【摘要】 目的探讨急性心肌梗死(AMI)合并心源性休克(CS)出现急性肺水肿接受急诊经皮冠状动脉介入治疗(PCI)时早期应用机械辅助肺通气对于住院期间死亡率及血流动力学的影响。方法入选2015年1月至2016年12月期间就诊于天津市胸科医院CCU病房的急性心肌梗死患者。所有入选患者接受急诊冠状动脉(冠脉)造影检查,并根据病变特点完成急诊PCI,根据应用辅助通气类型分为侵入性机械辅助通气(IMV)组和非侵入性辅助通气(NIV)组。调查两组患者的临床资料、血流动力学指标、住院期间死亡率,分析IMV对于临床预后的影响。结果在急性心肌梗死的患者中,心源性休克的发生率为8.2%,83.5%的CS合并急性肺水肿。接受IMV患者造影结果示TIMI血流0-1级的比例明显高于NIV(P<0.05),IMV组的Ph值、氧分压明显低于NIV组,乳酸水平高于NIV组(P<0.05);IMV组的IABP使用时间、辅助通气时间短于NIV组,差异有统计学意义(P<0.05)。IMV组与NIV组比较术后即刻中心静脉压(CVP)、肺动脉压(PAP)、肺毛细血管楔压(PCWP)、平均动脉压(MAP)值比较差异没有统计学意义(P>0.05);IMV组术后3 h、6 h、12 h、24 h CVP、PAP、PCWP均低于NIV患者(P<0.05);IMV组MAP术后3 h、6 h、12 h均高于NIV患者(P<0.05)差异比较有统计学意义。接受IMV死亡率33.33%,接受NIV死亡率40.7%,差异无统计学意义(χ~2=0.412,P=0.521)。Logistic回归分析提示FMC时间过长、肝功能衰竭、肾功能衰竭、术后TIMI血流<3级为AMI发生CS院内死亡的独立风险因素(P<0.05),而使用IMV未增加患者死亡风险(P=0.629,95%CI:0.117～34.837)。结论 AMI合并CS出现急性肺水肿的患者,早期行急诊介入治疗,置入IABP的同时,在基础麻醉状态下予以气管插管,呼吸机辅助呼吸,采用中等水平的PEEP模式,可以明显增加患者的生存获益。更多还原

【Abstract】 Objective To investigate the effects of early invasive mechanical ventilation(IMV) on the mortality and hemodynamics in acute pulmonary edema during primary PCI for patients with acute myocardial infarction(AMI) and cardiogenic shock(CS). Methods Patients with AMI who were admitted to the coronary care unit(CCU) of Tianjin Chest Hospital between January 2015 and December 2016 were selected. All enrolled patients underwent emergency coronary angiography and completed emergency PCI treatment according to the characteristics of the lesions. They were divided into IMV group and non-invasive ventilation(NIV) group according to the type of applied assisted ventilation. The clinical data, hemodynamic indexes, and mortality during hospitalization of the two groups of patients were compared, and the impact of IMV on clinical prognosis was analyzed. Results Among AMI patients, the incidence of CS was 8.2%, and 83.5% of patients developed CS with acute pulmonary edema. The results of angiography of patients receiving IMV showed that the proportion of TIMI blood flow grade 0-1 was significantly higher than that of NIV group(P<0.05). The Ph value and oxygen partial pressure of the IMV group were significantly lower than those of the NIV group, and the lactate level was higher than that of the NIV group(P<0.05). The use time and assisted ventilation time of IMV group were shorter than that of NIV group, and the difference was statistically significant(P<0.05). There was no significant difference in CVP, PAP, PCWP, MAP values between the IMV group and the NIV group immediately after operation(P>0.05). CVP, PAP and PCWP of IMV group were lower than those of NIV patients at 3 h, 6 h, 12 h and 24 h after operation(P<0.05). The IMV group had a statistically significant difference in MAP after 3 h, 6 h, and 12 h after NIV patients(P<0.05). The mortality rate was 33.33% in the IMV group and 40.7% in the NIV group. The difference was not statistically significant(χ~2=0.412, P=0.521). Logistic regression analysis suggests that FMC time is too long, liver failure, renal failure, postoperative TIMI blood flow <3 is an independent risk factor for CS hospital death in AMI(P<0.05), but the use of IMV does not increase the risk of death in patients(P=0.629, 95%CI:0.117～34.837). Conclusion For patients with acute pulmonary edema and AMI combined with CS, early emergency interventional treatment can significantly increase the survival benefit of the patient, including: under basic anesthesia, endotracheal intubation at the same time as intra-aortic balloon pump is placed, assisted breathing by ventilator moderate positive end-expiratory pressure mode.更多还原