冠狀動脈繞道手術病人延遲拔管危險因素分析

Risk factors analysis on delayed extubation among patients poster coronary artery by-pass surgery

劉瑞芳(Jui-Fang Liu) ； 林蕙鈴(Hui-Ling Lin) ； 方瑱珮(Tien-Pei Fang) ； 陳瑞娥(Jui-O Chen) ； 沈連喜(Lien-Shi Shen) ； 杜美蓮(Mei-Lien Tu)

《呼吸治療》 18卷1期 (2019/07) Pp. 13-25

https://doi.org/10.6269/JRT.201907_18(1).0002

摘要

研究目的：呼吸器通氣時間延長又稱延遲拔管，是接受冠狀動脈繞道手術病人重要的問題之一，甚至造成死亡風險增加。已知有許多因素致使此類病人延遲拔管，無法脫離呼吸器，但目前國內卻很少關於影響冠狀動脈繞道手術後病人延遲拔管危險因素的分析，因此，本研究旨在探討冠狀動脈繞道手術病人延遲拔管之危險因素。研究方法：本研究為回溯性研究，分析2009年1月至2013年12月，某醫學中心接受冠狀動脈繞道手術超過24小時未拔管之病人（延遲拔管組），及小於24小時內成功拔管病人（早期拔管組）之病歷資料，比較兩組病人手術前、手術中、及手術後相關危險因素的差異。研究結果：研究共納入356位接受冠狀動脈繞道手術病人（延遲拔管組98位；早期拔管組258位）。術前風險因素評估發現，延遲拔管組病人平均年齡較高（69.5±9.8歲比63.1±9.6歲，P＜0.001）。當與早期拔管組病人相比，延遲拔管組病人在手術前患心絞痛（P＝0.005）、心肌梗塞（P＝0.004）、及糖尿病者（P＝0.015）比率較高；肺功能（含用力呼氣肺活量、用力呼氣1秒量、用力呼氣中段流量）、及左心室功能（搏出量、射血比率）（P＜0.001）較差。在手術中合併其他手術（如：瓣膜置換術，迷宮手術）、主動脈內氣球幫浦使用、體外維生系統使用、手術總時間、血流阻斷時間等方面，延遲拔管組病人明顯較多（P＜0.01）。在手術後最大吸氣壓力，最大吐氣壓力、呼吸次數、潮氣容積、及淺快呼吸指數延遲拔管組病人較差（P＜0.01）。腎衰竭、肺炎、出血、再插管率、再度手術、及氣管切開術在延遲拔管組病人較高（P＜0.05）。結論：本研究發現手術前、手術中、及手術後諸多危險因素會造成延遲拔管，這些因素均可提供臨床照護者作為高危照護，及脫離呼吸器之參考。

關鍵字

冠狀動脈繞道手術 ； 延遲拔管 ； 呼吸器通氣時間延長 ； 共病症 ； 高齡

並列摘要

Introduction: Prolonged ventilation, also known as delayed extubation, is one of the most severe complications of coronary artery bypass grafting (CABG; also known as coronary artery bypass surgery) and may lead to death. Many factors contribute to delayed extubation and difficult weaning from the ventilator. Limited research has investigated predictive factors for delayed extubation after CABG in Taiwanese patients. This study explored risk factors of CABG surgery leading to delayed extubation in Taiwan. Methods: This retrospective study was conducted in a medical center from January 2009 to December 2013. Medical chart data, including extubation time (＞24 h for the delayed extubation group and ＜24 h for the early extubation group), demographics, history, events during surgery, and related postoperative factors, were obtained from patients after CABG. Results: A total of 356 patients were included for analysis (delayed extubation: n=98; early extubation: n=258). Preoperative risk factors for delayed extubation were advanced age (69.52 ± 9.84 y vs. 63.09 ± 9.61 y, P ＜ 0.001), history of angina (P ＜ 0.001), myocardial infraction (P=0.004), and diabetes (P=0.015); poor pulmonary function test results (forced vital capacity, forced expiratory volume in 1 s, and maximal midexpiratory flow); and poor left heart function (stroke volume and ejection fraction, P ＜ 0.001). Risk factors occurring during surgery were joined surgery (valve replacement and Maze surgery), intra-aortic balloon pump (IABP), extracorporeal membrane oxygenation (ECMO), longer operation time, and longer clamping time (all P ＜ 0.01). Poor lung function tests were postoperative indicators for delayed extubation and included lower maximal inspiratory pressure, maximal expiratory pressure, respiratory rate, tidal volume and rapid shallow breathing index as well as poor left heart function (including stroke volume and ejection fraction). The rate of renal failure, pneumonia, bleeding, reintubation, reoperation, tracheostomy in delayed extubation group were higher than early extubation group. Conclusions: This study showed that many risk factors would cause delayed extubation in the preoperative, intraoperative and postoperative stage. The results would be references for high risk patients in caring and weaning from the ventilator.

並列關鍵字

coronary artery bypass grafting ； delayed extubation ； prolonged mechanical ventilation ； multimorbidity ； old age