重症脑血管病患者气管切开选择时机的探讨  

Timing exploration of tracheostomy in patients with severe cerebrovascular disorders

作　　者：刘慧权[1] 张建宁[2] 尹悦 柳兴军[1] 陈子祥[1] 

机构地区：[1]天津市海河医院神经外科,300350 [2]天津医科大学总医院神经外科,天津市神经病学研究所 [3]天津医科大学国际医学院

出　　处：《中华神经外科杂志》2018年第1期68-71,共4页Chinese Journal of Neurosurgery

摘　　要：目的探讨需机械通气的重症脑血管病患者的合适气管切开时机。方法回顾性纳入2009年1月至2014年12月天津市海河医院神经外科重症监护病房（NICU）和天津医科大学总医院NICU行气管切开的153例重症脑血管病患者，按照入住NICU至气管切开时间分为早期切开组（〈4d，简称早切组，共80例）和晚期切开组（7—14d，简称晚切组，共73例）。对比两组的NICU住院时长，总住院时长，镇静药、呼吸机以及抗生素使用时长，肺炎发生率，病死率，神经功能改善情况，气管切开相关并发症以及拔管时间。结果早切组在平均NICU住院时长、平均总住院时长、平均镇静药使用时长、平均呼吸机使用时长、平均抗生素使用时长方面优于晚切组（均P〈0．01）。早切组较晚切组肺炎发生率低（P〈0．01）。在气管切开并发症发生情况、NICU病死率、住院总病死率、出院时改良Rankin量表评分（mRS）方面，两组差异均无统计学意义（均P〉0．05）。随访时间为6个月。早切组获随访70例，晚切组获随访64例。获随访的早切组患者的拔管时间早于晚切组患者（P=0．03）。结论对于需较长时间机械通气的重症脑血管病患者，与晚期气管切开相比，早期实施气管切开可减少N1CU住院时长，总住院时长，镇静药、呼吸机以及抗生素使用时长，且肺炎发生率更低，拔管时间较早；但对住院期间病死率和神经功能方面无明显改善。Objective To explore the appropriate timing of tracheostomy in patients with severe cerebrovascular disorders requiring mechanical ventilation. Methods A retrospective analysis was conducted regarding patients with severe cerebrovascular disorders undergoing tracheostomy at the Neurosurgical Care Units （ NICU ） o[ General Hospital, Tianjin Institute of Neurology, Tianjin Medical University and Tianjin Haihe Hospital from January 2009 to December 2014. Early tracheostomy （ET） was defined as that performed on days 1 -4 and late tracheostomy （LT） on days 7 - 14 post admission to NICU. ET was performed in 80 patients and LT in 73 patients. The primary outcome was length of stay at the NICU and secondary outcomes were diverse aspects of the NICU course. Results The ICU length of stay, total length of hospital stay, duration of sedation, days of mechanical ventilation and duration of antibiotic use for patients undergoing ET were significantly shorter in comparison with those in the LT group （ all P 〈 0.01 ）. Patients receiving ET had a significantly lower incidence of pneumonia in comparison with those in the LT group （P 〈0.01 ）. Between the ET and LT groups, no significant difference was observed with regard to ICU mortality, hospital mortality or average score at discharge according to the modified Rankin scale （all P 〈 0.05 ）. The follow-up time is 6 months. Decannulation occurred earlier （58.2 ＋ 27.2 vs. 69.0 _ 26.8 d, P =0. 03 ） in the ET group. Conclusions Compared with LT, ET could be advantageous in patients with severe cerebrovascular disorders and relatively long period of mechanic ventilation in terms of shorter length of ICU stay, length of hospital stay, duration of sedation, days of mechanical ventilation and duration of antibiotic use. ET may reduce the incidence of pneumonia but does not seem to be associated with the improvement in mortality or neurologic outcome.

关 键 词：脑血管障碍 重症监护病房 气管切开术 预后 

分 类 号：R743[医药卫生—神经病学与精神病学]