探讨目标导向灌注管理对主动脉夹层手术脑保护的影响

Retrospective study of goal-directed perfusion management in cerebral protection in patients with aortic dissection

目的探讨目标导向灌注管理对于主动脉夹层深低温停循环手术患者脑保护的影响。方法回顾分析2016年3月至2019年3月Stanford A型主动脉夹层患者行主动脉弓置换术中应用中深低温停循环结合顺行性脑灌152例,予以倾向性分析匹配分组,目标导向灌注策略进行体外循环管理55例(GDP组),传统灌注策略管理55例(TP组)。TP组管理策略采用体表面积流量匹配管理。GDP组采用氧供-氧耗指标管理,并设定导向目标。主要事件包括术后机械通气时间>48 h、ICU停留时间,术后脑血管事件、谵妄、院内死亡等。结果两组停循环时间[TP组(25.42±7.33)min,GDP组(24.77±6.85)min]、术后机械通气延长(TP组5例vs.GDP组4例)、ICU停留时间(TP组平均3.9 d vs.GDP组3.5 d)均无统计学意义差异(P>0.05)。GDP组死亡2例(围术期心梗、脑出血),TP组3例(恶性心律失常、脑梗、多脏衰)。脑血管事件发生GDP组术后脑梗1例、脑出血1例,TP组脑梗2例。不同灌注策略术后脑血管事件、院内死亡率差异无统计学意义(P>0.05)。谵妄GDP组发生4例,TP组8例(P<0.05)。结论相比传统灌注管理策略,目标导向管理策略下行主动脉夹层手术可减少术后谵妄的发生,更有利于改善大脑保护。

Objective To investigate the effect of goal-directed perfusion management on brain protection in patients with aortic dissection undergoing hypothermic circulatory arrest surgery.Methods A group of 152 patients with Stanford type A aortic dissection undergoing aortic arch replacement with deep hypothermic circulatory arrest and antegrade cerebral perfusion from March 2016 to March 2019 were analyzed retrospectively.Patients were matched to controls using propensity score method-55 cases of goal-directed perfusion strategy management(GDP group)versus 55 cases of traditional perfusion strategy management(TP group).The body surface area matching pump flow was used as TP group management strategy.Oxygen supply-oxygen consumption indicators were used in the GDP group to manage and set targets.The primary outcomes included postoperative mechanical ventilation time>48 h,intensive care unit stay time,postoperative cerebrovascular events,delirium,and in-hospital death.Results The circulatory arrest time was 25.42±7.33 min in TP group and 24.77±6.85 min in GDP group(P>0.05)respectively.There was no significant difference in postoperative mechanical ventilation time>48 h(5 in TP group vs.4 in GDP group)and intensive careunit stay time(3.9 days in TP group vs.3.5 days in GDP group)(P>0.05).Two patients died in GDP group(perioperative myocardial infarction,cerebral hemorrhage),and 3 patients died in TP group(malignant arrhythmia,cerebral infarction,multiple organ dysfunction).One patient developed cerebral infarction and another patient developed cerebral hemorrhage in GDP group.There were 2 cases of cerebral infarction in TP group.There was no significant difference in postoperative cerebrovascular events and in-hospital mortality between two groups(P>0.05).Patients in TP group exhibited more delirium than in GDP group(8 cases vs 4 cases)(P<0.05).Conclusion Goal-directed perfusion management strategy was associated with reduced postoperative delirium after aortic arch replacement.