肝脏手术中大出血患者术后死亡的危险因素分析及护理

摘要

Objective To examine the risk factors of poor prognosis in massive bleeding during hepatectomy. Methods Sixty-one patients experienced massive hemorrhage were included death group including 22 deaths and survival group 39 recovered patients. The factors related to different prognostic results were compared by univariate and multivariate analysis. Results The analysis showed the risk factors included the amount of blood transfusion during the operation >10 000 mL, the Pringle maneuver time >35 minutes, pH<7.2 when transferred to ICU, acute kidney failure or the time of mechanical ventilation >4 hrs. Conclusion The nurses play an important role in the early postoperative period of high risk patients with massive intraoperative blood transfusion more than 10 000 mL, the Pringle maneuver time >35 minutes and pH<7.2 when transferred to ICU who need special nursing and closely monitoring. Guided by the surgeries and anesthetists, it is significant to stop the bleeding and restrict the crystal, regular monitoring the artery blood gas and withdraw the endotracheal tube as soon as possible. Early judgment and reporting for the second operation in time is beneficial to improving their postoperative survival rate.%目的：分析肝脏切除术中大出血患者预后不佳的危险因素，指导护理工作。方法采用回顾性研究方法，选取2008年1月-2012年12月在东方肝胆外科医院接受肝脏切除手术患者61例，根据不同结局将其分为死亡组与康复组，比较两组病例在围术期资料差异。结果单因素分析发现：在年龄、Child-Pugh 分级、手术时间、肝门阻断时间、术中输血量、转入 ICU 时 pH 及血红蛋白值、急性肾功能衰竭、机械通气时间超过4h 共9个方面，两组差异有统计学意义（P<0.05）。采用逐步回归行多因素分析发现：4个因素为肝脏切除术中大出血患者术后死亡的独立危险因素（P<0.05），即术中输血量>10000 mL、肝门阻断时间>35 min、转入ICU 时 pH<7.2，急性肾功能衰竭和机械通气>4 h。结论控制术中输血量、术中肝门阻断时间，控制患者转入 ICU 时的 pH 值、急性肾功能衰竭和机械通气时间，能降低肝脏切除术中大出血患者术后死亡的风险。提示对具有前述危险因素的患者，医护的团队合作特别重要，除了手术医生规避相应风险之外，护士应在手术日和术后1 d，严密监护患者生命体征、腹腔引流情况等，警惕腹腔出血先兆症状，早期汇报，及时二次手术等，均有利于提高该类患者术后的生存率。