先天性心脏病伴重度肺动脉高压体外循环术后拔管时机探讨  

Discussion on the timing of extubation in patients with severe pulmonary hypertension undergoing congenital heart surgery

作　　者：张文波[1] 唐白云[1] 孙培吾[1] 殷胜利[1] 王治平[1] 张希[1] 

机构地区：[1]中山大学附属第一医院心脏外科,广州510080

出　　处：《中国医师进修杂志》2009年第12期1-5,共5页Chinese Journal of Postgraduates of Medicine

基　　金：广东省科技计划重点基金（2007B080701039）

摘　　要：目的探讨先天性心脏病（CHD）伴重度肺动脉高压（PH）体外循环（CPB）术后的拔管时机。方法对行CPB手术的40例CHD伴重度PH患者的临床资料进行回顾性分析，按术后机械通气时间是否〉24h，分为早期拔管组（19例）和延迟拔管组（21例），比较两组影响拔管的围手术期因素。行多因素Logistic回归分析确定延迟拔管（机械通气时间≥72h）的影响因素。结果两组术前NYHA心功能分级、撤机后肺循环与体循环收缩压比值（Pp／Ps）、CPB时间、CPB温度比较差异有统计学意义（P〈0．05或〈0．01）。术后早期缺氧发作（OR=0．022，95％CI0．001～0．580）和严重低氧血症（OR=0．031，95％CI0．002～0．568）是延迟拔管的独立危险因素。结论CHD伴重度PH患者若术前NYHA心功能分级≥Ⅲ级、撤机后Pp／Ps〉0．5、CPB时间〉90min或CPB温度〈32℃，可考虑延迟拔管。对术后早期有缺氧发作或严重低氧血症者，宜延迟拔管并加强心功能和肺动脉压监测；对无上述情况且术后心肺功能稳定者可考虑早期拔管。Objective To discuss the timing of extubation in patients of congenital heart disease （CHD） with severe pulmonary hypertension （PH） undergoing connective surgery with cardiopulmonary bypass （CPB）. Methods A retrospective study of 40 patients of CHD with severe PH was completed. According to whether the duration of mechanical ventilation （MV） 〉 24 hours, patients were divided into two groups, early extubation group （19 patients ） and late extubation group （21 patients ）. Perioperative variables that might influence duration of MV were compared between the two groups. Multivariate statistical analysis with Logistie regression was used for these patients to analyze the perioperative variables to determine risk factors for prolonged MV （MV ≥ 72 hours）. Results Between the two groups, preoperative NYHA class, Pp/Ps at the time of coming off bypass, CPB duration, and CPB temperature were siguifieandy different （P 〈 0.05 or 〈 0.01 ）. Anoxie spell （OR = 0.022, 95%CI 0.001-0.580） and severe hypoxemia （OR = 0.031,95% CI0.002-0.568 ） in the early postoperative period were the risk factors for prolonged MV. Conclusions The timing of extubation in these patients should be determined individually. Late extubation may fit those with advanced NYHA class, high Pp/Ps at the time of coming off bypass, prolonged CPB duration, or hypothermic CPB. For those with anoxic spell or severe hypoxemia in the early postoperative period, ultrasonic cardiography and pulmonary artery catheter monitoring help to guide treatment for prglonged MV. For else patients who with postoperative stable cardiopulmonary function, early extubation maybe feasible.

关 键 词：心脏病 高血压 肺性 体外循环 拔管 

分 类 号：R65[医药卫生—外科学]