影响肝移植术后早期二次气管插管生存率的危险因素分析
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摘要
目的探讨影响肝移植术后早期二次气管插管生存率的危险因素,为提高患者生存率提供实践经验和理论依据。方法回顾性分析2005年1月—2012年12月在武警总医院实施原位肝移植治疗并于术后早期接受二次气管插管患者的病例资料,统计术后3个月内患者生存情况,按照术后3个月时的生存情况分为生存组和死亡组。比较两组患者术前、术中及供肝等重要参数情况,将生存率作为因变量,对纳入的变量先后进行单因素和多因素回归分析,筛选出对生存率有显著影响的自变量。结果本组55例二次插管患者术后3个月时生存率为30.9%(17/55)。死亡组术前终末期肝病模型(model for end stage liver disease,MELD)评分(U=52.00,P <0.001)、国际标准化比值(U=167.50,P <0.001)、血清总胆红素值(U=191.00,P=0.016)、肺部感染合并症发生率(χ~2=5.30,P=0.001)及腹水合并症发生率(χ~2=5.33, P=0.001)均显著高于生存组。年龄、术前血肌酐水平、门静脉血栓发生率、胸水发生率、肝移植手术时长和无肝期时长、术中出血量和输血量、供肝热缺血时间和冷缺血时间等在两组间均无统计学差异。回归分析结果显示肺部感染合并症与MELD评分(OR=6.157,P=0.042;OR=1.312,P <0.001)是影响二次插管生存率的独立危险因素。结论对于肝移植受者,术前MELD评分及肺部感染合并症是影响术后早期二次气管插管生存率的独立危险因素。术前积极控制肺部感染并努力降低MELD评分有助于提高生存率。
Objective To explore the risk factors affecting the survival rate of reintubation after liver transplantation, and to provide practical experience and theoretical basis for improving the survival rate of patients. Methods A retrospective analysis was performed on patients who underwent orthotopic liver transplantation in our hospital from January 2005 to December 2012. The patient's survival was calculated within three months after surgery. According to the survival condition at three months after operation, they were divided into survival group and death group. The preoperative, intraoperative and donor liver parameters were compared between the two groups. The survival rate was used as the dependent variable. The included variables were analyzed by single factor and multivariate regression analysis, and the independent variables with significant influence on survival rate were selected. Results The survival rate of 55 patients with reintubation was 30.9%(17/55). Preoperative model forend-stage liver disease(MELD)score(U = 52.00, P < 0.001), international normalized ratio(U = 167.50, P < 0.001), serum total bilirubin value(U = 191.00, P = 0.016), incidence of pulmonary infection complication in the death group(χ~2= 5.30, P = 0.001) and the incidence of ascites complication(χ~2= 5.33, P =0.001) were significantly higher than in the survival group. Age, preoperative serum creatinine level, portal vein thrombosis rate, incidence of pleural effusion, length of liver transplantation surgery, duration of anhepatic period, intraoperative blood loss, blood transfusion, warm ischemia time of donor liver and cold ischemia time were not statistical different. Regression analysis showed that the pulmonary infection comorbidity and MELD score remained in the logistic regression equation(OR = 6.157, P = 0.042;OR = 1.312, P < 0.001) were independent risk factors that affects the survival rate of reintubation. Conclusion For liver transplant recipients, preoperative MELD score and pulmonary infection comorbidity are independent risk factors for the survival rate of secondary tracheal intubation in the early postoperative period. Active control of pulmonary infection before surgery and efforts to reduce MELD scores can help improve survival.
Objective To explore the risk factors affecting the survival rate of reintubation after liver transplantation, and to provide practical experience and theoretical basis for improving the survival rate of patients. Methods A retrospective analysis was performed on patients who underwent orthotopic liver transplantation in our hospital from January 2005 to December 2012. The patient's survival was calculated within three months after surgery. According to the survival condition at three months after operation, they were divided into survival group and death group. The preoperative, intraoperative and donor liver parameters were compared between the two groups. The survival rate was used as the dependent variable. The included variables were analyzed by single factor and multivariate regression analysis, and the independent variables with significant influence on survival rate were selected. Results The survival rate of 55 patients with reintubation was 30.9%(17/55). Preoperative model forend-stage liver disease(MELD)score(U = 52.00, P < 0.001), international normalized ratio(U = 167.50, P < 0.001), serum total bilirubin value(U = 191.00, P = 0.016), incidence of pulmonary infection complication in the death group(χ~2= 5.30, P = 0.001) and the incidence of ascites complication(χ~2= 5.33, P =0.001) were significantly higher than in the survival group. Age, preoperative serum creatinine level, portal vein thrombosis rate, incidence of pleural effusion, length of liver transplantation surgery, duration of anhepatic period, intraoperative blood loss, blood transfusion, warm ischemia time of donor liver and cold ischemia time were not statistical different. Regression analysis showed that the pulmonary infection comorbidity and MELD score remained in the logistic regression equation(OR = 6.157, P = 0.042;OR = 1.312, P < 0.001) were independent risk factors that affects the survival rate of reintubation. Conclusion For liver transplant recipients, preoperative MELD score and pulmonary infection comorbidity are independent risk factors for the survival rate of secondary tracheal intubation in the early postoperative period. Active control of pulmonary infection before surgery and efforts to reduce MELD scores can help improve survival.
