瓣膜手术后急性心脏功能衰竭体外膜式氧合治疗

目的:探讨体外膜式氧合(ECMO)治疗瓣膜手术后急性心脏功能衰竭的经验。方法:回顾2005年9月至2009年7月期间,我院心脏外科监护病房(ICU)收治70例瓣膜手术后因急性心脏功能衰竭接受ECMO辅助的患者的临床资料。男性43例,女性27例,年龄15～74岁,平均(53±12)岁,采用静脉-动脉(V-A)转流模式。结果:46例(65.7%)成功脱离ECMO,38例(54.3%)痊愈出院。平均ECMO辅助中位数时间59(1,206)h,平均监护室停留中位数时间4(1,19)d。主要并发症为出血21(30.0%)例,感染9(12.8%)例,肾功能衰竭需要透析17(24.2%)例,氧合器血浆渗漏20(28.5%)例及肢体缺血3(4.2%)例。结论:ECMO是治疗瓣膜手术后急性心脏功能衰竭的一种有效的机械辅助方法,及时安装并积极防治并发症可降低死亡率。     

深低温停循环下主动脉弓手术后患者预后分析

目的:探讨在深低温停循环(DHCA)状态下,主动脉弓手术后患者预后危险因素。方法:回顾性分析我院心脏外科2006年1月至2007年12月期间主动脉弓手术后患者的临床资料。结果:58例主动脉弓手术,术后死亡6例,病死率10.34%。单因素分析发现转机时间、术后血肌酐水平、术后神经功能障碍及需要连续肾脏替代治疗是影响预后的危险因素。结论:围手术期急性肾损伤和中枢神经系统损伤是手术死亡的独立危险因素。     

肾功能损伤分级系统在成人心脏术后的应用

Objective The aim of this study was to evaluate of adilty of two acute renal failure-specific scoring systenms (the classification by Bellome et al and the AKIN criteria) for predicting hospital mortality after cardiac surgery in adult patients. Methods Between October 1 st 2006 to Decemjber 31 st 2006, 509 adult patients who ungerwent coronary artery bypass grafting (CABG) and/ or valve operation were enrolled in this study. The medical data collection included gender, age, types of operation, perioperative he- modynamic parameters, urine output, biochemical parameters and outcome. Renal function was assessed daily according to the classi- ficatinn by Bellomo and the AKIN criteria, respectively. As references, Acure Physiology and Chronic Health Evaluation(APACHE) Ⅱ and Sepsis-related Organ Failure Assessment (SOFA) score were also calculated. Resuits Three hundred and forty-one patients were male (67.0%), and 168 were female (33.0%), mean age was (56.2±12.0) years old. Tnree hundred and nine patieats un- derwent CABG, 182 underwent valve operation and 18 underwent CABG plus valve operation, Mean duration of ventilation support was (20.4±17.7) houra, and the ICU stay was (1.4±1.0) days. Postoperative hospital stay was (13.8±9.1) days. According to the classification by Bellomo., the highest in-hospital mortality was 52.9% in ARFS group. Mahiplicatinn of in-hospital morality rate was abserved (X2 for trend, P<0.01) in 0.4% (non-ARF), 1.2% (stage 1), 12.0% (stal～ 2) and 32.4% (stage 3) of pa- tients based on the AKIN criteria. By applying the area under the receiver operating characteristic ourve, the classification by Bellomo and the AKIN criteria had good discriminative power. Furthering, multivariate logistic regression analysis verified that the Odds Ratio of the AKIN criteria was 5.478 (P =0.028, 95% Confidence Interval 1.027- 24.856), after adjusting for gender and age. Con- clusion Analytical data confinned good discriminative power of both the AKIN criteria and the classification by Bellomo for predicting hospital mortality of adult postoperative patient with ARF.     

RIFLE肾功能分级对心脏术后ECMO辅助病人转归的预测意义

目的 探讨RIFLE肾功能分级系统与住院死亡的相关关系,并探讨其对病人转归的预测意义.方法 收集2004年10月至2006年11月40例心脏手术后应用体外膜肺氧合(ECMO)进行支持治疗的成年病人资料,包括术后呼吸机辅助时间、监护室停留时间及转归等.结果 ECMO辅助平均(56.8±44.1)h.32例成功脱离ECMO,脱机率为80%,22例生存出院,总病死率45%.RIFLE分级系统ROC曲线下面积为0.904(95%可信区间0.798～1.010,P＜0.01)与病死率之间有很好的相关性.结论 RIFLE分级系统能够可靠预测ECMO辅助治疗病人的预后及死亡,应用简便、快捷.     

