急性主动脉夹层围术期急性肺损伤与D-二聚体和纤维蛋白原降解产物的相关性

摘要

目的 探讨急性主动脉夹层(AAD)围术期急性肺损伤(ALI)的发生与D-二聚体和纤维蛋白原降解产物(FDP)的相关性.方法 纳入2012年10月至2013年12月首都医科大学附属北京安贞医院符合入组条件的AAD患者共53例,在全身麻醉、深低温停循环和选择性脑灌注下行主动脉弓替换及象鼻支架置入术(孙氏手术).根据术前是否发生ALI分为术前ALI组(A组,22例)组和术前非ALI组(C组,31例).收集患者年龄、性别、体重指数、发病时间、合并症、术中出入量、ICU呼吸机治疗时间等资料.选取术前12 h(T1)、麻醉诱导后(T2)、术毕(T2)和术后12 h(T4)4个时点测定氧合指数、D-二聚体和FDP.2组结果比较采用独立因素t检验,各因素与氧合指数的相关性采用多元线性回归分析.结果 A组T1、T2、T3、T4时点氧合指数分别为189 ±65、193±62、131 ±40、105±32;C组T1、T2、T3、T4时点氧合指数分别为366±57、362±46、300±48、249±48.A组T1、T2、T3、T4时点氧合指数均明显低于C组(均P＜0.05).A组T1、T2、T3、T4时点D-二聚体值分别为(2 952±1040)、(3 061±1 395)、(4 040±1 216)、(4 084±1 863)μg/L;C组T1、T2、T3、T4时点D-二聚体值分别为(1 428±486)、(1 493±554)、(2 507 ±638)、(2 628±556) μg/L.A组T1、T2、T3、T4时点D-二聚体值均高于C组(均P＜0.05).A组T1、T2、T3、T4时点FDP值分别为(18±5)、(17±6)、(27±10)、(23±9) mg/L;C组T1、T2、T3、T4时点FDP值分别为(6±3)、(7±4)、(12±6)、(12±8)mg/L.A组各时点FDP值均高于C组(均P＜0.05).与T1比较,2组中T3和T4氧合指数均下降而D-二聚体和FDP上升(均P＜0.05).手术失血量和ICU呼吸机治疗时间比较,A组均明显高于C组[(1 524±458)ml比(1 175±327)ml,(27 ±8)h比(17 ±7)h,均P＜0.05].多元线性回归分析显示,D-二聚体与氧合指数呈负相关(r=-0.620,P＜0.01),FDP与氧合指数呈负相关(r=-0.689,P＜0.01).结论 AAD患者术前即可发生ALI,且围术期ALI程度逐渐加重.术前发生ALI的患者,围术期ALI程度及D-二聚体和FDP水平均明显增加,且D-二聚体和FDP与氧合指数呈负相关.%Objective To analyze the correlation among acute lung injury (ALI),D-dimer (DD) and fibrin degradation product (FDP) of acute aortic dissection (AAD) in perioperative period.Methods Between October 2012 and December 2013,53 AAD patients had Sun's Procedure under general anaesthesia and DHCA.The cases were grouped according to the situation of preoperative ALI.Group A(22 cases):ALI occurred during preoperative period;group C(31 cases):ALI did not occur during preoperative period.Demographic data were collected.Multiple perioperative factors including age,gender,BMI,AAD onset time,complications,intake and output,mechanic ventilation time in ICU.PaO2/F1O2 and Levels of D-dimer (DD) and fibrin degradation product (FDP) were measured 12h before operation(T1),after anesthesia induction (T2),before the end of operation (T3) and 12 h after operation(T4) respectively.Statistical analysis was processed by SPSS13.0 software.Groups were compared with t test and correlation analysis with multiple linear regression.Results The PaO2/FiO2 of T1,T2,T3,T4 of group A were 1 189 ±65,193 ±62,131 ±40,105 ±32; the PaO2/FiO2 ofT1,T2,T3,T4 of group C were 366 ±57,362 ±46,300 ±48,249 ±48.The PaO2/FiO2 was significantly lower in group A than in group C at all time points(all P＜0.05).The DD of T1,T2,T3,T4 of group A was (2 952 ± 1 040),(3 061 ± 1 395),(4 040 ± 1 216),(4 084 ± 1 863) mg/L.The DD ofT1,T2,T3,T4 of group C was(1 428 ±486),(1 493 ±554),(2 507 ± 638),(2 628 ± 556) mg/L.The FDP of T1,T2,T3,T4 of group A was (18 ± 5),(17 ± 6),(27 ± 10),(23 ± 9) mg/L.The FDP of T1,T2,T3,T4 of group C was (6 ± 3),(7 ± 4),(12 ± 6),(12 ± 8) mg/L.DD and FDP were significantly higher in group A than in group C at all time points(all P ＜ 0.05).Blood loss and mechanic ventilation time in ICU were significantly higher in group A than in group C at all time points[(1 524 ±458)ml vs(1 175 ± 327) ml,(27 ± 8) h vs(17 ± 7) h,all P ＜ 0.05].DD and PaO2/FiO2 showed a negative correlation (r =-0.620,P ＜0.01).FDP and PaO2/FiO2 showed a negative correlation (r =-0.689,P ＜ 0.01).Conclusions The AAD patients can be attacked with preoperative ALI.The severity of ALI has a gradually increasing trend throughout the procedure.DD,FDP and PaO2/FiO2 have a negative correlation.