Halpern V J, Kline R G, D'Angelo A J, Cohen J R
Department of Surgery, Long Island Jewish Medical Center, New Hyde Park, NY 11040, USA.
J Vasc Surg. 1997 Dec;26(6):939-45; discussion 945-8. doi: 10.1016/s0741-5214(97)70005-3.
There has been much discussion in the literature of factors that affect the mortality rate of patients who undergo repair of ruptured abdominal aortic aneurysms. Some studies have suggested restricting patient selection for repair on the basis of certain preoperative factors including age, increased creatinine level, low hemoglobin level, loss of consciousness, electrocardiographic changes, and preoperative cormorbid medical conditions. A retrospective review of 96 patients who underwent repair of a ruptured abdominal aortic aneurysm was performed to determine whether these factors would necessarily be applicable to all populations.
A retrospective chart review of all patients who underwent repair of a ruptured abdominal aortic aneurysm was performed over a study period of 20 years. Data was analyzed by both univariate and multivariate analysis.
The mean age of the patients was 73 years. The intraoperative mortality rate was 23%. The in-hospital mortality rate was 60.4%, with a 30-day mortality rate of 56.3%. By univariate analysis of various factors associated with the mortality rate, hemoglobin level, creatinine level, lowest preoperative and average intraoperative systolic blood pressure, packed red blood cells transfused, estimated blood loss, intraoperative urine output, and temperature were statistically significant. A history of loss of consciousness was also statistically significant. No preoperative comorbid medical conditions were significant, nor was age. On a multivariate analysis, preoperative factors of loss of consciousness, a lowest preoperative systolic blood pressure less than 90 mm Hg, a hemoglobin level less than 10 g/dl, and a creatinine level greater than 1.5 mg/dl were predictive of death. The effects of the hemoglobin level, creatinine level, and loss of consciousness on the mortality rate were strongest in patients who had a lowest preoperative systolic blood pressure greater than 90 mm Hg. In patients who had the sets of preoperative factors that were associated with a 100% mortality rate, there were intraoprative factors that influenced their death.
These findings suggest that the factors (loss of consciousness, creatinine level, hemoglobin level) that are predictive of death may be a reflection of shock in this patient population. Further studies should be directed to optimizing preoperative resuscitation. Patients who have a ruptured abdominal aortic aneurysm should not be denied therapy on the basis of any specific set of preoperative factors.
文献中对影响腹主动脉瘤破裂修复患者死亡率的因素已有诸多讨论。一些研究建议根据某些术前因素限制修复手术的患者选择，这些因素包括年龄、肌酐水平升高、血红蛋白水平降低、意识丧失、心电图改变以及术前合并的内科疾病。对96例行腹主动脉瘤破裂修复术的患者进行回顾性研究，以确定这些因素是否必然适用于所有人群。
对20年间所有行腹主动脉瘤破裂修复术的患者进行回顾性病历审查。采用单因素和多因素分析方法对数据进行分析。
患者的平均年龄为73岁。术中死亡率为23%。住院死亡率为60.4%，30天死亡率为56.3%。通过对与死亡率相关的各种因素进行单因素分析，血红蛋白水平、肌酐水平、术前最低和术中平均收缩压、输注的红细胞压积、估计失血量、术中尿量和体温具有统计学意义。意识丧失史也具有统计学意义。术前合并的内科疾病和年龄均无统计学意义。多因素分析显示，意识丧失、术前最低收缩压低于90 mmHg、血红蛋白水平低于10 g/dl以及肌酐水平高于1.5 mg/dl等术前因素可预测死亡。血红蛋白水平、肌酐水平和意识丧失对死亡率的影响在术前最低收缩压高于90 mmHg的患者中最为显著。在具有与100%死亡率相关的术前因素组合的患者中，存在影响其死亡的术中因素。
这些发现表明，预测死亡的因素（意识丧失、肌酐水平、血红蛋白水平）可能反映了该患者群体的休克情况。应进一步开展研究以优化术前复苏。腹主动脉瘤破裂的患者不应基于任何特定的术前因素组合而被拒绝治疗。