心脏手术后患者的镇静治疗

心脏病患者心脏功能储备降低，部分患者合并高血压、糖尿病等，常伴有呼吸、肝、肾功能减退，且手术创伤大、介入操作多，体外循环又可导致血液稀释、组织水肿、缺血-再灌注损伤等，加之患者术前精神压力大，术后容易发生焦虑躁动，循环状况不稳定时易发生意外。适当镇静治疗，对减轻患者应激反应，降低机体氧耗，维持血流动力学稳定很重要。     

心脏直视术后肺部真菌感染临床分析

目的 探讨心脏手术后肺部真菌感染的相关因素及治疗.方法 回顾2004年1月-2006年12月324例心脏直视手术后发生医院感染病例的临床资料.结果 共发生肺部真菌感染61例,占同期医院感染的18.8%,患者均病情危重且使用过广谱抗菌药物及糖皮质激素,36例患者机械通气时间＞1周;白色假丝酵母菌最多见,其次为光滑假丝酵母菌,药敏结果显示,氟康唑、伊曲康唑及5-氟胞嘧啶等具有良好的抗菌活性.结论 心脏手术后肺部真菌感染呈增加趋势,其发病与基础疾病严重、长时间机械通气、使用广谱抗菌药物等密切相关.     

冠状动脉旁路移植术后ICU监护时间延长的危险因素

目的 分析冠状动脉旁路移植术后ICU监护时间延长的危险因素.方法 1997年至2009年间单纯冠状动脉旁路移植术病人1318例,按ICU监护时间分2组,ICU监护时间≤72 h l113例,ICU监护时间＞72 h 205例.对两组病人术前多项指标进行单因素和多因素分析.结果 病人平均年龄(67.4±9.4)岁,男996例(75.6%),女322例(24.4%),两组病人的ICU监护时间分别为(40.1±22.5)h和(122.6±48.7)h,院内死亡分别占13.7%和1.2%.单因素分析显示,2组病人体外循环手术的比例、体外循环时间和阻断时间、远端吻合口数、术后升压药应用、呼吸机辅助时间和院内死亡方面差异有统计学意义.年龄、心功能(NYHA分级)Ⅲ～Ⅳ级,术前左室射血分数(LVEF)＜0.40、术前肾功能不全、脑血管和(或)周围血管病、慢性阻塞性肺疾病、近期心肌梗死、介入治疗病史、左主干和三支病变是ICU监护时间延长的危险因素.多因素分析显示,年龄、心功能(NYHA分级)Ⅲ～Ⅳ级的比例、LVEF、术前肾功能不全、慢性阻塞性肺疾病、近期心肌梗死、PCI病史和三支病变是ICU监护时间延长的危险因素.结论 LVEF＜0.40、近期心肌梗死、术前肾功能不全和慢性阻塞性肺疾病是术后ICU监护时问延长的主要高危因素.

Abstract：

Objective To describe the preoperative factors of prolonged intensive care unit length of stay after coronary artery bypass grafting. Methods From 1997 to 2009, 1318 patients underwent isolated CABG in our hospital. Retrospective analysis was performed on these cases. Univariate and multivariate analyses for preoperative risk factors were performed. Prolonged length of ICU stay was defined as initial admission to ICU exceeding 72 h. Results The mean age of patients ( 322women and 996 men) was (67.4±9.4) years. Of 1318 patients undergoing isolated CABG from 1997 to 2009, 205 experienced prolonged length of ICU stay. The length of ICU stay was (40.1 ± 22.5 ) hours and ( 122.6 ± 48.7 ) hours separately.Overall in-hospital mortality was higher among these 205 patients ( 13.7% vs. 1.2%, P ＜0.05 ). The overall mortality was 3.1%. In univariate analyses, there were statistically significant differences with respect to the percentage of CPB, total bypass time, cross-clamp time, number of distal anastomoses, use of pressor agent, use of intro-aortic balloon pump,time of ventilation and hospital mortality. The significant risk factors were age, NYHA class Ⅲ/Ⅳ, left ventricular ejection fraction(LVEF) ＜0.40, renal failure, cerebrovascular and/or peripheral vascular disease, chronic obstructive pulmonary disease, recent acute myocardial infarction, prior percutaneous coronary intervention, left main stenosi, three-vessels disease. The variables entered into the multivariate logistic regression were age, NYHA class Ⅲ/Ⅳ, LVEF ＜0.40, renal failure, chronic obstructive pulmonary disease, recent acute myocardial infarction, prior percutaneous coronary intervention, three-vessels disease. According to the outcome of multivariate logistic regression, we can conclude the model of probability forecast and create a new variable named Pre. The area under ROC curve of the new variable Pre was larger than other variables. Conclusion The main risk factors of prolonged ICU length of stay were LVEF ＜ 0.40, recent acute myocardial infarction, renal failure and chronic obstructive pulmorary disease. The AUC of variable Pre was higher than other' s , which indicated that new variable Pre combining each variable was more valuable than single variable with respect to prediction. A predicted probability of 0. 754 was used as cut-off point for the prognostic test.     

