体外循环下心脏瓣膜术后气管插管延迟拔除的危险因素分析-现代医学

体外循环下心脏瓣膜术后气管插管延迟拔除的危险因素分析

单位：1. 川北医学院附属医院心脏大血管外科, 四川南充 637000;
2. 川北医学院临床医学系, 四川南充 637000

分类号：R654.2

出版年·卷·期（页码）：2023·51·第二期（163-169）

摘要：

目的：探究体外循环（CPB）下心脏瓣膜术后气管插管延迟拔除的相关影响因素，进一步分析其独立危险因素。方法：收集220例符合纳入排除标准患者的临床资料，将其分为延迟拔管组（术后带管时间≥24 h）及非延迟拔管组（术后带管时间<24 h），分析两组相关指标差异，确定相关影响因素，再行多因素Logistic回归分析，最终确定其独立影响因素。结果：220例心脏瓣膜术后患者发生延迟拔管者有43例，发生率为19.55%，围术期死亡14例，发生率6.36%。单因素分析显示与CPB下心脏瓣膜术后延迟拔管的发生有关因素为：（1）性别、年龄、吸烟史、脑梗史、心功能NYHA分级、三尖瓣反流程度、肺动脉高压程度；（2）术前血小板计数、门冬氨酸氨基转移酶、碱性磷酸酶、前白蛋白及血红蛋白水平；（3）术前甲状腺功能异常、行冠脉造影、合并心房颤动；（4）术中体外循环时间及主动脉阻断时间（均P<0.05）。多因素二元Logistic回归分析示术前低血小板计数（校正OR=0.989，95%CI 0.982～0.996）、术前低血红蛋白水平（校正OR=0.970，95%CI 0.950～0.990）、术前合并房颤（校正OR=3.123，95%CI 1.232～7.913）及术中体外循环时间延长（校正OR=1.017，95%CI 1.003～1.030）均为体外循环下心脏瓣膜术后延迟拔管的独立危险因素（P<0.05）。延迟拔管组ICU停留时间（P<0.001）及术后住院时间（P=0.035）延长，其围术期并发症发生率及病死率均高于非延迟拔管组。结论：术前低血小板计数、术前低血红蛋白水平、术中体外循环时间延长及术前合并房颤是心脏瓣膜术后气管插管延迟拔除的独立危险因素；心脏瓣膜术后气管插管延迟拔除会增加围术期并发症的发生率及病死率，延长患者ICU停留时间及术后住院时间。

Objective: To explore the related factors of delayed extubation of endotracheal intubation after heart valve operation under cardiopulmonary bypass(CPB), and further analyze its independent risk factors. Methods: The clinical data of 220 patients who met the inclusion and exclusion criteria were collected and divided into delayed extubation group(postoperative tube time ≥ 24 h) and non-delayed extubation group(postoperative tube time<24 h). The differences between the two groups were analyzed to determine the relevant influencing factors. Multivariate Logistic regression analysis was employed to determine the independent influencing factors. Results: Among the 220 patients after heart valve operation, delayed extubation occurred in 43 cases(19.55%). 14 cases died in perioperative period, with an incidence of 6.36%. Univariate analysis showed that the following factors were related to the occurrence of delayed extubation after heart valve operation under CPB:(1) gender, age, smoking history, cerebral infarction history, cardiac function NYHA classification, tricuspid regurgitation degree, pulmonary hypertension degree;(2) preoperative platelet count, aspartate aminotransferase, alkaline phosphatase, prealbumin and hemoglobin levels;(3) preoperative thyroid dysfunction, coronary angiography and atrial fibrillation;(4) time of cardiopulmonary bypass and of aortic blockade. Multivariate Logistic regression analysis showed that preoperative low platelet count(OR=0.989, 95%CI 0.982-0.996), preoperative low hemoglobin level(OR=0.970, 95%CI 0.950-0.990), preoperative atrial fibrillation(OR=3.123, 95%CI 1.232-7.913) and prolonged intraoperative cardiopulmonary bypass(OR=1.017, 95%CI 1.003-1.030) were independent risk factors for delayed extubation of heart valves under CPB(P<0.05). The ICU stay time(P<0.001) and postoperative hospitalization time(P=0.035) were prolonged in the delayed extubation group, and the perioperative complications and mortality were higher than those in the non-delayed extubation group. Conclusion: Preoperative low platelet count, preoperative low hemoglobin level, prolonged CPB time and preoperative atrial fibrillation are independent risk factors for delayed extubation of endotracheal intubation after cardiac valve operation. Delayed extubation can increase the incidence of perioperative complications and mortality, and prolong the ICU and postoperative hospital stay.

