【摘要】 目的 探讨重症监护病房(ICU)上腹部手术后患者发生急性呼吸衰竭(呼衰)的危险因素。方法 回顾性分析2014年1月1日至2019年12月31日北京大学人民医院ICU收治的肝胆外科上腹部手术后患者的临床资料。根据患者术后是否发生急性呼衰分为呼衰组和非呼衰组,分析两组患者人口学资料[性别、年龄、体质量指数(BMI)、抽烟史、手术史],合并症(糖尿病、高血压、冠心病、肾功能不全、腹水),实验室检查(术前白蛋白、总胆红素、白细胞计数、血红蛋白、血小板计数、纤维蛋白原、凝血酶原时间、活化部分凝血活酶时间),手术情况(手术时间、是否腹腔镜手术、是否多部位手术),麻醉及术中情况(美国麻醉医师学会分级、术中低血压、术中最低体温、术中入液量、术中失血量、术中尿量、是否神经阻滞),入ICU后情况[急性生理学与慢性健康状况评分Ⅱ(APACHEⅡ)、乳酸、首日入量、是否输血]等的差异,筛选出可能的影响因素;应用Logistic回归模型分析上腹部手术后患者发生急性呼衰的危险因素。结果 共收集393例上腹部手术后转入ICU患者的资料,术后发生急性呼衰患者127例(32.3%)。呼衰组患者的院内病死率高于非呼衰组(4.72%比0.37%,P=0.002),气管插管时间和ICU住院时间均长于非呼衰组[气管插管时间:11.0(4.0,31.0)h比5.5(3.5,10.0)h,ICU住院时间:3(2,6)d比2(2,2)d,均P<0.001]。与非呼衰组比较,呼衰组患者女性占比更高,年龄更大,BMI更高,高血压、肾功能不全患者比例更高,手术时间更长,术中低血压患者更多,实施神经阻滞的患者更少,入ICU乳酸更高。Logistic回归分析显示,年龄[优势比(OR)=1.028,P=0.021]、BMI(OR=1.183,P=0.001)和手术时间(OR=1.003,P=0.003)是ICU上腹部手术后患者发生急性呼衰的独立危险因素;而神经阻滞是上腹部术后患者的保护性因素(OR=0.186,P=0.015)。结论 ICU上腹部术后发生急性呼衰的患者病死率更高,气管插管时间和ICU住院时间更长。高龄、高BMI和手术时间过长患者更易发生呼衰,而神经阻滞可以减少呼衰的发生。更多还原

【Abstract】 Objective To investigate the risk factors of occurrence of acute respiratory failure in patients of intensive care unit(ICU) after upper abdominal surgery.Methods The clinical data of post-operative patients having undergone upper abdominal surgery in the department of hepatohiliaiy surgery admitted to the ICU in Peking University People’s Hospital from January 1,2014 to December 31,2019 were retrospectively analyzed.According to the occurrence of acute respiratory failure or not,they were divided into a respiratory failure group and a non-respiratory failure group.The following items and data were analyzed:demographic data [sex,age,body mass index(BMI)],smoking history,history of surgery,complications(diabetes,hypertension,coronary heart disease,renal insufficiency,ascites),laboratory tests(preoperative albumin,total bilirubin,white blood cell count,hemoglobin,platelet count,fibrinogen,prothrombin time,activated partial thromboplastin time),surgical situation(the operation time,whether laparoscopic surgery or whether multi-site surgery were performed),anesthesia status [American Society of Anesthesiologist(ASA)gradation,intra-operative hypotension,intra-operative minimum body temperature,intra-operative fluid infusion volume,intra-operative amount of blood loss,intra-operative urine volume,nerve block present or not],acute physiology and chronic health evaluation Ⅱ(APACHE Ⅱ),amount of lactic acid used,fluid infusion volume,whether blood transfusion being used,etc.differences on the first day of admission were observed to screen out the possible influencing factors;Logistic regression model was used to analyze the risk factors of occurrence of acute respiratory failure in patients after upper abdominal surgery.Results A total of 393 patients were transferred to ICU after upper abdominal surgery,and127 patients(32.3%) developed acute respiratory failure after surgery.The mortality of patients with acute respiratory failure group was higher than those in non-acute respiratory failure group(4.72% vs.0.37%,P=0.002),and the duration of tracheal intubation in patients with respiratory failure was longer than that in the non-respiratory failure group [hours:11.0(4.0,31.0) vs.5.5(3.5,10.0),P <0.001],patients with respiratory failure had longer ICU stay than those without respiratory failure [days:3(2,6) vs.2(2,2),P <0.001].Compared with patients without respiratory failure,the patients with respiratory failure had higher proportions of women,older age,higher BMI,hypertension and renal insufficiency,longer operation time,more intra-operative hypotension,less implementation of nerve block and higher lactic acid level on ICU admission.Logistic regression analysis showed that older age [odds ratio(OR)= 1.028,P=0.021],higher BMI(OR=1.183,P=0.001),and longer operative time(OR=1.003,P=0.003) were the independent risk factors for the occurrence of acute respiratory failure in ICU patients after upper abdominal surgery,however,nerve block was a protective factor for the occurrence of acute respiratory failure in such patients(OR=0.186,P=0.015) for the above mentioned patients.Conclusions The patients with acute respiratory failure after upper abdominal surgery in the ICU have higher mortality,longer endotracheal intubation time,and longer ICU stay.The patients with advanced age,higher BMI and prolonged surgical time are more likely to develop respiratory failure,however,nerve block analgesia can reduce the occurrence of respiratory failure in such patients.更多还原