【作者】 张钊；

【导师】 缪长虹；

【作者基本信息】 复旦大学 ， 麻醉学， 2010， 硕士

【摘要】 目的：研究术前合并重度呼吸功能不全的择期中上腹部及以上非心脏手术患者的围术期转归情况,通过分析总结,探讨术前、术中及术后各项因素与围术期转归之间的关系,并筛选出有意义的危险因素。方法：回顾复旦大学附属中山医院2006年9月1日至2009年8月31日期间,合并重度呼吸功能不全并且行中上腹部及以上非心脏择期手术患者的临床资料,总结此类患者的围术期转归情况,并将可能的相关因素与围术期不良事件的发生、术后入住重症监护室(ICU)时间及术后住院时间等情况做单因素及多因素回归分析,筛选出有意义的危险因素,建立风险模型。结果：55例患者中有21例(38.18%)患者在围术期发生不良事件,1例死亡。围术期不良事件主要为术后肺部并发症(PPCs,18/21)和心血管系统并发症(7／21,包括严重的心律失常和心功能衰竭)。各项研究因素与围术期不良事件的单因素分析结果显示,合并重度混合性通气功能障碍(P=0.024)、应用双腔气管导管(P=0.018)、术中吸入氧浓度过高(P=0.038)及术前第一秒用力呼气量FEV1≤0.8L (P=0.043)是增加围术期不良事件发生的危险因素；Logistic回归分析得出应用双腔气管导管(OR=7.08)、通气障碍类型为混合性(OR=5.69)及无组织器官切除的手术方式(OR=0.20)是影响围术期不良事件发生的相关因素；研究因素与术后入住ICU时间的多重线性回归的结果表明年龄(Coef.=0.154976)、术前动脉血氧分压小于60mmHg (Coef.=11.71539)、术前使用激素类药物大于等于3天(Coef.= 3.121874)、中上腹部手术(Coef.=-23.53693)及发生手术并发症(Coef.=36.47372)为有意义的相关因素；与术后住院时间的多重线形回归的结果表明体质指数(BMI) (Coef=2.091116)、合并糖尿病(Coef.=-9.192909)、术前白蛋白水平(Coef.=-0.4028801)、术前最大通气量占预计值百分比(MVV%)水平(Coef.=-87.31409)、单纯全麻(Coef.=-6.217967)、手术时间(Coef.=0.060829)、中上腹部手术(Coef.=-15.20421)及发生手术并发症(Coef.=41.37919)为有意义的相关因素。结论：术前合并重度呼吸功能不全的患者,择期行中上腹部及以上手术围术期不良事件的发生率较高,主要为术后肺部并发症(PPCs)和心血管系统并发症(包括严重的心律失常和心功能衰竭)。合并混合性通气功能障碍、应用双腔气管导管、术中吸入氧浓度过高、术前FEV1≤0.8L是围术期不良事件发生的危险因素。年龄增加、术前动脉血氧分压小于60mmHg、发生手术并发症会延长患者术后入住ICU的时间；BMI增加、术前白蛋白水平降低、术前MVV%降低、手术时间延长及发生手术并发症会延长患者术后住院时间。更多还原

【Abstract】 Purpose:In order to screening the risk factors which were related to the outcome of the patients with severe respiratory dysfunction who sustained elective upper abdominal and non-cardiac thoracic surgery, We analyzed the relationship between preoperative, intraoperative, postoperative factors and the outcome of these patients.Material and Methods:We reviewed the patients with severe respiratory dysfunction that received upper abdominal and non-cardiac thoracic surgery in Zhongshang hospital from sep. 1 2006 to aug.31 2009. The possible risk factors and outcome of these patients including the occurrence of adverse events peri-operatively, ICU time and post-operative hospitalization was reviewed. All these data was analyzed via monofactor and multifactor regress in order to screening the significant risk factors and build the risk model.Outcome:Perioperative adverse events occurred in 21 patients (21/55,38.18%) and 1 patient died. Postoperative pulmonary complications (PPCs,18/21) and cardiovascular complications(7/21) including sever arrhythmia and heart failure were most common. Monofactor analysis indicated severe mixed ventilation dysfunction(P=0.024), double lumen endotracheal tube intubation (P=0.018), high concentration oxygen inhalation during operation(P=0.038) and FEV1≤0.8L preoperatively (P=0.043) were the risk factors that would increase the incidence rate of perioperative adverse events. Logistic regress indicated that double lumen endotracheal tube intubation (OR=7.08), severe mixed ventilation dysfunction (OR=5.69) and resection or reconstruction of organs (OR=0.20) were the risk factors. Multiple liner regress indicated age (Coef.=0.154976)、preoperative PaO2<60mmHg (Coef.=11.71539), preoperative glucocorticosteroid application≥3 days (Coef.=3.121874), upper abdominal surgery (Coef.=-23.53693) and operation related complication (Coef.= 36.47372) were the significant related factors to ICU time; BMI (Coef.= 2.091116), dibetes (Coef.=-9.192909), preoperative serum albumin level (Coef.=-.4028801), preoperative MVV% level(Coef.=-87.31409), simple general anesthesia (Coef.=-6.217967) surgery time (Coef.=0.060829), upper abdominal surgery (Coef.=-15.20421) and surgery related complications (Coef.= 41.37919) were related factors to postoperative hospitalization.Conclusions:There is a high incidence rate of adverse events in patients with severe respiratory dysfunction who sustain elective upper abdominal and non-cardiac thoracic surgery. The main adverse events are postoperative pulmonary complications (PPCs) and cardiovascular complications including severe arrhythmia and heart failure. Mixed ventilation dysfunction, double-lumen endotracheal intubation, high oxygen inhalation, preoperative FEV1≤0.8L are the risk factors that could increase the incidence rate of perioperative adverse events. Increasing of Age, preoperative PaO2<60mmHg, surgery related complication will prolong the ICU time. Increasing of BMI, operation time, the decreasing of preoperative albumin level and MVV% will prolong the postoperative hospitalization.更多还原