«上一篇/Previous Article|本期目录/Table of Contents|下一篇/Next Article»

《天津医科大学学报》[ISSN:1006-8147/CN:12-1259/R]

卷:

28卷

期数:

2022年04期

页码:

418-422

栏目:

临床医学

出版日期:

2022-07-20

文章信息/Info

Title:

The correlative risk factors of sternal dehiscence in patients undergoing coronary artery bypass grafting

文章编号:

1006-8147（2022）04-0418-05

作者:

王萌¹; 2; 宋衍秋³; 梁慧敏¹; 陈欣²; 王联群²; 王春梅¹

（1.天津医科大学护理学院，天津300070； 2. 天津市胸科医院心血管外科，天津300222；3.天津市胸科医院心血管病研究所，天津300222）

Author(s):

WANG Meng¹; 2; SONG Yan-qiu³; LIANG Hui-min¹; CHEN Xin²; WANG Lian-qun²; WANG Chun-mei¹

（1.School of Nursing，Tianjin Medical University，Tianjin 300070，China；2.Department of Cardiovascular Surgery，Tianjin Chest Hospital，Tianjin 300222，China; 3. Cardiovascular Institute，Tianjin Chest Hospital，Tianjin 300222，China）

关键词:

冠状动脉旁路移植术; 胸骨哆开; 危险因素

Keywords:

coronary artery bypass grafting;  sternal dehiscence; risk factors

分类号:

R619+.5

DOI:

-

文献标志码:

A

摘要:

目的：探讨冠状动脉旁路移植术（CABG）患者术后胸骨哆开（SD）发生的相关危险因素。方法：选取2014年1月至2020年6月于天津市胸科医院择期行CABG，术后发生SD的患者80例（SD组）；选择同期手术、同年龄、同性别CABG术后未发生SD的患者160例，按照1：2匹配，作为对照组。比较两组一般临床资料、术前生化指标、既往病史、手术相关指标，对有统计学差异的指标进行多因素条件Logistic回归分析，绘制受试者工作特征（ROC）曲线。结果：SD组体重指数（BMI）（t=4.848，P<0.001）、吸烟患者（χ2=5.245，P=0.022）、术中体外循环（χ2=15.375，P<0.001）、胸部切口感染发生率（χ2=25.920，P<0.001）高于对照组，术前心功能NYHA分级高的患者发生SD比率（χ2=28.467，P<0.001）高于对照组，SD组充血性心衰发生率（χ2=4.709，P=0.030）高于对照组，SD组呼吸机辅助通气时间（t=4.631，P<0.001）显著长于对照组，两组其余指标差异无统计学意义。条件Logistic回归分析结果显示BMI（OR=1.222，95%CI：1.098～1.360，P<0.001）、吸烟（OR=2.012，95%CI：1.005～4.026，P=0.048）、术前心功能差（OR=3.150，95%CI：1.619～6.127，P=0.001）、术中体外循环（OR=4.429，95%CI：1.542～12.721，P=0.001）、胸部切口感染（OR=53.516，95%CI：5.419～528.511，P=0.001）及呼吸机辅助通气时间（OR=1.016，95%CI：1.006～1.027，P=0.005）差异有统计学意义。ROC曲线分析表明，Logistic拟合呼吸机辅助通气时间、BMI、术前NYHA分级、体外循环、吸烟及胸部切口感染六个协变量的整体模型（变量pre_1）ROC曲线下面积为0.833（P＜0.001，95%CI：0.775～0.892）。呼吸机辅助通气时间＞17.756 ｈ、BMI＞26.5 kg/m2、术前NYHA心功能分级≥Ⅲ级时约登指数最大。结论：呼吸机辅助通气时间>17.75 h、BMI>26.5 kg/m2、术前NYHA心功能分级≥Ⅲ级，同时伴有吸烟、使用体外循环及胸部切口感染是CABG患者发生SD的危险因素。

Abstract:

Objective： To investigate the risk factors of sternal dehiscence（SD） in patients undergoing coronary artery bypass grafting （CABG）. Methods: A total of 80 patients with SD after undergoing CABG at Tianjin Chest Hospital from January 2014 to June 2020 were selected as the subjects，and 160 patients without postoperative SD （1:2 matched according to the simultaneous surgery，same age and same gender） were included in the control group. Patients in the two groups were compared for general clinical data，preoperative biochemical indexes，past medical history，and surgery-related indexes. The indexes with statistical differences were subject to multivariate conditional Logistic regression analysis，and the receiver operating characteristic（ROC） curves were plotted. Results:The body mass index（BMI）（t=4.848，P<0.001），the patients who smoke（χ2=5.245，P=0.022），cardiopulmonary bypass（χ2=15.375，P<0.001），and the incidence of chest incision infection（χ2=25.920，P<0.001） in the SD group were significantly higher than those in the control group. The difference in the preoperative classification of the NYHA cardiac function（χ2=28.467，P<0.001） between the SD group and the control group was statistically significant. The incidence of poor cardiac functionin（χ2=4.709，P=0.030） in the SD group was higher than that in the control group. The duration of mechanical ventilation（t=4.631，P<0.001） in the SD group was significantly longer than that in the control group. The results of multivariate conditional Logistic regression analysis showed that the differences in BMI（OR=1.222，95%CI ：1.098-1.360，P<0.001），smoking（OR=2.012，95%CI：1.005-4.026，P=0.048），preoperative classification of the NYHA cardiac function（OR=3.150，95% CI：1.619-6.127，P=0.001），cardiopulmonary bypass（OR=4.429，95% CI：1.542-12.721，P=0.001），chest incision infection（OR=53.516， 95%CI：5.419-528.511，P=0.001），and ventilator-assisted ventilation time（OR=1.016，95%CI：1.006-1.027，P=0.005） were statistically significant . As shown in the ROC curve，the corresponding area under the curve of the byparameterization of the model（variable pre_1） with the ventilator-assisted ventilation time，BMI，preoperative classification of the NYHA cardiac function，cardiopulmonary bypass，smoking，and chest incision infection was 0.833（P=0.000，95% CI ：0.775-0.892）. The Youden index reached its peak when the ventilator-assisted ventilation time was 17.75 hours，the BMI was 26.5 and the preoperative classification of the NYHA cardiac function is greater than or equal to class Ⅲ. Conclusion: The risk of SD will be significantly increased in the patients with the ventilator-assisted ventilation time is greater than 17.75 hours，BMI is greater than 26.5 kg/m2，the preoperative classification of the NYHA cardiac function is greater than or equal to class Ⅲ and accompanied by smoking，cardiopulmonary bypass and chest incision infection.

参考文献/References:

[1] 周峰，高永顺，刘吉福.等.封闭负压引流联合胸大肌肌瓣翻转手术治疗心脏术后胸骨切口深部感染51例[J].右江医学，2019，47（7）：558-560．
[2] 朱鹏，尤颢，刘菲，杨谦.心脏外科术后胸骨哆开的外科治疗[J].华西医学，2016，31（5）：850-853.
[3] SASO S，JAMES D，VECHT J A，et al. Effect of skeletonization of the internal thoracic artery for coronary revascularization on the incidence of sternal wound infection[J]. Ann Thorac Surg，2010，89（2）： 661-670.
[4] MOTOMATSU Y，IMASAKA K，TAYAMA E，et al. Midterm results of sternal band closure in open heart surgery and risk analysis of sternal band removal[J]. Artif Organs，2016，40（2）：153-158.
[5] KALAB M，KARKOSKA J，KAMINEK M，et al. Reconstruction of massive post-sternotomy defects with allogeneic bone graft： four-year results and experience using the method[J]. Int Card Thorac Surg，2016，22（3）：305-313.
[6] ORHAN S N，OZYAZICIOGLU M H. Evaluation of sternum closure methods by means of a nonlinear finite element analysis[J]. Proc Inst Mech Eng H，2019，233（12）： 1282-1291.
[7] GALLINA F T，MELIS E，FORCELLA D，et al. Sternal wound dehiscence after median sternotomy：an alternative closure technique[J]. J Card Surg，2021，36（7）： 2603-2604.
[8] HIROYUKI K，AL-MAISARY S S A，PAYAM A，et al. The number of wires for sternal closure has a significant influence on sternal complications in high-risk patients[J]. Int Card Thor Surg，2009，15（4）： 665-670.
[9] SHU D，LI J，ZHAO Y，et al. Comparison of polyetheretherketone cables and stainless steel wires for sternal fixation after median sternotomy[J]. J Int Med Res，2021，49（9）： 3000605211041265.
[10] VYMAZAL T，ASTRAVERKHAVA M，DURILA M.Rotational thromboelastometry helps to reduce blood product consumption in critically Ill patients during small surgical procedures at the Intensive Care Unit-a retrospective clinical analysis and literature search[J]. Transfus Med Hemother，2018，45（6）：385-387.
[11] MORIASKI A，HOSONO M，MURAKAMI T，et al.Effect of negative pressure wound therapy followed by tissue flaps for deep sternal wound infection after cardiovascular surgery：propensity score matching analysis[J]. Int Card Thor Surg，2016，23：397-402.
[12] 沈长军，吴远林，杨朝坤，等. 冠状动脉旁路移植术169临床应用体会[J]. 中国妇幼健康研究，2017，28（S4）：1-6.
[13] PIWNICA-WORMS W，AZOURY SC，KOZAK G，et al. Flap reconstruction for deep sternal wound infections：factors influencing morbidity and mortality[J]. Ann Thorac Surg，2020，109（5）：1584-1590.
[14] GUDBJARTSSON T，JEPPSSON A. Wound infections following open heart surgery-review[J]. Laeknabladid，2019，105（4）：177-182.
[15] VESTEINSDOTTIR E，HELGASON K O，SVERRISSON K O，et al. Infections and outcomes after cardiac surgery-The impact of outbreaks traced to transesophageal echocardiography probes[J]. Acta Anaesthesiol Scand，2019，63（7）：871-878.
[16] SHARIF-KASHABI B，SHAHABI P，MANDEGAR M H，et al. Smoking and wound complications after coronary artery bypass grafting[J]. J Surg Res，2016，200（2）：743-748.
[17] JALEEL Z，BLASBERG E，TROIANO C，et al. Association of vaping with decreased vascular endothelial growth factor expression and decreased microvessel density in cutaneous wound healing tissue in rats[J]. Wound Repair Regen，2021，29（6）：1024-1034.
[18] ELLIS P. The impact of smoking on wound healing：the role of the nurse[J]. Br J Nurs，2018，27（6）： S10-S14.
[19] BUKVIC MOKOS Z，MISE J，BALIC A，et al. Understanding the relationship between smoking and hidradenitis suppurativa[J]. Acta Dermatovenerol Croat，2020，28（1）：9-13.
[20] 张东，景东帅，赵真，等. 心脏直视术后中老年患者胸骨哆开的危险因素分析[J].世界最新医学信息文摘，2014，14（3）：64-73.
[21] LISTEWNIK M J，JEDRZEJCZAK T，MAJER K，et al. Complications in cardiac surgery：an analysis of factors contributing to sternal dehiscence in patients who underwent surgery between 2010 and 2014 and a comparison with the 1990-2009 cohort[J]. Adv Clin Exp Med，2019，28（7）：913-922.
[22] MOLINA J E，LEW RSL，HYLAND K J. Postoperative sternal dehiscence in obese patients： incidence and prevention[J]. Ann Thorac Surg，2004，78（3）：912-917.
[23] 张正刚，向道康，朱西安，等.手术后胸骨哆开的原因分析与护理体会[J].中西医结合心血管病杂志，2016，4（34）：69-72.
[24] KMIECIK S A，STAMMERS A H，PETTERSON C M，et al. The effect of volume replacement on serum protein concentration during cardiopulmonary bypass[J]. J Extra Corpor Technol，2001，33（4）：227-232.
[25] HAMMER S，LOEFF M，REICHENSPURNER H，et al. Effect of cardiopulmonary bypass on myocardial function，damage and inflammation after cardiac surgery in newborns and children[J]. Thorac Cardiovasc Surg，2001，49（6）： 349-354.
[26] 赵子牛，程兆云，王圣，等.冠状动脉搭桥术后胸骨哆开的原因分析及诊治[J]. 武汉大学学报（医学版），2012，33（6）：909-911.

相似文献/References:

[1]王永旺,喻文立,王清平,等.急性血小板分离或自体血回输对体外循环冠状动脉旁路移植术患者血液保护的影响[J].天津医科大学学报,2016,22(06):494.
　WANG Yong-wang,YU Wen-li,WANG Qing-ping,et al.Blood-saving effects of acute plateletpheresis and autologous blood transfusion in patients undergoing coronary artery bypass grafting by CPB[J].Journal of Tianjin Medical University,2016,22(04):494.
[2]孟祥雪,邓伟丽,刘文静,等.冠状动脉旁路移植术后早期心脏康复对预后的影响[J].天津医科大学学报,2019,25(06):590.
　MENG Xiang-xue,Deng Wei-li,Liu Wen-jing,et al.The effect of early rehabilitation after coronary artery bypass grafting on prognosis[J].Journal of Tianjin Medical University,2019,25(04):590.

备注/Memo

备注/Memo:

作者简介:王萌（1989-），女，硕士在读，研究方向：护理学；通信作者：王春梅，E-mail：cmwang8543@126.com。

常用功能

更新日期/Last Update: 2022-07-20