心外科术后连续肾脏替代治疗患者医院感染危险因素及预后

目的 探讨心脏外科手术后连续肾脏替代治疗患者医院感染及预后的危险因素.方法 回顾性分析医院2006年1月～2007年12月的心外科术后连续肾脏替代治疗患者医院感染资料.结果 两年来医院对125例心外科术后肾功能衰竭患者进行连续肾脏替代治疗,其中59例发生了医院感染,感染率为47.20%;分离病原菌158株,其中革兰阴性杆菌74株(46.84%),革兰阳性球菌58株(36.71%),真菌26株(16.46%);Logistic回归分析医院感染与术后机械通气时间(X1)、住院时间(X2)、住ICU时问(X3)有关,差异有统计学意义(χ~2=48.642,P＜0.01);医院感染组患者病死率为66.10%,非医院感染组病死率49.94%,两组病死率差异有统计学意义(χ~2=6.168,P=0.013).结论 医院感染是心外科术后连续肾脏替代治疗患者死亡危险因素,提高患者生存率应控制医院感染.     

肾功能分级在成人心脏术后肾功能衰竭的应用

Objective To evaluate the ability of the RIFLE classification to predict hospital mortality in adult patients who underwent cardiac surgery. Methods From October Ist 2006 to December 31st 2006, five hundred and nine adult patients who underwent coronary artery bypass grafting and/or valve operation were enrolled in this study. Renal function was assessed daily according to the RIFLE classification, meanwhile, APACHE Ⅱ score and SOFA score were also evaluated, as well as the maximum scores were recorded. Results Mean duration of ventilation support was 18(14 - 19) hours, the time of ICU stay was 1.4 ± 1.0 days, and the time of postoperative hospital stay was 12. 0(10.0- 15.0) days. 167 patients (32. 8%) incurred postoperative ARF according to the RIFLE classification. The overall mortality was 4. 3% (22/502). A significant increase (P < 0. 01) was observed for mortality based on RIFLE classification. By applying the area under the receiver operating characteristic curve, the RIFLE classification had more powerful discrimination power [0. 933, (95% CI 0. 872 -0. 995) ,P <0. 001]. Conclusions ARF is one of the major complications in postcardiotomy patients. Analytical data suggested the good discriminative power of the RIFLE classification for predicting inpatient mortality of adult postoperative patient with ARF, and the RIFLE classification is simple and practically performed. According to the RIFLE classification, patients with RIFLE class I or class F incur a significantly increased risk of in-hospital mortality compared with those who never develop ARF.     

肾功能损伤分级在心脏术后肾脏替代治疗中的应用

目的 探讨肾功能损伤分级(AKIN分级)在心脏术后肾脏替代治疗时机选择中的作用. 方法 2006年9月至2007年10月在我院首次行冠状动脉旁路移植术和/或心瓣膜手术100例患者中,根据AKIN分级,选取最高分级在2级、3级的患者,并结合是否接受肾脏替代治疗(RRT)将患者分为4组:A组:2级接受RRT治疗;B组:2级未接受RRT治疗;C组:3级接受RRT治疗;D组:3级未接受RRT治疗,记录4组患者临床资料和临床转归等. 结果 4组患者术后肾功能均出现不同程度的损伤,血肌酐最高值分别为197.8±32.1 μmol/L,154.1±40.1 μmol/L,330.9±78.2 μmol/L和339.1±107.7 μmol/L,明显高于术前.4组患者住院病死率分别为16.7%、14.3%、52.2%和56.3%,C组患者住院病死率高于A组(χ2=5.487,P=0.019)和B组(χ2=11.036,P=0.001),D组患者住院病死率明显高于A组(χ2=5.812,P=0.016)和B组(χ2=11.003,P=0.001),其中以D组患者的病死率最高. 结论 心脏术后患者肾功能损伤分级进入AKIN分级2级时接受RRT有可能改善其临床预后.