心脏术后脑梗塞患者的临床分析与重症监护治疗

Clinical analysis and treatment of patients with cerebral infarction after cardiac surgery

目的分析心脏术后脑梗塞发生时间，总结脑梗塞患者的重症监护治疗和预后，为术后脑梗塞的临床防治提供依据。方法回顾性研究2014年1月至2016年12月心脏术后7天内出现中枢神经系统损伤的临床表现，并行头颅CT和（或）MRI检查证实脑梗塞的患者。将脑梗塞患者分为体外循环和非体外循环组，比较两组患者临床资料。脑梗塞定义为任何局灶或全灶神经症状持续超过24h，早发脑梗塞定义为术后24h之内的脑梗塞，迟发脑梗塞定义为术后24h以后的脑梗塞。结果共41例心脏术后脑梗塞患者纳入研究，其中早发脑梗塞患者12例，迟发脑梗塞患者29例。非体外循环组患者早发脑梗塞发生比例明显低于体外循环组（P=0．01）。本研究中患者均采用综合疗法对症支持治疗。体外循环组和非体外循环组ICU住院分别（9．63±6．42）天和（8．19±4．63）天，总住院（24．25±13．51）天和（19．14±12．81）天，差异有统计学意义（P〈0．05）。出院时日常生活活动能力量表〈50分的严重残疾8例，4例病情恶化自动出院，1例死亡。结论与非体外循环患者相比，体外循环下早发脑梗塞者较多。治疗早发和迟发脑梗塞应使用不同的策略。围手术期脑梗塞严重影响患者的预后和生存质量。

Objective To analyse the timing of cerebral infarction after cardiac surgery, summarize the intensive care treatment and prognosisof patients with cerebral infarction, and provide the basis for clinical prevention and treatment of postoperative cerebral infarction. Methods A retrospective review of patients undergoing cardiac surgery between January 2014 and December 2016 in our department. Patients had the clinical manifestations of central nervous system injury within 7 days after surgery and confirmed cerebral infarction by CT or MRI examination. The cerebral infarction patients were divided into the on- pump and off-pump group, and the clinical data were compared between the two groups. Cerebral infarction was defined as any focal or global neurological deficits lasting for more than 24 hours. Cerebral infarction was classified as early cerebral infarction when it occurred less than 24 hours postoperatively, and delayed cerebral infarction when it occurred more than 24 hours post- operatively. Results In a total of 41 patients with cerebral infarction were included in the study. Early cerebral infarction occurred in 12 patients and delayed cerebral infarction occurred in 29 patients. The off-pump group patients had significantly lower risk of early cerebral infarction （P = 0.01 ）. All patients in this study were treated with comprehensive therapy. The time of on-pump and aft-pump group staying in ICU was respectively （9.63 ± 6.42 ）days and （8.19 ±4.63 ）days, the total length of hospital stay was（24.25 ± 13.51 ） days and（ 19.14± 12.81 ） days, the difference was statistically significant（ P 〈 0.05）. When discharged BI was severe disability in 8 cases, deterioration of discharged automatically in 4 cases, death in 1 cases. Conclusion Compared with patients undergoing off-pump CABG, patients undergoing on-pump surgery more frequently had early cerebral infarction. Early and delayed cerebral infarction differed in their mechanisms. Different preventive strategies should be applied in future intervention. Perioperative cerebral infarction seriously affected the patient＇s prognosis and quality of life.