引文
[1]Saidi R F.Liver transplantation:What every gastroenterologist should know about it[J].Middle East J Dig Dis,2018,10(2):69-74.
[2]Lan X,Zhang H,Li HY,et al.Feasibility of using marginal liver grafts in living donor liver transplantation[J].World J Gastroenterol,2018,24(23):2441-2456.
[3]Wray C L.Advances in the anesthetic management of solid organ transplantation[J].Adv Anesth,2017,35(1):95-117.
[4]Glanemann M,Langrehr JM,Müller AR,et al.Incidence and risk factors of prolonged mechanical ventilation and causes of reintubation after liver transplantation[J].Transplant Proc,1998,30(5):1874-1875.
[5]Chinachoti T,Poopipatpab S,Buranatrevedhya S,et al.The Thai Anesthesia Incident Monitoring Study(Thai AIMS)of post anesthetic reintubation:an analysis of 184 incident reports[J].J Med Assoc Thai,2008,91(11):1706-1713.
[6]De A L,Alberti C,Azoulay E,et al.Impact of unplanned extubation and reintubation after weaning on nosocomial pneumonia risk in the intensive care unit:a prospective multicenter study[J].Anesthesiology,2002,97(1):148-156.
[7]郑卫萍,沈中阳,郑虹,等.肝移植术后预防乙型肝炎复发单中心治疗方案的变迁[J/CD].实用器官移植电子杂志,2015,3(4):209-214.
[8]牛玉坚.乙型肝炎免疫球蛋白在预防肝移植后乙型肝炎复发中的作用[J].中华器官移植杂志,2006,27(12):763-764.
[9]王乐天,沈中阳,牛玉坚.核苷类似物联合乙肝免疫球蛋白预防肝移植后乙肝病毒再感染的远期效果[J].武警医学,2010,21(11):939-940.
[10]牛玉坚,臧运金,陈新国,等.乙型肝炎免疫球蛋白不同给予方式对肝移植别人血清HBsAg和HBsAb水平的影响[J].中华肝胆外科杂志,2007,13(2):108-111.
[11]Loinaz C,Gonzalez EM.Marginal donors in liver transplantation[J].Hepato Gastroenterol,2000,47(31):256-263.
[12]史颖弘,田孟鑫,樊嘉.《欧洲肝病学会肝移植临床实践指南(2015年)》推荐意见[J].临床肝胆病杂志,2016,3(3):429-431.
[13]Kamath PS,Wiesner RH,Malinchoc M,et al.A model to predict survival in patients with end-stage liver disease[J].Hepatology,2001,33(2):464-470.
[14]Machicao VI.Model for end-stage liver disease-sodium score:the evolution in the prioritization of liver transplantation[J].Clin Liver Dis,2017,2l(2):275-287.
[15]谢秀华,孔心涓,饶伟.肝移植术后感染并发症的研究现状及进展[J/CD].实用器官移植电子杂志,2017,59(1):61-64.
[16]Porowski D,Wirkowska A,Hryniewiecka E,et al.Liver failure impairs the intrahepatic elimination of interleukin-6,tumor necrosis factor-alpha,hepatocyte growth factor,and transforming growth factor-beta[J].Biomed Res Int,2016,2015(5):1-7.
[17]王兴强,刘懿禾.肝衰竭患者肝功能评估与支持治疗[J/CD].实用器官移植电子杂志,2016,4(3):147-150.
[18]孙丽莹,刘菇禾,郑卫萍,等.影响肝移植术后早期预后的相关危险因素分析[J].中华肝胆外科杂志,2005,11(11):730-733.
[19]Chihara Y,Egawa H,Oga T,et al.Predictive factors for reintubation following noninvasive ventilation in patients with respiratory complications after living donor liver transplantation[J/OL].Plos One,2013,8(12):e81417.
[20]郭庆良,卢实春,王孟龙,等.影响慢性重型肝炎肝移植生存率的相关危险因素分析[J].中华肝胆外科杂志,2008,14(6):374-377.
