心冠狀動脈繞道手術後延遲脫離呼吸器之原因分析

研究背景: 根據衛生福利部2016年統計資料，心臟疾病佔台灣十大死亡原因第二名，其中心血管疾病為主要死亡原因，而心冠狀動脈疾病是最常見的心血管疾病，急性冠心症有1/3的病患會死亡，而死亡的病患中約有50%係於發作後1小時內發生，且約有2/3在到達醫院之前即已死亡。急性冠心症主要為心冠狀動脈阻塞所致，血管阻塞50-70%可能需內外科處置介入治療，內科治療以經皮穿刺氣球擴張術或血管支架置放為主(percutaneous coronary intervention, PCI)，不適宜內科或治療失敗則以外科冠狀動脈繞道手術治療，手術後呼吸器使用是常態，而與呼吸器相關的肺炎併發症，通常於48-72小時發生，且死亡率高達20~30%，故呼吸器的早期脫離，為心冠狀動脈繞道手術後照護重要的一環。研究目的: 以手術後呼吸照護之觀點，回溯性研究收集2014至2017年，台灣中部地區某醫學中心，接受心冠狀動脈繞道手術病人，分析手術後侵襲性呼吸器(invasive mechanical ventilation, IMV)使用大於24小時，延遲脫離之相關因素，包括病人特性、健康狀況及共病、手術方式，進一步分析預後狀況包括併發症及死亡率。研究方法: 本研究為回溯性、單一醫學中心，呼吸器延遲脫離之定義為大於24小時仍未脫離侵襲性呼吸器，逐一查閱電子病歷、呼吸治療科及心臟外科之檔案統計分析。研究結果: 本研究共收集545例心冠狀動脈繞道手術之病人，排除年齡20歲以下及資料不完整之個案，剩餘495例可供統計分析，結果顯示，大於24小時脫離呼吸器之原因，Euro-score II每增加1%，會增加1.08倍的風險，手術時間每增加1小時則會增加1.33倍，高血壓患者是沒有高血壓患者2.07倍；機械手臂輔助手術是非機械手臂輔助手術的0.34倍；而手術有併發症患者是沒有併發症患者的6.66倍。結論與建議: 本研究結果顯示，心冠狀動脈繞道手術後呼吸器延遲脫離原因包括：Euro-score II、手術時間、高血壓、機械手臂輔助手術、併發症等因素，此研究可以提供臨床醫療團隊，於冠狀動脈繞道手術後脫離呼吸器的照護參考。

Background: Based on the statistics of the Ministry of Health and Welfare in 2016, heart disease accounts for the second leading cause of death in Taiwan. The cardiovascular disease is the main cause of death, and coronary artery disease is the most common cardiovascular disease. Totally about one-third acute coronary heart disease patients die, and half of the deaths occur within one hour after the attack. About two-thirds of the patients die before reaching the hospital. Acute coronary heart disease is mainly caused by obstruction of the coronary arteries. Obstruction up to 50-70% of coronary arteries requires medical intervention or surgical treatment. Medical intervention is based on percutaneous coronary intervention (PCI) ball dilatation or vascular stent. If medical treatment failure or contraindicated, surgical treatment with coronary bypass is used. The use of mechanical respirator during operation or after surgery is routine respiratory support. But the respiratory complications associated with respirator usually occur in 48-72 hours, the mortality rate may up to 20-30% in reported literature. Therefore, early weaning of ventilator after coronary artery bypass surgery is a important issue in the postoperative care.Objectives:As a postoperative respiratory care view point, we conducted retrospective studies of patients who with post-coronary artery bypass surgery (CABG) at a medical center in central Taiwan from 2014 to 2017. Patients undergoing CABG were analyzed for the use of invasive mechanical ventilation (IMV) after surgery for more than 24 hours defined as prolonged mechanical ventilation. The primary objects were factors related to prolonged ventilator including patient characteristics, health status, comorbidity and surgical methods, secondary objects analyzed the prognosis including patient complications and mortality.Methods:This study is a retrospective, single medical center. Prolonged ventilation is defined as greater than 24 hours without extubated the invasive respirator. One-by-one access to the electronic medical records, respiratory therapy records and cardiac surgery file as a data bases for statistical analysis.Results:A total of 545 patients undergoing coronary artery bypass surgery were collected in this study. Excluding patients under the age of 20 years and incomplete data, the remaining 495 patients were available for statistical analysis. The results showed, the probability of prolong mechanical ventilators greater than 24 hours. (1) For Euro-score II increase of 1 %, will increase 1.08 times of risk. (2) For operative time, add of 1 hour operative time will increase by 1.33 times of risk. (3) For patients with hypertension will be 2.07 times higher than the patients without hypertension. (4) The patients with robotic surgery will be 0.34 times risk than who with non-robotic surgery. (5) Patients with postoperative complications had a 6.66 times of risk than patients without complications.Conclusions and recommendations:The results of this study show that the causes of prolonged mechanical ventilation after coronary CABG surgery include: Euro-score II, operative time, patient hypertension, robotic surgery, and postoperative complications. These studies can provided the causes and informations for further improvement of respiratory care and early weaning from ventilator after the CABG surgery.