优化选择性动脉灌注策略在Stanford A型主动脉夹层全弓置换术中的应用  

Optimized selective arterial perfusion approach in total aortic arch replacement of Stanford type A aortic dissection

作　　者：于浩 童光[1] 颜涛[1] 王晓莉 王晓武[1] 马涛 董文鹏[1] 吴路加 张卫达[1] YU Hao;TONG Guang;YAN Tao;WANG Xiao-li;WANG Xiao-wu;MA Tao;DONG Wen-peng;WU Lu-jia;ZHANG Wei-da(Department of Cardiovascular Surgery,PLA Guangzhou General Hospital,Guangzhou Clinical Medicine College of Navy Medical University(Second Military Medical University),Guangzhou 510010,Guangdong,China)

机构地区：[1]海军军医大学(第二军医大学)附属广州临床医学院,解放军广州总医院心血管外科,广州510010

出　　处：《第二军医大学学报》2018年第4期404-410,共7页Academic Journal of Second Military Medical University

基　　金：国家自然科学基金青年科学基金(81500183),军队临床高新技术重大项目(2014gxjs031),广东省医学科学技术研究基金(A2014486).

摘　　要：目的探讨优化选择性动脉灌注策略在Stanford A型主动脉夹层全主动脉弓置换术中的疗效。方法 2016年9月至2017年10月,我院31例接受全主动脉弓置换孙氏手术的Stanford A型主动脉夹层患者应用优化选择性动脉灌注策略(O-CPB组),其中男25例、女6例,平均年龄(50.87±9.08)岁;以2015年1月至2017年10月我院60例应用传统体外循环灌注方式完成全主动脉弓置换孙氏手术的Stanford A型主动脉夹层患者为对照组(T-CPB组),其中男52例、女8例,平均年龄(48.38±12.46)岁。比较两组围手术期血生化指标和临床数据,并用多因素logistic回归方法分析术后30 d患者死亡的危险因素。结果与T-CPB组比较,O-CPB组患者的手术体外循环时间短、停循环时间短、手术耗时少[(206.90±39.92)min vs(276.37±29.92)min、(5.03±1.54)min vs(21.73±6.67)min、(396.68±58.57)min vs(469.28±69.77)min,P均<0.01]。O-CPB组患者血制品消耗量少于T-CPB组、重症监护病房(ICU)滞留时间短于T-CPB组[(1 401±738)m L vs(1 705±580)m L、(5.94±2.45)d vs(7.42±3.53)d,P均<0.05]。O-CPB组患者的术后血乳酸浓度和C-反应蛋白浓度均低于T-CPB组[(6.10±3.80)mmol/L vs(8.11±4.51)mmol/L、(72.13±22.86)mg/L vs(84.78±17.07)mg/L;P<0.05,P<0.01]。O-CPB组患者术后清醒时间早于T-CPB组[(3.32±1.11)h vs(4.14±1.59)h,P<0.05)]。O-CPB组和T-CPB组患者的术后24 h内Richmond镇静程度评分绝对值分别为1.23±1.06和2.15±1.30,差异有统计学意义(P<0.01)。O-CPB组患者的术后氧合指数高于T-CPB组[(234.42±79.51)mm Hg vs(183.10±77.26)mm Hg,P<0.01;1 mm Hg=0.133 k Pa],有创通气时间短于T-CPB组[(50.19±37.63)h vs(70.12±40.84)h,P<0.05)。O-CPB组和T-CPB组患者的术后30 d内病死率分别为6.45%(2/31)和11.67%(7/60),两组间差异无统计学意义(P>0.05)。多因素logistic回归分析结果显示,停循环时间≥31 min和血制品消耗量≥1 390 m L是Stanford A型主动脉夹层患者全主动脉弓置换术后30 d内死亡的独�Objective To explore the curative effect of optimized selective arterial perfusion approach in the total aortic arch replacement of the Stanford type A aortic dissection.Methods From Sep.2016 to Oct.2017,31 Stanford A aortic dissection patients received total aortic arch replacement with cardiopulmonary bypass of optimized selective arterial perfusion approach(O-CPB group,25 males and 6 females,aged[50.87±9.08]years old)in our hospital.And 60 Stanford A aortic dissection patients,who underwent total aortic arch replacement with cardiopulmonary bypass of traditional approach in our hospital from Jan.2015 to Oct.2017,were included as control(T-CPB group,52 males and 8 females,aged[48.38±12.46]years old).The perioperative blood biochemistry parameters and clinical data were compared between the two groups.Multivariate logistic regression was used to analyze the risk factors for postoperative 30-day mortality.Results Compared with the T-CPB group,the O-CPB group had significantly shorter extracorporeal circulation time,circulatory arrest time and operation time([206.90±39.92]min vs[276.37±29.92]min,[5.03±1.54]min vs[21.73±6.67]min and[396.68±58.57]min vs[469.28±69.77]min,all P<0.01).The blood consumption volume and ICU detention time were significantly less in the O-CPB group versus the T-CPB group([1 401±738]mL vs[1 705±580]mL and[5.94±2.45]d vs[7.42±3.53]d,both P<0.05).The postoperative blood lactate and C-reactive protein concentrations in the O-CPB group were significantly lower than those in the T-CPB group([6.10±3.80]mmol/L vs[8.11±4.51]mmol/L and[72.13±22.86]mg/L vs[84.78±17.07]mg/L;P<0.05,P<0.01).The patients in the O-CPB group were awake earlier than those in the T-CPB group([3.32±1.11]h vs[4.14±1.59]h,P<0.05).The absolute value of postoperative Richmond agitation-sedation scale(RASS)score of the O-CPB and T-CPB groups were 1.23±1.06 and 2.15±1.30,respectively,and the difference was statistically significant(P<0.01).In O-CPB group,the oxygenation index was significantly higher and mechani

关 键 词：主动脉夹层 主动脉弓置换术 体外循环 中低体温 双侧顺行脑灌注 

分 类 号：R654[医药卫生—外科学]