妊娠合并主动脉疾病患者围术期管理的临床分析

Clinical analysis of perioperative management in pregnant patients with aortic disease

目的:研究合并主动脉疾病的孕产妇在围术期给予兼顾各主要系统功能和孕产妇需求特点的重症集束化治疗,观察治疗效果。方法:收集2012年12月1日至2018年8月31日,北京安贞医院心脏大血管外科收治合并主动脉疾病并行手术治疗的孕产妇,术后返回心外科监护室(ICU)的18例患者,术后给予集束化治疗。包括:①循环系统:维持心排、调整血管张力、根据容量状态失液成分调整补液速度与种类;②呼吸系统:抗炎性反应、减少肺间质渗出、循环平稳后翻身体疗、中低水平肺复张、拔管后氧合指数PaO2/FiO2<200者行无创正压通气至少6 h;③生殖系统:产妇予催产素、管理宫腔水囊、回奶等治疗,孕妇有分娩先兆与妇产科配合决定分娩方式等;④其他出凝血与神经、内分泌系统治疗;维护肝肾功能,急性肾损伤(AKI)尽早行连续性肾脏替代治疗(CRRT);加强心理护理与ICU早期康复。结果:处理后与入ICU时(0 h)比较:①心率24 h时上升,48 h之后下降;平均动脉压(MAP)24 h时上升,48 h之后下降;乳酸:24 h时较0 h时有明显升高(P<0.05),之后下降,出ICU时明显减低(P<0.05);②呼吸频率无显著性差异;与0 h时比较PaO2/FiO224 h时下降[(235.6±45.7)vs.(167.3±27.5),P<0.05],48 h仍有降低[(235.6±45.7)vs.(186.6±23.2),P<0.05],72 h时无明显差异;③主要合并症:谵妄3例(16.7%),切口愈合不良3例(16.7%),二次气管插管2例(11.1%),肺部感染2例(11.1%),急性呼吸窘迫综合症1例(5.6%);④住院时间(15.0±4.4)d,ICU时间(5.6±2.5)d。结论:主动脉疾病围术期孕产妇呼吸系统及循环系统不稳定于术后24 h时高发,积极集束化处理可有效改善,各系统并发症发生率较高,需注意谵妄发生率及切口愈合情况,综合制定围术期管理方案。

Objective:To study the effect of perioperative intensive bundle therapy on pregnant patients complicated with aortic disease.Methods:18 pregnant patients with aortic disease recovering from the operation in the Center for Cardiac Intensive Care,Beijing Anzhen Hospital between Dec.1,2012 to Aug.31,2018,were investigated.All these patients accepted the bundle therapy in ICU,which included:①Circulatory system:maintain cardiac output and vascular tension,adjust the speed and type of fluid according to the volume and loss state;Respiratory system:anti-inflammatory drug,reduction of pulmonary interstitial exudation,low level lung recruitment,and noninvasive positive pressure ventilation;③Reproductive system:The puerperas were given the treatment of oxytocin,returns to the milk and so on;④Coagulation,nerve and endocrine system,and maintain the function of liver and kidney,if acute kidney injury(AKI)occurs,continuous renal replacement therapy(CRRT)should be given as soon as possible,psychological nursing and early rehabilitation should be paid attention in ICU.Results:Compared to the time of coming ICU(0 h),①The heart rate(HR)increased at 24 h,decreased at 48 h;mean arterial pressure(MAP)increased at 24 h and decreased at 48 h;lactic acid:at 24 h was significantly higher than 0 h(P<0.05);②There was no significant difference in respiratory rate(RR);The PaO2/FiO2 decreased at 24 h[(235.6±45.7)vs.(167.3±27.5),P<0.05]and still decreased at 48 h[(235.6±45.7)vs.(186.6±23.2),P<0.05]compared with that at 0 h;③Complications:delirium in 3 cases(16.7%),poor wound healing in 3 cases(16.7%),secondary endotracheal intubation in 2 cases(11.1%),pulmonary infection in 2 cases(11.1%);④Hospitalization time(15.0±4.4)d,ICU time(5.6±2.5)d.Conclusions:The unstable of respiratory and circulatory system occurred frequently at 24 hour after the operation for pregnant patients with aortic disease,bundle treatment could improve these,and other systems may also be damage,the incidence of delirium and wound healing should be paid attention to,it is necessary to make a comprehensive plan for perioperative management.