急性A型主动脉夹层术前低氧血症危险因素分析
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摘要
目的:分析急性A型主动脉夹层(AAD)术前低氧血症的危险因素,以便为其合理治疗提供依据。方法:回顾性分析2015年1月至2018年2月期间首都医科大学附属北京安贞医院连续收治的505例AAD患者,根据氧合指数是否<300mmHg(1mmHg=0. 133kPa)分为低氧血症(+)组和低氧血症(-)组,分析两组患者围术期的各项指标,归纳总结术前并发低氧血症的危险因素。结果:AAD术前低氧血症发生率为46. 5%(235/505),其中低氧血症(-)组Pa O2/Fi O2为(371. 8±57. 5) mm Hg,低氧血症(+)组Pa O2/Fi O2为(230. 2±47. 1) mm Hg。单因素分析中有统计学意义的因素包括体重、体质量指数、收缩压、吸烟史、胸腔积液、心包积液、PLT计数、白细胞计数、肌钙蛋白、C反应蛋白、活化部分凝血活酶时间、纤维蛋白原定量、D-Dimer定量、纤维蛋白原降解产物(P <0. 05)。Logistic回归分析纤维蛋白原(OR=0. 972,P <0. 01),WBC计数(OR=1. 138,P <0. 01),收缩压(OR=0. 992,P=0. 02),吸烟史(OR=1. 517,P=0. 05),胸腔积液史(OR=2. 069,P <0. 01)为危险因素。结论:AAD术前低氧血症发生率高,纤维蛋白原浓度、WBC收缩压、吸烟史,胸腔积液史为其发生低氧血症重要危险因素,临床诊疗中应给予此类患者呼吸功能监测及治疗上高度重视。
Objective: To identify the risk factors of preoperative hyoxemia( HO) patients with acute type A aortic dissection( AAD). Methods: This was a retrospective study of patients treated between January2015 and February 2018 in the Department of Cardiovascular Surgery,Anzhen Hospital,China. All of these505 patients with AAD that underwent surgery treatment were divided into HO( +) group and HO(-) group.Univariable and multivariable analyses were performed on the clinical data of these patients. Results: HO occurred in 46. 5%( 235/505) of patients with AAD. The duration of ventilation and the lengths of intensive care unite were significantly longer in patients with HO,activity of daily lving scale were significantly lower than HO(-) group. The risk factors of preoperative HO were weight,BMI,SBP,smoking,pleural effusio,pericardial effusion,blood platelet count,white blood cell count( WBC),troponin,CRP,Activated partial thromboplastin time( APTT),fibrinogen,D-Dimer,fibrinogen degradation product( FDP). Multivariable binary logistic regression analysis show that WBC,fibrinogen,SBP,smoking,pleural effusion were the independent risk factors to HO. Conclusion: WBC,fibrinogen,SBP,smoking,pleural effusion were found to be significantly independent predict factors for preoperative HO.
Objective: To identify the risk factors of preoperative hyoxemia( HO) patients with acute type A aortic dissection( AAD). Methods: This was a retrospective study of patients treated between January2015 and February 2018 in the Department of Cardiovascular Surgery,Anzhen Hospital,China. All of these505 patients with AAD that underwent surgery treatment were divided into HO( +) group and HO(-) group.Univariable and multivariable analyses were performed on the clinical data of these patients. Results: HO occurred in 46. 5%( 235/505) of patients with AAD. The duration of ventilation and the lengths of intensive care unite were significantly longer in patients with HO,activity of daily lving scale were significantly lower than HO(-) group. The risk factors of preoperative HO were weight,BMI,SBP,smoking,pleural effusio,pericardial effusion,blood platelet count,white blood cell count( WBC),troponin,CRP,Activated partial thromboplastin time( APTT),fibrinogen,D-Dimer,fibrinogen degradation product( FDP). Multivariable binary logistic regression analysis show that WBC,fibrinogen,SBP,smoking,pleural effusion were the independent risk factors to HO. Conclusion: WBC,fibrinogen,SBP,smoking,pleural effusion were found to be significantly independent predict factors for preoperative HO.
引文
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[15] Thygesen K,Alpert J S,Jaffe A S,et al. Third universal definition of myocardial infarction.[J]. Glob Heart,2012,58(12):275-295.
[16] Yuyong Liu,Lu Han,Jiachen Li,et al. Consumption coagulopathy in acute aortic dissection:principles of management. J Cardiothorac Surg,2017,12:50.
[17] Belenkie I,Dani R,Smith E R,et al. Ventricular interaction during experimental acute pulmonary embolism[J]. Circulation,1988,78(3):761.
[18] Neukamm A M,Hiseth A D,Hagve T A,et al. High-sensitivity cardiac troponin T levels are increased in stable COPD.[J].Heart,2013,99(6):382-387.
