Hammermeister K E, Burchfiel C, Johnson R, Grover F L
Denver Veterans Administration Medical Center, CO 80220.
Circulation. 1990 Nov;82(5 Suppl):IV380-9.
As part of a prospective program to use risk-adjusted outcome (operative mortality and morbidity) as a measure of quality of care, we have analyzed perioperative complication data in 10,634 patients representing 73% of all patients undergoing cardiac surgery requiring cardiopulmonary bypass at Veterans Administration medical centers between April 1, 1987, and March 31, 1989. One or more complications occurred in 15% of patients undergoing coronary artery bypass grafting, and in 24% of patients undergoing valve and other cardiac surgery. Patients experiencing one or more complications had an eightfold to 10-fold increase in operative mortality compared with patients with no perioperative complications. The most frequent complication was requirement for mechanical ventilation for at least 48 hours occurring in 8% of patients undergoing coronary artery bypass and in 15% of patients undergoing valve and other cardiac surgery; 24-25% of these patients died within 30 days of surgery or as a direct result of a surgical complication. Previous heart surgery was a strong predictor of development of one or more complications in both groups of patients, being associated with an adjusted relative risk of 1.6-2.0. Other important predictors in both surgical groups were surgical priority, older age, peripheral vascular disease, and higher serum creatinine. Although a number of preoperative risk factors could be identified for the development of renal failure, low cardiac output, and requirement for prolonged mechanical support, few risk factors could be identified for the development of mediastinitis and reoperation for bleeding. This observation suggests that mediastinitis and reoperation for bleeding are more likely the result of technical factors rather than patient-related risk factors.
作为一项前瞻性计划的一部分，该计划旨在将风险调整后的结果（手术死亡率和发病率）作为医疗质量的衡量标准，我们分析了1987年4月1日至1989年3月31日期间在退伍军人管理局医疗中心接受需要体外循环的心脏手术的所有患者中73%的10634例患者的围手术期并发症数据。接受冠状动脉搭桥术的患者中有15%发生了一种或多种并发症，接受瓣膜及其他心脏手术的患者中有24%发生了此类情况。与无围手术期并发症的患者相比，发生一种或多种并发症的患者手术死亡率增加了8至10倍。最常见的并发症是需要机械通气至少48小时，在接受冠状动脉搭桥术的患者中有8%出现，在接受瓣膜及其他心脏手术的患者中有15%出现；这些患者中有24%至25%在手术后30天内死亡或直接死于手术并发症。既往心脏手术是两组患者发生一种或多种并发症的有力预测因素，调整后的相对风险为1.6至2.0。两个手术组中的其他重要预测因素包括手术优先级、年龄较大、外周血管疾病和较高的血清肌酐水平。尽管可以确定一些术前风险因素与肾衰竭、低心输出量以及需要长时间机械支持的发生有关，但对于纵隔炎和因出血而再次手术的发生，几乎找不到风险因素。这一观察结果表明，纵隔炎和因出血而再次手术更可能是技术因素而非与患者相关的风险因素导致的结果。
