急性Stanford A型主动脉夹层孙氏手术后呼吸功能不全的治疗

Treatment Experiences of Acute Respiratory Dysfunction after Sun's Procedure in Patients with Acute Stanford Type A Aortic Dissection

目的探讨急性Stanford A型主动脉夹层患者在深低温停循环（DHCA）下行孙氏手术后,发生急性呼吸功能不全（ARD）的危险因素及治疗策略。方法 2013年1月至2014年12月,武汉同济医院收治的急性Stanford A型主动脉夹层患者108例,在深低温停循环（鼻温降至22℃）下行孙氏手术。ARD定义为术后72h内发生的低氧血症（PaO2/FiO2≤150）,除外术后心源性肺水肿、肺部感染、血/气胸等因素引起的低氧血症。据此将所有患者分为两组：术后呼吸功能不全发生组与术后呼吸功能正常组。比较两组患者的临床资料及治疗方法。结果 51例患者术后发生ARD,发生率47%（51/108）。该组体质量指数、吸烟者比例及术中输血量均显著高于术后呼吸功能正常组（均P〈0.05）。术后呼吸功能不全发生组采用较高PEEP的机械通气,行多次肺复张,更强的利尿脱水以及其他综合治疗。其中28例3d内脱离呼吸机,12例5~7d脱离呼吸机,11例因机械通气时间超过7d行气管切开,院内死亡4例。结论急性Stanford A型主动脉夹层孙氏术后早期ARD发生率为47%。高体质量指数、吸烟史及术中大量输血是ARD发生的危险因素。适当的呼吸机治疗、肺复张,以及利尿脱水等综合治疗策略对于急性Stanford A型主动脉夹层孙氏手术后ARD有较好的疗效。

Objective To explore the risk factors and therapeutic strategy of acute respiratory dysfunction（ARD）after Sun＇s surgery in patients with acute Stanford type A aortic dissection.Methods One hundred and eight patients with acute Stanford type A aortic dissection received Sun＇s procedure under deep hypothermic circulatory arrest（DHCA）（nose temperature below 22℃）between January 2013 and December 2014 in Tongji Hospital.Postoperative ARD was diagnosed according to hypoxia（PaO2/FiO2≤150）that occurred within 72 hof surgery in the absence of cardiogenic pulmonary edema,pneumonia,hemopneumothorax,pneumothorax and so on.All patients were divided into two groups：respiratory dysfunction group and normal respiratory function group.Clinical data and therapeutic methods were compared between the two groups.Results A total of 51patients（51/108,47%）developed postoperative ARD.The body mass index（BMI）,the proportion of smokers and the volume of blood transfusion were significantly higher in respiratory dysfunction group than those in normal respiratory function group（P〈0.05）.Postoperative treatments in respiratory dysfunction group included mechanical ventilation with higher positive end expiratory pressure（PEEP）,more recruitment maneuvers,enhanced diuretic therapy,dehydration and other comprehensive treatments.Among them,28 patients were successfully weaned from ventilation within 3days after operation,and 12 patients from ventilation within 5-7days after operation.Tracheotomy was performed in 11 patients with prolonged ventilation which lasted more than 7days.Death occurred in four cases in ARD group.Conclusion The incidence of ARD after surgery in patients with acute Stanford type A aortic dissection is 47%.The risk factors of postoperative ARD include high BMI,smoking history and massive blood transfusion during operation.Comprehensive treatments including proper mechanical ventilation,recruitment maneuver,diuretic therapy and other supportive therapy are effective for ARD after surgery in patients with acute type A aortic dissection.