[19] Vieira-De-Abreu A,Campbell R A,Weyrich A S,et al. Platelets:versatile effector cells in hemostasis,inflammation,and the immune continuum[J]. Sem Immunopathol,2012,34(1):5-30.
[20]孙博,刘楠,邢晓燕,等.急性Stanford A型主动脉夹层围术期急性肺损伤与D-二聚体相关性的探讨[J].心肺血管病杂志,2013,32(1):26-29.
[21] Mahadev S,Salome C M,Berend N,et al. The effect of low lung volume on airway function in obesity.[J]. Respir Physiol Neurobiol,2013,188(2):192.
[22]钟明华,古君,张尔永.血浆IL-6、CRP和TNF-α水平在主动脉夹层患者病程中的变化及意义[J].四川大学学报(医学版),2015,46(02):234-237.
[2] Golledge J,Eagle KA. Acute aortic dissection. Lancet 2008;372:55-66.
[3] Nan L,Wei Z,Ma W,et al. Risk factors for hypoxemia following surgical repair of acute type A aortic dissection[J]. Int Cardiovasc Thorac Surg,2016,24(2).
[4] Matthay M A,Zemans R L. The acute respiratory distress syndrome:pathogenesis and treatment[J]. Annu Rev Pathol,2011,6(1):147-163.
[5]尚蔚,刘楠,孙立忠,等.急性A型主动脉夹层术后急性呼吸功能不全的治疗[J].心肺血管病杂志,2012,31(5):519-522.
[6] Luo F,Zhou X L,Li J J,et al. Inflammatory response is associated with aortic dissection.[J]. Age Res Rev,2009,8(1):31-35.
[7] Del P F,Proietta M,Tritapepe L,et al. Inflammation and immune response in acute aortic dissection[J]. Ann Med,2010,42(8):622-629.
[8] Talla K,Dmytriw A A,Nguyen E. Acute type A aortic dissection with mediastinal hematoma mimicking massive pulmonary embolus[J]. Int J Cardiovas Imag,2016,33(2):1-2.
[9] Isselbacher E M. Thoracic and Abdominal Aortic Aneurysms[J]. Circulation,2005,111(6):816-28.
[10] Weismüller B T,Modlich O,Drobinskaya I,et al. Gene expression in acute Stanford type A dissection:a comparative microarray study[J]. J Translational Med,4,1(2006-07-06),2006,4(1):29.
[11] Fahy R J,Lichtenberger F,Mckeegan C B,et al. The acute respiratory distress syndrome[J]. Am J Respir Cell Mol Biol,2003,28(4):499.
[12] Campbell P,Misset B,Wiener-Kronish J,et al. The acute respiratory distress syndrome[M]//Trauma. 2004.
[13] Wu Z,Ruan Y,Chang J,et al. Angiotensin II is related to the acute aortic dissection complicated with lung injury through mediating the release of MMP9 from macrophages[J]. Am J Transl Res,2016,8(3):1426-1436.
[14] Lumachi F,Marzano B,Fanti G,et al. Relationship between body mass index,age and hypoxemia in patients with extremely severe obesity undergoing bariatric surgery.[J]. Vivo,2010,24(5):775-777.
[15] Thygesen K,Alpert J S,Jaffe A S,et al. Third universal definition of myocardial infarction.[J]. Glob Heart,2012,58(12):275-295.
[16] Yuyong Liu,Lu Han,Jiachen Li,et al. Consumption coagulopathy in acute aortic dissection:principles of management. J Cardiothorac Surg,2017,12:50.
[17] Belenkie I,Dani R,Smith E R,et al. Ventricular interaction during experimental acute pulmonary embolism[J]. Circulation,1988,78(3):761.
[18] Neukamm A M,Hiseth A D,Hagve T A,et al. High-sensitivity cardiac troponin T levels are increased in stable COPD.[J].Heart,2013,99(6):382-387.
[19] Vieira-De-Abreu A,Campbell R A,Weyrich A S,et al. Platelets:versatile effector cells in hemostasis,inflammation,and the immune continuum[J]. Sem Immunopathol,2012,34(1):5-30.
[20]孙博,刘楠,邢晓燕,等.急性Stanford A型主动脉夹层围术期急性肺损伤与D-二聚体相关性的探讨[J].心肺血管病杂志,2013,32(1):26-29.
[21] Mahadev S,Salome C M,Berend N,et al. The effect of low lung volume on airway function in obesity.[J]. Respir Physiol Neurobiol,2013,188(2):192.
[22]钟明华,古君,张尔永.血浆IL-6、CRP和TNF-α水平在主动脉夹层患者病程中的变化及意义[J].四川大学学报(医学版),2015,46(02):234-237.