冠状动脉旁路移植术后围术期中-重度消化道出血危险因素分析

Perioperative risk factors for moderate-severe gastrointestinal bleeding after coronary artery bypass grafting

目的:了解冠状动脉旁路移植术后围术期中-重度消化道出血的发生率及其相关的危险因素。方法:回顾并总结我院2017年11月—2022年10月1 129例因冠状动脉粥样硬化心脏病行冠状动脉旁路移植手术患者的临床资料,了解中-重度消化道出血的发生率,采用logistic回归方程分析冠状动脉旁路移植术后中-重度消化道出血发生的相关危险因素。结果:13例患者术后出现中-重度消化道出血,其中柏油样便或鲜血样便11例,呕吐咖啡样物伴排柏油样便2例,中-重度消化道出血发生率1.2%,共5例患者死亡,病死率为38.5%。行消化道内镜检查8例:其中明确出血部位6例,下消化道出血患者4例,均为结肠应激性溃疡形成引起的出血,行部分或全部结肠切除术;上消化道出血2例,1例患者为胃底部溃疡引起的活动性出血行胃次全切1例,1例为十二指肠球部溃疡出血行内镜下止血1例。6例手术治疗出血患者中1例因术后多器官功能衰竭死亡,病死率为16.7%。共7例患者(5例未行内镜检查,2例行内镜检查,但无法明确出血部位)采取保守治疗,其中4例患者死亡,病死率为57.1%。Logistic多元回归分析结果显示,主动脉内球囊反搏(IABP)的应用(OR:2.41,95%CI 1.33~5.37,P=0.006)和低心排综合征(OR:3.27,95%CI 1.23~9.29,P=0.028)是冠状动脉旁路移植术后中-重度消化道出血的危险因素。结论:中-重度消化道出血是冠状动脉旁路移植术后少见和严重的并发症,对于围术期IABP应用和并发低心排综合征患者应警惕消化道出血的发生。

Objective To investigate the incidence of perioperative severe gastrointestinal bleeding after coronary artery bypass grafting and its risk factors.Methods The clinical data of 1129 patients undergoing coronary artery bypass grafting were summarized. Logistic regression equation was used to analyze the risk factors of moderate to severe gastrointestinal bleeding after coronary artery bypass grafting.Results There were 13 patients with moderate to severe gastrointestinal bleeding after operation, including 11 cases with tarry stool or blood stool, 2 cases with coffee vomiting and tarry stool discharge. The incidence of moderate to severe gastrointestinal bleeding was 1.2%, and a total of 5 patients died, with a fatality rate of 38.5%. Endoscopy of digestive tract was performed in 8 cases, including 6 cases with definite bleeding site and 4 cases with lower digestive tract bleeding. All of them were caused by colonic stress ulcer formation. Partial or total colectomy was performed. There were 2 cases of upper digestive tract hemorrhage, 1 case of active bleeding caused by stomach bottom ulcer underwent subtotal gastric resection, and 1 case of duodenal bulbar ulcer hemorrhage underwent endoscopic hemostasis. Among the 6 patients with hemorrhage after operation, 1 patient died due to multiple organ failure after operation, and the case fatality rate was 16.7%. A total of 7 patients(5 patients did not undergo endoscopy, 2 patients underwent endoscopy, but the bleeding site could not be identified) were treated conservatively. Four patients died, and the fatality rate was 57.1%. Logistic multiple regression analysis showed that IABP(OR: 2.41, 95%CI 1.33-5.37, P=0.006) and low cardiac production syndrome(OR: 3.27, 95%CI 1.23-9.29, P=0.028) were risk factors for moderate to severe gastrointestinal bleeding after coronary artery bypass grafting.Conclusion Moderate to severe gastrointestinal bleeding is a rare and serious complication after coronary artery bypass grafting. Patients with perioperative IABP and low cardiac output syndrome should be wary of gastrointestinal bleeding.