Prolonged mechanical ventilation after cardiac surgery: Outcome and predictors
Prolonged mechanical ventilation after cardiac surgery: Outcome and predictors
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DOI：
10.1016/j.jtcvs.2009.05.034
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发表时间：
2009-10-01
影响因子：
6
通讯作者：
Chastre, Jean
中科院分区：
文献类型：
--
作者：
Trouillet, Jean-Louis;Combes, Alain;Chastre, Jean
目的：心脏手术后机械通气时间延长是一种严重的并发症，需要寻求新的治疗策略。我们的目的是确定患者仍然需要机械通气3天后，手术和那些成功断奶的第10天，以避免不必要的和潜在的危险干预，如tracheostomy.Methods：所有连续的患者仍然机械通气3天后，心脏手术被列入一个前瞻性观察队列。记录患者的术前、术中和术后数据。结果：2620例心脏手术患者中，163例患者术后第3天仍在接受机械通气。到第10天，50例（31%）患者成功脱机，78例（48%）仍在接受机械通气，35例（21%）死亡。多变量回归分析保留了6天-3个与成功断奶相关的因素（比值比）：尿量500 mL/24小时或以上（16.47），格拉斯哥昏迷评分为15（9.75），动脉碳酸氢盐≥ 20 mmol/ L（6.09），血小板计数≥ 100 g/L（3.18），无肾上腺素/去甲肾上腺素强心剂支持的患者（2.84），无肺损伤（2.40）。基于该模型β系数的简单评分的受试者工作特征曲线下面积为0.84（95%置信区间，0.78-0.91）。根据该评分系统所选的阈值，只有3%至17%的患者会接受不必要的干预。基于术后天数的简单评分-3个生理参数可能有助于重症监护医师早期识别成功快速脱离机械通气的可能性很大的患者，从而防止旨在缩短机械通气持续时间的不必要程序和相关程序。并发症
Objective: Prolonged mechanical ventilation after cardiac surgery is a serious complication that warrants search for new treatment strategies. Our objective was to identify patients still requiring mechanical ventilation 3 days after the operation and those successfully weaned by day 10 to avoid needless and potentially hazardous interventions, such as tracheostomy.Methods: All consecutive patients still mechanically ventilated on day 3 after cardiac surgery were included in a prospective observational cohort. Patients' preoperative, intraoperative, and postoperative data were recorded. Logistic regression analysis was used to identify factors associated with successful weaning from mechanical ventilation by postoperative day 10.Results: Among 2620 patients who underwent cardiac surgery, 163 were still receiving ventilatory assistance on day 3. By day 10, 50 (31%) patients had been successfully weaned, 78 (48%) were still receiving mechanical ventilation, and 35 (21%) had died. Multivariable regression analysis retained 6 day-3 factors associated with successful weaning (odds ratio): urine output 500 mL/24 hours or greater (16.47), Glasgow coma score of 15 (9.75), arterial bicarbonates 20 mmol/ L or greater (6.09), platelet count 100 g/L or greater (3.18), patients without inotropic support with epinephrine/norepinephrine (2.84), and absence of lung injury (2.40). The area under the receiver operating characteristics curve for the simple score based on this model's beta-coefficients was 0.84 ( 95% confidence intervals, 0.78-0.91). Depending on the threshold chosen for this scoring system, only 3% to 17% of the patients would have received a needless intervention.Conclusions: A simple score based on postoperative day-3 physiologic parameters might help intensivists early identify patients with a strong likelihood of success in rapid weaning from mechanical ventilation and therefore prevent needless procedures aimed at reducing duration of mechanical ventilation and related complications.