Stanford A型主动脉夹层体外循环中氧供与术后30天死亡率的关系  

Relationship between oxygen delivery during cardiopulmonary bypass and the 30-day postoperative mortality of Stanford type A aortic dissection based on the restricted cubic spline model

作　　者：林天晓 陈星 孟维朋 官莉[1] 郑少忆[1] 彭勤宝 LIN Tianxiao;CHEN Xing;MENG Weipeng;GUAN Li;ZHENG Shaoyi;PENG Qinbao(Department of Cardiovascular Surgery,Nanfang Hospital,Southern Medical University,Guanghou 510515,Guangdong,China)

机构地区：[1]南方医科大学南方医院心血管外科,广东广州510515

出　　处：《暨南大学学报（自然科学与医学版）》2023年第3期297-304,315,共9页Journal of Jinan University(Natural Science & Medicine Edition)

基　　金：广东省医学科学技术研究基金项目(B2021025)。

摘　　要：目的:探讨接受手术治疗的Stanford A型主动脉夹层(AAD)患者在体外循环(CPB)中平均氧供(DO2)与术后30 d死亡率的关系,并探究最低氧供(DO_(2)^(min))安全阈值范围。方法:回顾性分析2018年1月至2022年7月收治的176例行孙氏手术的AAD患者的临床资料,其中男性156例(88.6%),年龄(50.9±12.4)岁,根据术后30 d内生存情况分为存活组(n=159)和死亡组(n=17),先采用Cox比例风险模型确定影响AAD患者术后30 d死亡的影响因素,再用限制性立方样条(RCS)模型分析经上述因素调整后的氧供(DO2)与术后30 d死亡率的剂量反应关系。结果:多因素Cox比例风险模型分析结果显示,CPB时间[HR(95%CI):1.016(1.007,1.025),P<0.01]及术后使用连续肾替代治疗[HR(95%CI):3.73(1.12,12.39),P=0.03]是AAD患者术后30 d死亡的独立危险因素;调整后的RCS模型分析显示,DO2与AAD患者术后30 d死亡率呈“L”型关系(非线性检验,P=0.029),当DO2<320 mL·min^(-1)·m^(-2)时,随着DO2的减小,患者术后30 d死亡的风险显著上升,在高流量复温阶段当DO2<444 mL·min^(-1)·m^(-2)时也发生类似现象,而高于参考点的DO2均未对结局事件产生显著影响。结论:CPB过程中DO2与AAD患者术后30 d死亡率呈非线性关系,维持转流全过程的平均DO2≥320 mL·min^(-1)·m^(-2)以及复温阶段的DO2≥444 mL·min^(-1)·m^(-2)可能有助于降低术后30 d死亡风险,高于上述参考值的DO2似乎不能进一步改善临床结局。Objective:The present study aimed to investigate the relationship between the average oxygen delivery(DO_(2))during cardiopulmonary bypass(CPB)and the 30-day postoperative mortality of the patients with acute Stanford type A aortic dissection(AAD)and to determine the safe threshold range of minimum oxygen delivery(DO_(2)^(min))。Methods:The clinical data of 176 AAD patients who underwent Sun's procedure from January 2018 to July 2022,were retrospectively analyzed.156(88.6%)of them were men,and the average age of the whole population was(50.9±12.4)years old.The whole patients were divided into a survival group(n=159)and a death group(n=17)based on their survival situation.Cox proportional hazards model was applied to determine the risk factors for 30-day postoperative mortality of the patients with AAD,and then restricted cubic spline model was used to analyze the dose response relationship between DO_(2) and 30-day postoperative mortality adjusted by the above factors.Results:Multivariate Cox proportional risk model analysis indicated that CPB time[HR(95%CI):1.016(1.007,1.025),P<0.01]and the application of Continuous renal replacement therapy[HR(95%CI):3.73(1.12,12.39),P=0.03]were the independent risk factors for 30-day postoperative death of the AAD patients.The adjusted restricted cubic spline model analysis demonstrated that there was an L shaped relationship between DO_(2) and 30 day postoperative mortality of the AAD patients(nonlinear test,P=0.029).When DO_(2) was low than 320 mL·min^(-1)·m^(-2),the incidence of 30-day postoperative death of the patients increased significantly with the decrease of DO_(2).A similar phenomenon could be observed when DO_(2) was low than 444 mL·min^(-1)·m^(-2)during the high-flow rewarming stage.However,DO_(2) higher than the reference point above made no significant difference to outcome events.Conclusion:There was a nonlinear relationship between DO_(2) during CPB and 30-day postoperative mortality rate of the AAD patients.Maintaining average DO_(2)≥320 mL·min^(-1)�

关 键 词：Stanford A型主动脉夹层 氧供 死亡率 连续肾替代治疗 最低阈值 限制性立方样条 

分 类 号：R654.1[医药卫生—外科学]