体外循环下心内直视手术后ARDS69例临床分析  

Analysis of acute respiratory distress syndrome after open heart surgery under cardiopulmonary bypass

作　　者：陈柏成[1] 肖颖彬[1] 钱桂生[2] 陈林[1] 钟前进[1] 王学锋[1] 王惠春[1] 刘晓莉[1] 

机构地区：[1]第三军医大学新桥医院心血管外科,重庆400037 [2]第三军医大学新桥医院全军呼吸内科研究所,全军呼吸病研究重点实验室,重庆400037

出　　处：《第三军医大学学报》2005年第14期1484-1487,共4页Journal of Third Military Medical University

基　　金：全军医学科学技术研究"十五"计划基金重点课题(01Z074)~~

摘　　要：目的观察心内直视手术后ARDS的病情演变与临床特征,并探讨其发病机制与诊治原则,以提高其抢救成功率。方法回顾性分析了1996年1月至2004年3月我科ICU收治的69例心内直视手术后ARDS病人临床资料。结果共发生心内直视手术后ARDS69例,占同期4680例体外循环心内直视手术的1·47%。多数发生于术后早期。所有病例术后均出现顽固性低氧血症,对常规的治疗效果不明显;同时存在气道压升高、肺顺应性降低;先后出现胸片改变。术后早期死亡15例,死亡率21.74%。其中12例死于多脏器功能衰竭,3例死于致死性的心律失常。术前心功能差,合并肝肾功能不全、糖尿病、高血压等多种疾病,存在哮喘、慢性支气管炎等病史、吸烟史、脑血管意外史,术中长时间转流或心肌保护不良,麻醉或体外循环过程中意外情况发生,急诊手术是心内直视手术后ARDS发生的高危因素。结论在心内直视手术后ARDS的诊治过程中强调早期发现与早期处理。尤其是针对具有高危因素的病人,作出早期诊断与处理,有利于争取抢救时机提高抢救成功率。在治疗中强调积极应用小潮气量保护性通气治疗,同时应用大剂量的激素与前列腺素E,积极防治防止其它脏器功能的损害。Objective To investigate the developing course and the characteristics of ARDS after cardiopulmonary bypass, gain insights into the pathophysiology of ARDS, establish appropriate protocols of diagnosis and management, and to improve the salvage of severe critical patients. Methods From January 1996 to March 2003, 69 cases of ARDS after CPB occurred in our ICU. The related clinic data of the patients was reviewed retrospectively. Results Sixty-nine cases among 4 680 cases of open heart operations presented ARDS with an incidence of 1.47%. Typical manifestations occurred at the early period of postoperation, including refractory hypoxia, stunned response to regular treatments, accompanied with higher airway pressure, lower pulmonary compliance and chest X-ray changes. There were 15 patients dead during early postoperation with mortality of 21.74%, among which 12 cases died of multiorgan failure, 3 cases of fatal arrhythmia. Poor cardiac function, coexisting diseases such as hepatic dysfunction, renal dysfunction, diabetes mellitus, hypertension, asthma or chronic pulmonary disease history, smoking history, cerebrovascular accidents, prolonged CPB time, mal-protection of myocardium during operation, emergency surgery, accidents during anesthesia or CPB and so on, are considered as risk factors of ARDS. Conclusion Early diagnosis and early treatment should be emphasized especially for the patients with high risk factors. Lower vital volume ventilation, high dose of glucocorticoid and prostaglandin E therapy are recommended. It is pivotal to prevent ensuing multiorgan failure.

关 键 词：心内直视手术 急性呼吸窘迫综合征 多脏器功能哀竭 危险因素 

分 类 号：R563.806[医药卫生—呼吸系统] R619[医药卫生—内科学]