肺动脉导管在妊娠合并肺动脉高压患者围产期的应用

The application of peripartum use of pulmonary artery catheter in pregnant patients with pulmonary hypertension

目的 探讨肺动脉导管（PAC）在妊娠合并肺动脉高压患者围产期的应用,为PAC在此类患者中的应用提供参考.方法 回顾性分析2006-2014年首都医科大学附属北京安贞医院综合外科ICU收治的妊娠合并肺动脉高压患者的临床资料,比较留置与未留置PAC患者的临床及预后.结果 术前超声心动图测量肺动脉收缩压,留置PAC患者为（103.0±24.1） mmHg（1 mmHg =0.133kPa）,未留置PAC患者为（96.4 ±27.3） mmHg,差异无统计学意义（P=0.175）.超声心动图测量肺动脉压与PAC测量肺动脉压比,有高估或低估的可能,差值波动在-38.4 ～ 49.5 mmHg.与未留置PAC患者比,留置PAC患者特发性肺动脉高压比例较高（20.0％比3.2％）;术中采用连续硬膜外麻醉比例高（89.1％比65.1％）;去甲肾上腺素、多巴酚丁胺、西地那非、前列地尔、伊洛前列素及低分子肝素的使用较多;病死率较高（16.4％比3.2％）;低体重儿（63.9％比30.6％）、极低体重儿（19.4％比13.9％）的比例较高;人工流产比例略低（5.5％比17.5％）.留置PAC患者术后ICU停留时间[6.0（5.0）d比1.0（3.0）d]、术后住院时间[8.0（6.0）d比8.0（4.0）d]、总住院费用[43 999.22（38 267.27）元比14 878.24（10 564.47）元]高于未留置PAC患者.PAC相关并发症的发生率为7.3％.结论 对临床症状较重的妊娠合并中、重度肺动脉高压患者留置PAC,有利于围产期持续肺动脉压监测及指导药物治疗,以改善患者的临床结局,降低短期病死率,而超声心动图测量肺动脉压不能替代PAC在肺动脉压监测中的地位.

Objective To investigate the application and value of pulmonary artery catheterization （PAC） in pregnant patients with pulmonary hypertension （PH）.Methods The clinical data of pregnant patients with PH who were treated between 2006 and 2014 in surgical intensive care unit （SICU） at Capital Medical University affiliated Beijing Anzhen Hospital were retrospectively analysed.The differences of the clinical characteristics and outcome between PAC inserted patients and PAC not inserted patients were compared.Results The systolic pulmonary artery pressure （sPAP） measured by preoperative echocardiography has no significant difference between the PAC inserted patients [（103.0 ± 24.1） mmHg （1 mmHg =0.133 kPa）] and PAC not inserted patients [（96.4 ±27.3）mmHg;P =0.175].SPAP may be overestimated or underestimated by echocardiography compared with PAC with a gap from-38.4 mmHg to 49.5 mmHg.The rates of idiopathic pulmonary arterial hypertension （20.0% vs 3.2%） and continuous use of epidural anesthesia （89.1% vs 65.1%） were higher in PAC inserted patients compared with PAC not inserted patients.Norepinephrine,dobutamine,sildenafil,alprostadil,iloprost and low molecular weight heparin were more widely used in PAC inserted patients.The mortality rate and the rates of low birth weight （63.9% vs 30.6%） and very low birth weight infants （19.4% vs 13.9%） were all higher in PAC inserted patients,while the rate of induced abortion was lower in this group （5.5% vs 17.5%）.The length of stay in surgical intensive care unit [6.0 （5.0） d vs 1.0 （3.0） d],postoperative length of stay [8.0 （6.0） d vs 8.0 （4.0） d] and total hospital costs [43 999.22 （38 267.27）RMB vs 14 878.24 （10 564.47） RMB] were all higher in PAC inserted patients.The incidence rate of PAC related complications was 7.3%.Conclusions In moderate or severe PH pregnant patients with severe clinical symptoms,perioperative insertion of PAC helps to monitor the perinatal pulmonary arterial pressure （PAP） and guide treatment,potentially improving clinical outcomes and lowering the short term mortality.PAC can＆#39;t be replaced by echocardiography in measuring PAP.