重症肌无力患者扩大胸腺切除术后延迟拔除气管插管的危险因素分析  

Analyses of the risk factors of delayed extubation after extended thymectomy in patients with myasthenia gravis

作　　者：王美平 孙雪琪 姜利 娄然 司权 王婷婷 卢高俊 Wang Meiping;Sun Xueqi;Jiang Li;Lou Ran;Si Quan;Wang Tingting;Lu Gaojun(Department of Critical Care Medicine,Xuanwu Hospital,Capital Medical University,Beijing100053,China;Department of Thoracic Surgery,Xuanwu Hospital,Capital Medical University,Beijing100053,China)

机构地区：[1]首都医科大学宣武医院重症医学科,北京100053 [2]首都医科大学宣武医院胸科,北京100053

出　　处：《中华内科杂志》2025年第1期52-59,共8页Chinese Journal of Internal Medicine

基　　金：北京市卫生健康委员会高层次公共卫生技术人才建设项目培养计划(学科带头人-2023-02-21)。

摘　　要：目的分析重症肌无力(MG)患者扩大胸腺切除术后延迟拔除气管插管的危险因素。方法回顾性分析2021年5月至2024年1月入住首都医科大学宣武医院重症医学科确诊为MG并行扩大胸腺切除术且存在气管插管、术后转入重症监护病房(ICU)的患者,根据术后机械通气时间是否超过48 h,分为延迟拔管组和成功拔管组。采用多因素logistic回归分析MG患者扩大胸腺切除术后延迟拔除气管插管的危险因素。结果95例患者中,延迟拔管组15例(15.8%),成功拔管组80例(84.2%)。与成功拔管组比,延迟拔管组患者机械通气时间(94.0 h比15.5 h,P<0.001)、住ICU时间(7.1 d比1.7 d,P<0.001)、总住院时间(16.0 d比9.1 d,P<0.001)明显延长。校正年龄、性别、体重指数、临床分型、病理分型、术前用溴比斯的明剂量、围手术期肺炎、肺功能异常、首次自主呼吸试验(SBT)通过率、抬颈时间>20 s,多因素logistic回归分析,结果显示,术前服用溴比斯的明的剂量每增加60 mg/d、病理分型为胸腺瘤、围术期肺炎、术前肺功能异常,使延迟拔管的风险分别增加29%(OR=1.290,95%CI 1.090~1.714)、1%(OR=1.009,95%CI 1.002~1.034)、3.9倍(OR=4.977,95%CI 1.486~10.939)及64%(OR=1.635,95%CI 1.396~2.682)。抬颈时间>20 s可使延迟拔管的风险降低48%(OR=0.524,95%CI 0.322~0.794)。结论术前服用较大剂量的溴比斯的明、术前肺功能异常、病理分型为胸腺瘤及围术期肺炎是MG患者术后延迟拔管的危险因素,抬颈时间超过20 s可降低延迟拔管的发生风险。对延迟拔管高风险的MG患者拔管前行抬颈试验判断肌肉力量,可降低气管插管复插率及其副作用。临床应早期识别此类患者,预防和控制危险因素,谨慎拔管,避免再次气管插管给患者带来损伤。Objective To explore the risk factors of delayed extubation after expanded thymectomy in patients with myasthenia gravis.MethodsPatients with myasthenia gravis who underwent expanded thymectomy from May 2021 to January 2024 and were admitted to Intensive Care Unit(ICU)after surgery were retrospectively analyzed.Patients were divided in to the delayed extubation and successful extubation according to the length of mechanical ventilation whether exceeding than 48 hours.Multivariable logistics regression was used to explore the risk factors for delayed extubation after expanded thymectomy in patients with myasthenia gravis.ResultsA total of 95 patients were included.15(15.8%)of whom were delayed extubation.Compared with the successful extubation patients,the length of mechanical ventilation(94.0 h vs.15.5 h,P<0.001),ICU station(7.1 days vs.1.7 days,P<0.001),and hospitalization station(16.0 days vs.9.1 days,P<0.001)were significantly prolonged in the delayed extubation patients.Adjusted for age,gender,BMI,clinical classification,pathological classification of thymoma,dose of pyridostigmine preoperative,perioperative pneumonia,preoperative pulmonary dysfunction,SBT passing for the first time,neck lift time greater than 20 seconds,the multivariable logistic regression shown,the risk of delayed extubation increased by 29%(OR=1.290,95%CI 1.090-1.714),1%(OR=1.009,95%CI 1.002-1.034),3.9-fold(OR=4.977,95%CI 1.486-10.939),and 64%(OR=1.635,95%CI 1.396-2.682)for every 60 mg/day increase in preoperative dose of pyridostigmine,pathological classification of thymoma,perioperative pneumonia,and preoperative pulmonary dysfunction,respectively.Neck lift time greater than 20 seconds can reduce the risk of delayed extubation 48%(OR=0.524,95%CI 0.322-0.794).ConclusionPreoperative administration of a large dose of pyridostigmine,pulmonary dysfunction,pathological classification of thymoma,and perioperative pneumonia were risk factors for delayed extubation after thymectomy in these patients.And neck lift time greater than 20 seconds dec

关 键 词：重症肌无力 扩大胸腺切除术 延迟拔管 

分 类 号：R47[医药卫生—护理学]