摘要
目的应用床旁超声技术评估StanfordA型主动脉夹层术后膈肌功能不全的发生情况，分析膈肌功能不全可能的危险因素以及对患者预后的影响。方法前瞻性收集2017年2月至5月入住复旦大学附属中山医院心脏外科监护室的成人升主动脉＋全／半弓置换＋降主动脉象鼻支架术后患者。行脱机试验时（T管脱机）应用床旁超声技术测量患者双侧膈肌位移，根据膈肌位移情况将其分成两组：膈肌功能不全组及膈肌功能正常组。比较两组患者基线资料、手术相关情况及预后指标。结果本研究共入组42例患者，其中膈肌功能不全组32例，膈肌功能正常组10例。与膈肌功能正常组相比，膈肌功能不全组患者患侧膈肌位移明显减小[（0．450±0．331）cmvs．（1．801±0．616）cm，P〈0．01]，健侧膈肌位移无明显变化[（2．013±0．655）cmvs．（1．801±0．616）cm，P=0．2541，此外，膈肌功能不全组患者膈肌厚度无明显变化[（0．184±0．028）cmw．（0．189±0．028）cm，P=0．559]，而膈肌厚度变异率明显下降[（4．67％±3．63）％vs．（23．58％±10．69）％，P〈0．01]，同时呼吸频率明显增快[（24．13±4．98）次／minvs．（20．50±3．17）次／min，P=0．037]。膈肌功能不全组患者阻断时间[（121．78±27．75）minvs．（93．10±18．84）min，P=0．004]、体外时间[（208．09±32．78）minvs．（182．70±24．38）min，P=0．03]明显延长，进一步二元logistic分析发现阻断时间延长是膈肌功能不全的高危因素；两组患者术后机械通气时间（88hvs．37h，P=0．194）差异无统计学意义，但膈肌功能不全组患者NIV使用率（46．88％vs．10％，P=0．036）显著增加。其他预后指标如术后并发症、病死率及住ICU时间两组患者差异无统计学意义。结论StanfordA型主动脉夹层术后膈肌功能不全较常见，高危因素为阻断时间延长。术后拔除口插管后序贯无创机械通气的治疗方案是可行的。
Objective To study the incidence, possible risk factors, and influence on patient outcomes of diaphragmatic dysfunction in patients after surgical treatment of type A aortic dissection using ultrasound. Methods Patients who received replacement of hemiarch or total arch with concomitant procedures concerning aortic pathology, and an elephant trunk procedure for the descending aorta were prospectively enrolled in this study from February to May 2017. After surgery, they were transferred to the cardiac surgical intensive care unit. They were divided into two groups based on diaphragmatic excursion： diaphragmatic dysfunction （DD） group and diaphragmatic fimction normal （DN） grouBilateral diaphragmatic excursions were evaluated using ultrasound during spontaneous breathing trial by T-tube. The differences in demographic characteristics, operation-related variables and outcomes were compared between the two groups. Results A total of 42 patients were enrolled in this study, and 32 of them suffered from diaphragmatic dysfunctions. Compared with DN group, the excursion of the influenced diaphragm in DD group was significantly reduced[（0.450 ± 0.331）cm vs. （1.801 ± 0.616）cm, P〈0.01], while the excursion of the non-influenced diaphragm was not reduced[（2.013±0.655）cm vs. （1.801±0.616） cm, P=0.254]. Diaphragmatic thickness was comparable [（0.184±0.028）cm vs. （0.189±0.028）cm, P=0.559 ] between the two groups while thickening fraction was significantly reduced in DD group[（4.67%±3.63）% vs. （23.58%±10.69）%, P〈0.01]. Meanwhile, respiratory rate was significantly higher in DD group as compared to DN group [（24.13 ±4.98）times/min vs. （20.50 ± 3.17）times/min, P=0.037]. Patients in DD group showed longer cross-clamp duration[（121.78±27.75）min vs. （93.10±18.84）min, P=0.004] and longer cardiopulmonary bypass duration [（208.09±32.78）min vs. （182.70±24.38）min, P=0.03] than patients in DN grouFurthermore, binary logistic analysis indicated that longer cross-clamp duration was the potential risk factor for diaphragmatic dysfunction after type A aortic dissection surgery. Mechanical ventilation duration was longer in DD group than in DN group （88 h vs. 37 h, P=0.194） but without statistical significance. The usage of noninvasive ventilation was significantly increased in DD group as compared to DN group （46.88% vs. 10%, P=0.036）. Other outcomes such as post-operative complications, mortality, ICU length of stay were comparable between the two groups. Conclusions Diaphragmatic dysfunction was very common after surgical treatment of type A aortic dissection. Longer duration of cross-clamp was considered as a potential risk factor of diaphragmatic dysfunction. A sequential management of noninvasive ventilation after extubation was feasible for diaphragmatic dysfunction after surgical treatment of type A aortic dissection.
作者
郝光伟
俞颖
马国光
侯君谊
杨晓梅
贺黉裕
屠国伟
罗哲
Hao Guangwei;Yu Ying;Ma Guoguang;Hou Junyi;Yang Xiaomei;He Hongyu;Tu Guowei;Luo Zhe(Department of Critical Care Medicin;Department of Anesthesiology,Zhongshan Hospital,Fudan University,Shanghai 200032,China)
出处
《中华急诊医学杂志》
CAS
CSCD
北大核心
2018年第8期887-892,共6页
Chinese Journal of Emergency Medicine
基金
国家自然科学基金（81500067）,上海市卫生和计划生育委员会科研课题（20154Y011）,上海市自然科学基金（16ZR1405600）
中山医院科研基金（2017ZSQN16,2016ZSQN23,2017ZSYXQN23）
关键词
膈肌
超声
A型主动脉夹层
Diaphragm
Ultrasound
Type A aortic dissection
作者简介
通信作者：屠国伟，Email：tu．guowei@zs-hospital．sh．cn；;通信作者：罗哲，Email：luo．zhe@zs-hospital．sh．cn
