odds ratio［

］=0.83，95%CI=0.73-0.95）. Endotracheal intubation before arrival in the operating room（

=2.36，95%CI=1.18-4.88），longer

cardiopulmonary bypass time （per 10-min increase：

=1.12，95%CI=1.03-1.22），higher lactate concentration at ICU admission（per 1 mmol/L increase：

=1.41，95%CI=1.08-1.88），higher vasoactive-inotropic score at ICU admission （per 5-point increase：

=1.72，95%CI=1.23-2.52），and a higher grade of residual lesions assessed by transesophageal echocardiography before leaving the operating room（per 1-grade increase：

=1.29，95%CI：1.02-1.63） were associated with a higher probability of prolonged ICU stay. The apparent area under the receiver operating characteristic curve（AUC） was 0.736 for the model. The AUC of repeated nested cross-validation was 0.707（95%CI=0.653-0.759），with a Brier score of 0.196，a calibration intercept of 0.036 （95%CI：-0.263 to 0.366），and a calibration slope of 1.057（95%CI=0.750-1.425）. For the sensitivity analysis model using the composite outcome，the AUC of repeated nested cross-validation was 0.701（95%CI=0.647-0.754）.

Conclusion

The L

-penalized logistic regression model based on information available at ICU admission demonstrated moderate discrimination during internal validation，although uncertainty remained. The model should be regarded as an exploratory early postoperative risk prediction tool for use at ICU admission. Because the prediction time point is ICU admission，the model does not support preoperative decision-making or preoperative ICU resource planning. Until independent temporal or external validation has been completed，the model should not be used to adjust monitoring intensity or guide clinical decision-making.

关键词

Keywords

references

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