ICU内重症产科患者有创机械通气现状与策略分析

Current situation and strategic for obstetric patients in ICU with invasive mechanical ventilation

摘要:

目的：探讨有创机械通气（invasive mechanical ventilation，IMV）在重症监护室（intensive care unit，ICU）内产科患者中的治疗现状与策略。方法：纳入仅采用IMV的ICU产科患者44例，其中生存24例，死亡20例；监测病人入ICU前、有创通气1、8、24和48 h的血气分析指标、呼吸频率、氯分压（PO2）、氧合指数（PO2/FiO2）和最终有创通气时间进行统计学分析。采用急性生理与慢性健康评分Ⅱ（acute physiology and chronic health evaluation Ⅱ，APACHEⅡ）和治疗干预评分系统（therapeutic interven－tion scoring system，TISS）评估接受IMV治疗产科病人病情危重情况和估计死亡风险并进行统计学分析。结果：生存组与死亡组一般情况比较，病人的APACHEⅡ评分、死亡风险系数、TISS评分、PO2/FiO2、怀孕次数均有统计学差异（P＜0.05）。生存组与死亡组病人有产后出血、贫血、弥散性血管内凝血（disseminated intravascular coagulation，DIC）、休克、多器官功能障碍综合征（multiple organ dysfunction syndrome，MODS）、妊娠高血压疾病均有统计学差异（P＜0.05）。接受IMV第1 h，患者末梢血氧饱和度（SPO2）和呼吸频率得到控制（P＜0.005）。接受IMV第8 h，患者氧合指数改善明显（P＜0.005），但内环境无明显改善。接受IMV第48 h，酸碱值（pH）、二氢化硫分压（PCO2）、碱剩余（BE）、吸入氧浓度（FiO2）差异明显（P＜0.005）。结论：对仅接受IMV产科病例，如未在短时间内脱机，死亡率高。APACHEⅡ和TISS评分是病情危重程度有效评估指标。入ICU最初有创通气8 h内环境无明显改善，贸然降低呼吸机参数是不可取的。IMV 8～24 h，此阶段可能是该类病例转归关键期，临床观察以24 h为界较好。IMV＞24 h死亡风险大，以＞48 h者更甚。IMV＞48 h者危及生命主要因素可能是酸碱失衡等内环境问题，治疗侧重点应落于此。

Abstract:

Objective：To investigate the current situation and therapeutic strategies for obstetric patients in ICU with invasive me－chanical ventilation（IMV）. Methods：Totally 44 patients in obstetric ICU using only IMV were enrolled，24 patients were survived and 20 patients were died. Patients’ blood gas，respiratory rate，PO2，PO2/FiO2 before entering ICU and at 1 h，8 h，24 h and 48 h after IMV were observed and compared. Acute physiology and chronic health evaluationⅡ（APACHEⅡ） and therapeutic intervention scor－ing system（TISS） were used to assess disease severity and estimated the risk of death for these patients. Results：APACHEⅡ score，mortality risk factor，TISS score，PO2/FiO2，number of pregnancies were different（statistically significant，P<0.05） between survival group and death group.The differences of postpartum hemorrhage，anemia，DIC，shock，MODS，hypertensive disorder complicating pregnancy were statistically significant（P<0.05） between the two groups. SPO2 and respiratory rate were stabilized with 1 h IMV.PO2/FiO2 was improved significantly after 8 h IMV，but internal environment was not significant improved.Patients’pH，PCO2，BE，FiO2 were significantly different with 48 h IMV（P<0.005）. Conclusion：Obstetric patients in the ICU with invasive mechanical ventila－tion have higher mortality rate if they are withdrawn in a short period. APACHEⅡand TISS are valid evaluations for assessing disease severity. Internal environment is not significant improved after 8 h of IMV and hastily reducing ventilator parameters is not desirable. IMV for 8-24 h might be suitable for estimating prognosis；24 h is a preferable observation point than others. Risk of death is higher when IMV>24 ht；it is even worse at 48 h. Deterioration of in－ternal environment such as acid-base imbalance may be the main factors that accounted for patients’ morbidity and should be the focus of treatment.