[21]王建立,范宁,王颖,等.肝移植术后慢性肾功能损伤的危险因素分析[J].中华消化外科杂志,2013,12(9):688-691.
[22]李占军,张迁龙,陈晓阳,等.肺保护性通气对不同MELD分值肝移植手术患者的肺保护作用[J].武警医学,2018,29(4):388-392.
[2]Lan X,Zhang H,Li HY,et al.Feasibility of using marginal liver grafts in living donor liver transplantation[J].World J Gastroenterol,2018,24(23):2441-2456.
[3]Wray C L.Advances in the anesthetic management of solid organ transplantation[J].Adv Anesth,2017,35(1):95-117.
[4]Glanemann M,Langrehr JM,Müller AR,et al.Incidence and risk factors of prolonged mechanical ventilation and causes of reintubation after liver transplantation[J].Transplant Proc,1998,30(5):1874-1875.
[5]Chinachoti T,Poopipatpab S,Buranatrevedhya S,et al.The Thai Anesthesia Incident Monitoring Study(Thai AIMS)of post anesthetic reintubation:an analysis of 184 incident reports[J].J Med Assoc Thai,2008,91(11):1706-1713.
[6]De A L,Alberti C,Azoulay E,et al.Impact of unplanned extubation and reintubation after weaning on nosocomial pneumonia risk in the intensive care unit:a prospective multicenter study[J].Anesthesiology,2002,97(1):148-156.
[7]郑卫萍,沈中阳,郑虹,等.肝移植术后预防乙型肝炎复发单中心治疗方案的变迁[J/CD].实用器官移植电子杂志,2015,3(4):209-214.
[8]牛玉坚.乙型肝炎免疫球蛋白在预防肝移植后乙型肝炎复发中的作用[J].中华器官移植杂志,2006,27(12):763-764.
[9]王乐天,沈中阳,牛玉坚.核苷类似物联合乙肝免疫球蛋白预防肝移植后乙肝病毒再感染的远期效果[J].武警医学,2010,21(11):939-940.
[10]牛玉坚,臧运金,陈新国,等.乙型肝炎免疫球蛋白不同给予方式对肝移植别人血清HBsAg和HBsAb水平的影响[J].中华肝胆外科杂志,2007,13(2):108-111.
[11]Loinaz C,Gonzalez EM.Marginal donors in liver transplantation[J].Hepato Gastroenterol,2000,47(31):256-263.
[12]史颖弘,田孟鑫,樊嘉.《欧洲肝病学会肝移植临床实践指南(2015年)》推荐意见[J].临床肝胆病杂志,2016,3(3):429-431.
[13]Kamath PS,Wiesner RH,Malinchoc M,et al.A model to predict survival in patients with end-stage liver disease[J].Hepatology,2001,33(2):464-470.
[14]Machicao VI.Model for end-stage liver disease-sodium score:the evolution in the prioritization of liver transplantation[J].Clin Liver Dis,2017,2l(2):275-287.
[15]谢秀华,孔心涓,饶伟.肝移植术后感染并发症的研究现状及进展[J/CD].实用器官移植电子杂志,2017,59(1):61-64.
[16]Porowski D,Wirkowska A,Hryniewiecka E,et al.Liver failure impairs the intrahepatic elimination of interleukin-6,tumor necrosis factor-alpha,hepatocyte growth factor,and transforming growth factor-beta[J].Biomed Res Int,2016,2015(5):1-7.
[17]王兴强,刘懿禾.肝衰竭患者肝功能评估与支持治疗[J/CD].实用器官移植电子杂志,2016,4(3):147-150.
[18]孙丽莹,刘菇禾,郑卫萍,等.影响肝移植术后早期预后的相关危险因素分析[J].中华肝胆外科杂志,2005,11(11):730-733.
[19]Chihara Y,Egawa H,Oga T,et al.Predictive factors for reintubation following noninvasive ventilation in patients with respiratory complications after living donor liver transplantation[J/OL].Plos One,2013,8(12):e81417.
[20]郭庆良,卢实春,王孟龙,等.影响慢性重型肝炎肝移植生存率的相关危险因素分析[J].中华肝胆外科杂志,2008,14(6):374-377.
[21]王建立,范宁,王颖,等.肝移植术后慢性肾功能损伤的危险因素分析[J].中华消化外科杂志,2013,12(9):688-691.
[22]李占军,张迁龙,陈晓阳,等.肺保护性通气对不同MELD分值肝移植手术患者的肺保护作用[J].武警医学,2018,29(4):388-392.