Rady M Y, Kodavatiganti R, Ryan T
Department of Cardiothoracic Anesthesia, Cleveland Clinic Foundation, Ohio, USA.
Chest. 1998 Jul;114(1):76-84. doi: 10.1378/chest.114.1.76.
To determine the incidence, diagnostic features, and perioperative predictors of acute cholecystitis after cardiovascular surgery.
Inception cohort study.
A tertiary care 54-bed cardiothoracic ICU.
All patients admitted to an ICU after cardiovascular surgery during a 42-month period.
Collection of relevant preoperative, operative, and ICU data from a database and medical charts.
Postoperative acute cholecystitis (AC).
Out of 11,330 admissions, 876 patients stayed in the ICU more than 7 days and 30 of them (3%) developed postoperative AC. AC was diagnosed a median of 26 days after cardiovascular surgery (interquartile range, 11 to 41 days). All patients with AC developed at least two criteria of the systemic inflammatory response syndrome (SIRS), and 16 of them (53%) were vasopressor-dependent on the day of diagnosis. Trends in biochemical testing of liver function were not diagnostic for AC. Death occurred in seven of 17 patients (41%) who underwent cholecystectomy, three of nine patients (33%) treated with percutaneous cholecystostomy, and one of four patients (25%) treated conservatively (p=not significant). Specific earlier predictors of AC were arterial vascular disease, preoperative oxygen delivery less than 430 mL/min x m2, longer times on cardiopulmonary bypass, surgical re-exploration, ICU course complicated by cardiac arrhythmia, mechanical ventilation > or = 3 days, bacteremia, and nosocomial infections.
The incidence of AC is low after cardiovascular surgery. Although SIRS and hemodynamic instability were common at the time of diagnosis, the delayed occurrence and lack of specificity of these features for AC limited their utility for early diagnosis. Specific predictors of AC should be sought in the ICU setting to identify patients who are at risk for AC after cardiovascular surgery. When identified, such predictors can prompt earlier diagnosis and treatment. Further evaluation of the selection criteria for different treatment options is needed in order to decrease the morbidity and mortality associated with AC.
确定心血管手术后急性胆囊炎的发病率、诊断特征及围手术期预测因素。
队列起始研究。
一家拥有54张床位的三级护理心胸外科重症监护病房。
42个月期间心血管手术后入住重症监护病房的所有患者。
从数据库和病历中收集相关的术前、术中及重症监护病房数据。
术后急性胆囊炎（AC）。
在11330例入院患者中，876例在重症监护病房停留超过7天，其中30例（3%）发生术后AC。AC在心血管手术后中位26天被诊断（四分位间距为11至41天）。所有AC患者均出现至少两条全身炎症反应综合征（SIRS）标准，其中16例（53%）在诊断当天依赖血管活性药物。肝功能生化检测趋势对AC无诊断意义。17例行胆囊切除术的患者中有7例（41%）死亡，9例行经皮胆囊造瘘术治疗的患者中有3例（33%）死亡，4例保守治疗的患者中有1例（25%）死亡（p值无统计学意义）。AC的特定早期预测因素为动脉血管疾病、术前氧输送量低于430 mL/min×m²、体外循环时间延长、再次手术探查、重症监护病房病程并发心律失常、机械通气≥3天、菌血症及医院感染。
心血管手术后AC的发病率较低。虽然诊断时SIRS和血流动力学不稳定很常见，但这些特征出现较晚且对AC缺乏特异性，限制了其早期诊断的作用。应在重症监护病房环境中寻找AC的特定预测因素，以识别心血管手术后有AC风险的患者。一旦识别出此类预测因素，可促使早期诊断和治疗。需要进一步评估不同治疗方案的选择标准，以降低与AC相关的发病率和死亡率。
