Rady M Y, Ryan T, Starr N J
Department of Cardiothoracic Anesthesia, Cleveland Clinic Foundation, OH, USA.
Crit Care Med. 1998 Feb;26(2):225-35. doi: 10.1097/00003246-199802000-00016.
To determine perioperative predictors of morbidity and mortality in patients > or =75 yrs of age after cardiac surgery.
Inception cohort study.
A tertiary care, 54-bed cardiothoracic intensive care unit (ICU).
All patients aged > or =75 yrs admitted over a 30-month period for cardiac surgery.
Collection of data on preoperative factors, operative factors, postoperative hemodynamics, and laboratory data obtained on admission and during the ICU stay.
Postoperative death, frequency rate of organ dysfunction, nosocomial infections, length of mechanical ventilation, and ICU stay were recorded. During the study period, 1,157 (14%) of 8,501 patients > or =75 yrs of age had a morbidity rate of 54% (625 of 1,157 patients) and a mortality rate of 8% (90 of 1,157 patients) after cardiac surgery. Predictors of postoperative morbidity included preoperative intraaortic balloon counterpulsation, preoperative serum bilirubin of >1.0 mg/dL, blood transfusion requirement of >10 units of red blood cells, cardiopulmonary bypass time of >120 mins (aortic cross-clamp time of >80 mins), return to operating room for surgical exploration, heart rate of >120 beats/min, requirement for inotropes and vasopressors after surgery and on admission to the ICU, and anemia beyond the second postoperative day. Predictors of postoperative mortality included preoperative cardiac shock, serum albumin of <4.0 g/dL, systemic oxygen delivery of <320 mL/ min/m2 before surgery, blood transfusion requirement of >10 units of red blood cells, cardiopulmonary bypass time of >140 mins (aortic cross-clamp time of >120 mins), subsequent return to the operating room for surgical exploration, mean arterial pressure of <60 mm Hg, heart rate of >120 beats/min, central venous pressure of >15 mm Hg, stroke volume index of <30 mL/min/m2, requirement for inotropes, arterial bicarbonate of <20 mmol/L, plasma glucose of >300 mg/dL after surgery, and anemia beyond the second postoperative day. During the study period, the study cohort used 6,859 (21.5%) ICU patient-days out of a total 31,867 ICU patient-days. Nonsurvivors used 2,023 (30%) ICU patient-days and patients with morbidity used 5,903 (86%) ICU patient-days.
Severe underlying cardiac disease (including shock, requirement for mechanical circulatory support, hypoalbuminemia, and hepatic dysfunction), intraoperative blood loss, surgical reexploration, long ischemic times, immediate postoperative cardiovascular dysfunction, global ischemia and metabolic dysfunction, and anemia beyond the second postoperative day predicted poor outcome in the elderly after cardiac surgery. Postoperative morbidity and mortality disproportionately increased the utilization of intensive care resources in elderly patients. Future efforts should focus on preoperative selection criteria, improvement in surgical techniques, perioperative therapy to ameliorate splanchnic and global ischemia, and avoidance of anemia to improve the outcome in the elderly after cardiac surgery.
确定75岁及以上患者心脏手术后围手术期发病和死亡的预测因素。
起始队列研究。
一家拥有54张床位的三级医疗心胸重症监护病房（ICU）。
在30个月期间因心脏手术入院的所有75岁及以上患者。
收集术前因素、手术因素、术后血流动力学以及入院时和ICU住院期间获得的实验室数据。
记录术后死亡、器官功能障碍发生率、医院感染、机械通气时间和ICU住院时间。在研究期间，8501例75岁及以上患者中有1157例（14%）心脏手术后发病率为54%（1157例患者中的625例），死亡率为8%（1157例患者中的90例）。术后发病的预测因素包括术前主动脉内球囊反搏、术前血清胆红素>1.0mg/dL、红细胞输血需求量>10单位、体外循环时间>120分钟（主动脉阻断时间＞80分钟）、返回手术室进行手术探查、心率>120次/分钟、术后及入住ICU时需要使用血管活性药物，以及术后第二天后出现贫血。术后死亡的预测因素包括术前心源性休克、血清白蛋白<4.0g/dL、术前全身氧输送<320mL/分钟/平方米、红细胞输血需求量>10单位、体外循环时间>140分钟（主动脉阻断时间>120分钟）、随后返回手术室进行手术探查、平均动脉压<60mmHg、心率>120次/分钟、中心静脉压>15mmHg、每搏量指数<30mL/分钟/平方米、需要使用血管活性药物、动脉血碳酸氢盐<20mmol/L、术后血浆葡萄糖>300mg/dL，以及术后第二天后出现贫血。在研究期间，研究队列在31867个ICU患者日中使用了6859个（21.5%）。非幸存者使用了2023个（30%）ICU患者日，发病患者使用了5903个（86%）ICU患者日。
严重的基础心脏病（包括休克、需要机械循环支持、低白蛋白血症和肝功能障碍）、术中失血、手术再次探查、长时间缺血、术后即刻心血管功能障碍、全身缺血和代谢功能障碍，以及术后第二天后出现贫血预示着老年患者心脏手术后预后不良。术后发病和死亡不成比例地增加了老年患者对重症监护资源的利用。未来的努力应集中在术前选择标准、手术技术的改进、改善内脏和全身缺血的围手术期治疗，以及避免贫血以改善老年患者心脏手术后的结局。
