主动脉夹层术后合并急性呼吸窘迫综合征的危险因素研究

Risk factors of acute respiratory distress syndrome after aortic dissection

目的研究主动脉夹层术后合并急性呼吸窘迫综合征(ARDS)的危险因素。方法本研究为病例对照研究。选择2018年1月至2020年1月西安交通大学医学院第一附属医院收治的216例Stanford A型主动脉夹层患者作为研究对象, 所有患者均行Stanford A型主动脉夹层术, 根据术后是否合并ARDS将其分为ARDS组(46例)和非ARDS组(170例)。收集所有患者临床资料[性别、年龄、体质量指数(BMI)、民族、居住地、吸烟史、糖尿病史、主动脉夹层病因]、围术期相关指标(主动脉阻断时间、围术期输血量)、术后并发症(心功能不全、肾功能不全、中枢神经系统并发症、肺部感染);记录术后48 h肿瘤坏死因子α(TNF-α), 记录术后12 h急性生理与慢性健康评分表(APACHE-Ⅱ)评分。以受试者工作特征曲线分析围术期输血量、术后48 hTNF-α、术后12 h APACHE-Ⅱ评分预测主动脉夹层术后合并ARDS的价值, 采取非条件logistic逐步回归分析主动脉夹层术后合并ARDS的危险因素。结果经单因素分析, 与非ARDS组相比, ARDS组术后肺部感染的患者比例较高, 并且ARDS组围术期输血量、术后48 h TNF-α、术后12 h APACHE-Ⅱ评分较高(P值均<0.05);经受试者工作特征曲线分析, 围术期输血量≥293.91 ml、术后48 h TNF-α≥112.34 ng/L、术后12 h APACHE-Ⅱ评分≥33.45分是主动脉夹层术后合并ARDS的最佳截断值(P值均<0.05);Logistic回归分析显示, 围术期输血量≥293.91 ml、术后48 h TNF-α≥112.34 ng/L、术后12 h APACHE-Ⅱ评分≥33.45分是主动脉夹层术后合并ARDS的危险因素(P<0.05)。结论围术期输血量≥293.91 ml、术后48 h TNF-α≥112.34 ng/L、术后12 h APACHE-Ⅱ评分≥33.45分是主动脉夹层术后合并ARDS的最佳截断值, 此外肺部感染是主动脉夹层术后合并ARDS的危险因素, 临床应密切关注符合以上指标和症状的患者。

Objective To investigate the risk factors of acute respiratory distress syndrome(ARDS)after aortic dissection(AD).Methods This was a case-control study.A total of 216 Stanford type A AD patients admitted to the First Affiliated Hospital of Xi′an Jiaotong University School of Medicine from January 2018 to January 2020 were selected as subjects.All patients underwent Stanford type A AD surgery.The patients were divided into ARDS group(46 cases)and non-ARDS group(170 cases)according to whether ARDS developed after operation.The following items were collected:the patients′clinical data[gender,age,body mass index(BMI),nationality,place of residence,history of smoking,history of diabetes,and AD cause],perioperative related index(aorta blocking time,perioperative blood transfusion amount),postoperative complications(cardiac insufficiency,renal insufficiency,complications,and pulmonary infection of the central nervous system).Tumor necrosis factorα(TNF-α)was recorded 48 h after operation,and acute physiology and chronic health scale(APACHE-Ⅱ)score was recorded 12 h after operation.The value of employing perioperative blood transfusion volume,postoperative 48 hTNF-α,and APACHE-Ⅱscore 12 h after operation to predict ARDS after AD was analyzed by using subject operating characteristic curve,and the risk factors of ARDS after AD were analyzed by conditional logistic stepwise regression.Results By univariate analysis,compared with non-ARDS group,ARDS group had a higher proportion of postoperative pulmonary infection,and the perioperative blood transfusion volume,48 h postoperative TNF-α,and 12 h postoperative APACHE-Ⅱscores were higher in ARDS group(P<0.05).According to the analysis of the operating characteristic curve of the subjects,the optimal cut-off values of ARDS after AD were perioperative blood transfusion volume≥293.91 ml,postoperative 48 h TNF-α≥112.34 ng/L,and postoperative 12 h APACHE-Ⅱscore≥33.45 points(all P<0.05).Logistic regression analysis showed that perioperative blood transfusion volume≥293.91 ml,TNF-α≥112.34 ng/L 48 h after operation,and APACHE-Ⅱscore≥33.45 points 12 h after operation were risk factors for ARDS after AD(P<0.05).Conclusions Perioperative blood transfusion volume≥293.91 ml,postoperative 48 h TNF-α≥112.34 ng/L,and postoperative 12 h APACHE-Ⅱscore≥33.45 points are the best cut-off values for ARDS after AD.In addition,pulmonary infection is a risk factor for ARDS after AD.Clinical attention should be paid to patients with the above indicators and symptoms.