Stanford A型主动脉夹层术后ICU停留时间延长风险因素分析

刘海渊; 高晴云; 张成鑫; 龚文辉; 葛圣林

doi:10.16766/j.cnki.issn.1674-4152.003581

Stanford A型主动脉夹层术后ICU停留时间延长风险因素分析

doi: 10.16766/j.cnki.issn.1674-4152.003581

安徽医科大学第一附属医院心脏大血管外科，安徽合肥 230022

基金项目:

安徽省自然科学基金项目 1908085MH241

详细信息

通讯作者:
葛圣林，E-mail：wenxian84@126.com

中图分类号: R654.2 R543.1
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出版历程
- 收稿日期: 2023-05-18
- 网络出版日期: 2024-09-05

The risk factors of postoperative prolonged ICU stay for the patients with Stanford type A aortic dissection

Department of Cardiovascular Surgery, the First Affiliated Hospital of Anhui Medical University, Hefei, Anhui 230022, China

摘要

摘要: 目的探讨导致Stanford A型主动脉夹层患者术后ICU停留时间延长的风险因素，并观察时间延长对于临床预后的影响。方法回顾性分析2018年12月—2022年9月安徽医科大学第一附属医院心脏大血管外科收治的100例Stanford A型患者的围手术期临床资料，根据术后在ICU停留时间是否超过7 d将患者分为ICU常规组(< 7 d，65例)和ICU延长组(≥7 d，35例)。对于患者术前及术中临床资料予以单因素分析，将单因素分析差异有统计学意义的变量纳入logistic回归分析并研究ICU停留时间延长的独立风险因素。结果单因素分析显示，2组患者急诊手术(P < 0.001)、术前尿素氮水平(P=0.001)、术前血糖水平(P=0.048)、体外循环时间(P=0.009)和手术时间(P=0.010)差异均有统计学意义。将上述因素纳入logistic回归分析，结果显示急诊手术(OR=0.192，P=0.003)、术前尿素氮水平(OR=0.775，P=0.013)和体外循环时间(OR=0.988，P=0.014)均是夹层术后ICU停留时间延长的独立影响因素。ROC曲线显示，3个变量联合预测价值(AUC=0.810)高于3个因素单独预测(急诊手术AUC=0.308、术前尿素氮水平AUC=0.288、体外循环时间AUC=0.340)。术后资料比较显示，2组患者四肢活动障碍(P < 0.001)、脏器严重损伤(P < 0.001)、气管切开(P < 0.001)、72 h内拔除气管插管(P < 0.001)、12 h内神志清醒(P < 0.001)、离院方式(P < 0.001)和住院时间(P=0.037)差异均有统计学意义。结论急诊手术、术前尿素氮水平和体外循环时间是Stanford A型患者术后ICU停留时间延长的影响因素，ICU延长组患者临床预后不良事件发生率较ICU常规组显著升高。针对风险因素采取积极的应对措施，有助于缩短患者术后ICU停留时间，改善临床转归。
- Stanford A型主动脉夹层 /
- ICU停留延长 /
- 风险因素
Abstract: Objective To explore the risk factors of postoperative prolonged ICU stay for the patients with Stanford type A aortic dissection and assessed the influence on the clinical outcome due to prolonged ICU stay. Methods A total of 100 patients with Stanford type A aortic dissection admitted in the Department of Cardiovascular Surgery, the First Affiliated Hospital of Anhui Medical University from December 2018 to September 2022 were enrolled as subjects. The clinical material of all patients was collected and analyzed retrospectively. The preoperative and intraoperative material for the patients in two groups were tested using univariate analysis, regular ICU stay (< 7 days, 65 cases) and prolonged ICU stay (≥7 days, 35 cases) based on the period in ICU and then the obtained significant variates were tested using logistic regression to determine the independent risk factors. Results Emergency surgery (P < 0.001), preoperative blood nrea nitrogen (P=0.001), preoperative glucose (P=0.048), cardiopulmonary bypass time (P=0.009) and operating time (P=0.010) were considered as significant variates using univariate analysis. Further, based on the findings of logistic regression, emergency surgery (OR=0.192, P=0.003), preoperative blood urea nitrogen (OR=0.775, P=0.013) and cardiopulmonary bypass time (OR=0.988, P=0.014) were identified as the independent risk factors of postoperative prolonged ICU stay. In the predictive model, the combination of all three factors (AUC=0.810) was more effective than any single factor (AUC=0.308, 0.288 and 0.340). For the clinical outcome assessment, there were significance on the disability of limbs (P < 0.001), severe organic injury (P < 0.001), tracheotomy (P < 0.001), extubation within 72 h after surgery (P < 0.001), awaking within 12 h after surgery (P < 0.001), discharging (P < 0.001) and hospital stay (P=0.037) in two groups. Conclusion Emergency surgery, preoperative urea nitrogen and cardiopulmonary bypass time are the risk factors of postoperative prolonged ICU stay and compared with the regular ICU stay group, the incidences of adverse events in the prolonged ICU stay group increase significantly. Risk factors should be handled proactively to reduce ICU stay and improve clinical outcome.
- Stanford type A aortic dissection /
- Prolonged ICU stay /
- Risk factors