参考文献：

[1] PETERS F, KARTHIKEYAN G, ABRAMS J, et al.Rheumatic heart disease:current status of diagnosis and therapy[J].Cardiovasc Diagn Ther, 2020, 10(2):305-315.
[2] WATKINS D A, BEATON A Z, CARAPETIS J R, et al.Rheumatic heart disease worldwide:JACC scientific expert panel[J].J Am Coll Cardiol, 2018, 72(12):1397-1416.
[3] ROTH G A, MENSAH G A, FUSTER V.The global burden of cardiovascular diseases and risks:a compass for global action[J].J Am Coll Cardiol, 2020, 76(25):2980-2981.
[4] MENSAH G A, ROTH G A, FUSTER V.The global burden of cardiovascular diseases and risk factors:2020 and beyond[J].J Am Coll Cardiol, 2019, 74(20):2529-2532.
[5] EL-ANDARI R, BOZSO S J, KANG J, et al.A comparison of surgical, total percutaneous, and hybrid approaches to treatment of combined coronary artery and valvular heart disease[J].Curr Opin Cardiol, 2020, 35(5):559-565.
[6] SUAREZ-PIERRE A, FRASER C D, ZHOU X, et al.Predictors of operative mortality among cardiac surgery patients with prolonged ventilation[J].J Card Surg, 2019, 34(9):759-766.
[7] JIN M, MA W G, LIU S, et al.Predictors of prolonged mechanical ventilation in adults after acute type-A aortic dissection repair[J].J Cardiothorac Vasc Anesth, 2017, 31(5):1580-1587.
[8] PANG X Y, FANG C C, CHEN Y Y, et al.Effects of ulinastatin on perioperative inflammatory response and pulmonary function in cardiopulmonary bypass patients[J].Am J Ther, 2016, 23(6):e1680-e1689.
[9] JACOBS J P, HE X, O'BRIEN S M, et al.Variation in ventilation time after coronary artery bypass grafting:an analysis from the society of thoracic surgeons adult cardiac surgery database[J].Ann Thorac Surg, 2013, 96(3):757-762.
[10] SPARROW H G, SWAN J T, MOORE L W, et al.Disparate outcomes observed within kidney disease:improving global outcomes(KDIGO) acute kidney injury stage 1[J].Kidney Int, 2019, 95(4):905-913.
[11] 梁克, 程可洛, 张万青, 等.老年患者心脏瓣膜置换术后低心排综合征相关因素的研究[J].中华实验外科杂志, 2013(5):1060-1061.
[12] 张汉君.心脏瓣膜手术术后延迟拔管的危险因素分析[D].芜湖:皖南医学院, 2021.
[13] DIWAN M, WOLVERTON J, YANG B, et al.Is nocturnal extubation after cardiac surgery associated with worse outcomes?[J].Ann Thorac Surg, 2019, 107(1):41-46.
[14] SANSON G, SARTORI M, DREAS L, et al.Predictors of extubation failure after open-chest cardiac surgery based on routinely collected data.The importance of a shared interprofessional clinical assessment[J].Eur J Cardiovasc Nurs, 2018, 17(8):751-759.
[15] 伍育旗, 张郁林, 俞斌, 等.心脏瓣膜病换瓣术后延迟拔管危险因素分析[J].中国综合临床, 2013, 29(12):1291-1294.
[16] SUGITA J, FUJIU K.Systemic inflammatory stress response during cardiac Surgery[J].Int Heart J, 2018, 59(3):457-459.
[17] FUJII Y, SHIRAI M, PEARSON J T, et al.Changes in inflammatory response during and after cardiopulmonary bypass using a rat extracorporeal circulation model[J].Annu Int Conf IEEE Eng Med Biol Soc, 2015, 2015:957-960.
[18] ZUHLKE L, KARTHIKEYAN G, ENGEL M E, et al.Clinical outcomes in 3343 children and adults with rheumatic heart disease from 14 low-and middle-income countries:two-year follow-up of the global rheumatic heart disease registry(the REMEDY study)[J].Circulation, 2016, 134(19):1456-1466.
[19] VASSILIOU A G, KOTANIDOU A, DIMOPOULOU I, et al.Endothelial damage in acute respiratory distress syndrome[J].Int J Mol Sci, 2020, 21(22):8793.
[20] PALIS J.Primitive and definitive erythropoiesis in mammals[J].Front Physiol, 2014, 5:3.
[21] PADMANABHAN H, SIAU K, CURTIS J, et al.Preoperative anemia and outcomes in cardiovascular surgery:systematic review and meta-analysis[J].Ann Thorac Surg, 2019, 108(6):1840-1848.
[22] DAI L, MICK S L, MCCRAE K R, et al.Preoperative anemia in cardiac operation:does hemoglobin tell the whole story?[J].Ann Thorac Surg, 2018, 105(1):100-107.
[23] KLEIN A A, COLLIER T J, BRAR M S, et al.The incidence and importance of anaemia in patients undergoing cardiac surgery in the UK-the first association of cardiothoracic anaesthetists national audit[J].Anaesthesia, 2016, 71(6):627-635.
[24] 王娜, 曾思思, 李佳蓓, 等.体外循环对血小板数量和功能的影响及机制[J].中国体外循环杂志, 2022, 20(1):53-58.
[25] TANG N, BAI H, CHEN X, et al.Anticoagulant treatment is associated with decreased mortality in severe coronavirus disease 2019 patients with coagulopathy[J].J Thromb Haemost, 2020, 18(5):1094-1099.
[26] PERDOMO J, LEUNG H, AHMADI Z, et al.Neutrophil activation and NETosis are the major drivers of thrombosis in heparin-induced thrombocytopenia[J].Nat Commun, 2019, 10(1):1322.
[27] RAJAKARUNA C, ROGERS C A, ANGELINI G D, et al.Risk factors for and economic implications of prolonged ventilation after cardiac surgery[J].J Thorac Cardiovasc Surg, 2005, 130(5):1270-1277.

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