单纯瓣膜置换术后机械通气时间延长的危险因素分析以及对临床预后的影响

Risk factors for prolonged mechanical ventilation after isolated heart valve replacement and its effect on clinical prognosis

摘要:

目的 探究单纯瓣膜置换（HVPI）术后机械通气时间延长（PMV）的发生率、危险因素以及对临床预后的影响。方法 回顾性分析该院心胸外科2013 年度的HVPI 的400 例患者。记录术前、术中以及术后等多种变量，进行单因素和多因素分析。呼吸机时间延长定义为术后呼吸机应用时间>24 h。结果 PMV患者87 例（21.8%）。单因素分析发现非PMV 组（A 组）与PMV 组（B 组）患者在总胆红素水平、心功能Ⅲ～Ⅳ级、左室舒张末径、左室射血分数、转机时间、手术当天引流量、血红蛋白、血清肌酐、血糖、乳酸等方面，差异有统计学意义（P <0.05）。多因素分析发现LVEF>50%（OR=0.051，95% CI ：0.005 ～0.541，P =0.014）是避免术后PMV 的保护因素，而转机时间>120 min（OR=2.144，95% CI ：1.061 ～ 4.335，P =0.034）、术后24 h 肌酐>133μmol/L（OR=2.979，95% CI ：1.463 ～ 6.069，P =0.003）和乳酸>5 mmol/L（OR=4.379，95% CI ：2.115 ～ 9.067，P =0.000）是导致术后PMV 的危险因素。术后PMV 患者组患者术后死亡率（OR=8.0，95% CI ：1.4 ～ 44.3，P =0.019）和ICU>2 d（OR=9.4，95% CI ：5.4 ～ 16.3，P =0.000）的风险较对照组增加。结论 HVPI 术后PMV 与左心收缩功能、转机时间、术后早期肌酐和乳酸水平等多因素相关，PMV 可导致术后死亡率增加和ICU 滞留时间延长。

Abstract:

Objective To investigate the incidence and risk factors of prolonged mechanical ventilation(PMV) in patients undergoing isolated heart valve prosthesis implantation (HVPI) and its influence on patients’ prognosis. Methods Totally 400 patients who underwent HVPI in the Department of Cardiothoracic Surgery of our hospital in 2013 were analyzed retrospectively. Preoperative, intraoperative and postoperative variables were analyzed as risk factors. PMV was defined as time of postoperative ventilation >24 hours. Results There were 87 patients (21.8%) who matched the diagnosis criterion of PMV. Univariate analysis showed that preoperative total bilirubin, heart function in grade III-IV, left ventricular end diastolic diameter, left ventricular ejection fraction (LVEF), cardiopulmonary bypass time, postoperative drainage volume, hemoglobin, serum creatinine, glucose and lactate (within 24 hours after HVPI) were significantly different between the non-PMV group (group A) and the PMV group (group B, all P < 0.05). Multivariate analysis showed that LVEF >50% (OR = 0.051, 95% CI: 0.005-0.541; P = 0.014) was an independent protective factor for postoperative PMV, but cardiopulmonary bypass time >120 min(OR = 2.144, 95% CI: 1.061-4.335; P = 0.034), postoperative creatinine >133 mol/L (OR = 2.979, 95% CI: 1.463-6.069; P = 0.003) and lactic acid >5 mmol/L (OR = 4.379, 95% CI: 2.115-9.067; P = 0.000) were the independent risk factors for PMV after HVPI surgery. The PMV group had significantly increased risks of postoperative mortality (OR = 8.0, 95% CI: 1.4-44.3; P = 0.019) and ICU stay time >2 days (OR = 9.4, 95% CI: 5.4-16.3; P = 0.000) compared with the control group. Conclusions Left ventricular systolic function, cardiopulmonary bypass time,postoperative level of creatinine and lactic acid are separately associated with PMV after HVPI. PMV can lead to increased postoperative mortality and prolonged ICU stay time.