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图 1 急诊手术、体外循环时间和术前尿素氮水平预测ICU停留时间是否延长的ROC曲线

Figure 1. ROC curves for emergency surgery, cardiopulmonary bypass time, and preoperative urea nitrogen levels to predict prolonged ICU stay

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表 1 2组Stanford A型主动脉夹层患者术前和术中资料比较

Table 1. Comparison of preoperative and intraoperative data between two groups of Stanford Type A aortic dissection patients

项目	ICU常规组(n=65)	ICU延长组(n=35)	统计量	P值
年龄(x±s, 岁)	53.17±11.69	53.31±10.11	0.062^a	0.951
体重(x±s, kg)	71.00±12.66	75.29±12.72	1.612^a	0.110
术前HCT(x±s, %)	34.51±8.46	35.14±7.61	0.370^a	0.712
术前Hb(x±s, g/L)	111.43±26.02	117.14±22.72	1.093^a	0.277
术前GLU[M(P₂₅, P₇₅), mmol/L]	6.57(5.99, 7.53)	7.15(6.35, 8.75)	-1.973^b	0.048
术前BUN[M(P₂₅, P₇₅), μmol/L]	6.40(5.29, 7.89)	8.30(6.50, 10.90)	-3.480^b	0.001
术前EF(x±s, %)	60.11±3.08	59.40±3.06	1.099^a	0.275
急诊手术[例(%)]	27(41.54)	29(82.86)	13.598^c	<0.001
CPB时间(x±s, min)	242.71±48.26	271.80±58.24	2.671^a	0.009
阻断时间(x±s, min)	183.35±52.76	203.60±69.27	1.636^a	0.105
DHCA时间(x±s, min)	32.75±12.85	31.17±13.88	0.558^a	0.579
冷复灌时间(x±s, min)	24.52±11.46	27.66±13.77	1.149^a	0.255
超滤量(x±s, mL)	4 715.38±1 586.19	4 880.00±1 760.31	0.461^a	0.646
手术时间(x±s, min)	518.62±86.04	571.09±110.29	2.630^a	0.010
停机HCT(x±s, %)	23.35±3.85	22.60±3.27	0.983^a	0.328
停机Hb(x±s, g/L)	80.05±11.60	78.91±11.46	0.467^a	0.641
注：^a为t值，^b为Z值，^c为χ²值。

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表 2 Stanford A型主动脉夹层患者ICU停留时间的多因素回归分析

Table 2. Multivariate regression analysis of ICU length of stay in patients with Stanford Type A aortic dissection

变量	B	SE	Waldχ²	P值	OR值	95% CI
急诊手术	-1.653	0.548	9.098	0.003	0.192	0.065~0.561
术前BUN	-0.255	0.102	6.203	0.013	0.775	0.634~0.947
CPB时间	-0.012	0.005	6.102	0.014	0.988	0.979~0.998

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表 3 急诊手术、术前尿素氮水平和体外循环时间的ROC曲线分析结果

Table 3. ROC curve analysis of emergency surgery, preoperative urea nitrogen level, and cardiopulmonary bypass time

变量	AUC	95% CI	标准误	P值
急诊手术	0.308	0.201~0.415	0.055	0.002
术前BUN	0.288	0.185~0.392	0.053	0.001
CPB时间	0.340	0.223~0.457	0.060	0.008
3项指标联合	0.810	0.722~0.897	0.045	<0.001

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表 4 2组Stanford A型主动脉夹层患者术后临床资料比较

Table 4. Comparison of postoperative clinical data between two groups of Stanford Type A aortic dissection patients

项目	ICU常规组(n=65)	ICU延长组(n=35)	统计量	P值
四肢活动障碍[例(%)]	0	12(34.28)	22.182^a	<0.001
脏器严重损伤[例(%)]	2(3.08)	14(40.00)	23.077^a	<0.001
气管切开[例(%)]	0	10(28.57)	17.582^a	<0.001
72 h内拔除气管插管[例(%)]	54(83.08)	10(28.57)	29.335^a	<0.001
12 h内神志清醒[例(%)]	56(86.15)	16(45.71)	18.445^a	<0.001
离院方式[例(%)]			24.969^a	<0.001
医嘱离院	62(95.38)	19(54.29)
非医嘱离院	3(4.62)	16(45.71)
住院时间[M(P₂₅, P₇₅)，d]	19.00(17.00, 27.50)	26.00(19.00, 37.00)	-2.084^b	0.037
注：^a为χ²值，^b为Z值。

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