2019 年第 11 期 第 14 卷

妊娠合并肺动脉高压患者围术期血流动力学分析

Perioperative hemodynamic monitoring in parturients with pulmonary hypertension

作者：林培容科雨彤梁翠赵芳赵丽云

英文作者：

单位：100029首都医科大学附属北京安贞医院麻醉中心

英文单位：

关键词：肺动脉高压；剖宫产；血流动力学

英文关键词：

• 摘要：

• 【摘要】目的    探讨妊娠合并肺动脉高压(PH)患者的围产期结局和围术期血流动力学特征。方法    选取2016年1月至2017年12月于首都医科大学附属北京安贞医院诊断为妊娠合并PH并接受剖宫产手术的患者44例，根据术前经胸超声心动图检查结果分为轻中度PH组（24例）和重度PH组（20例）。剖宫产手术采用连续硬膜外麻醉，比较2组一般临床情况［包括基线数据、年龄、术前纽约心脏病协会（NYHA）心功能分级、合并症等］以及麻醉前及胎儿娩出后5 min的血流动力学指标水平，包括舒张压、收缩压、心率、重脉压、系统血管阻力指数（SVRI）、心脏循环效率（CCE）、心排血指数、每搏输出指数、每搏输出量变异、心室内压力变化率、脉压变异、外周血管阻力、心输出量、每搏输出量等，记录临床结局，包括重症监护病房（ICU）停留时间、总住院时间和并发症发生情况。结果    术前轻中度PH组患者NYHA心功能分级Ⅰ级7例、Ⅱ级14例、Ⅲ级3例、Ⅳ级0例，重度PH组NYHA心功能分级Ⅰ级0例、Ⅱ级4例、Ⅲ级12例、Ⅳ级4例，轻中度PH组患者NYHA心功能分级优于重度PH组（P＜0.001）。与麻醉前比较，重度PH组胎儿娩出后5 min 系统血管阻力指数显著降低［(1 622±593)dyn/（sec·cm2）比（2 041±863）dyn/（sec·cm2）］，CCE显著升高［20.0(13.7,32.3)%比3.9(-0.8,23.9)%］，差异均有统计学意义（均P＜0.05）；重度PH组麻醉前及胎儿娩出后5 min脉压变异低于轻中度PH组［10（4,11）%比15（5,24）%、9（5,10）%比16（6,19）%］，差异均有统计学意义（均P＜0.05）。重度PH组平均住院时间和ICU停留时间均长于轻中度PH组［(11.6±4.0)d比（7.4±2.4）d、(60±42)h比（22±16）h］，差异均有统计学意义（均P＜0.05）,重度PH组产妇于术后3 d因心力衰竭死亡1例，出现呼吸系统并发症（呼吸衰竭）1例，胎儿死亡2例。结论    重度PH组患者分娩前心功能损害严重，产后平均住院时间及ICU停留时间较轻中度组更长。重度PH组CCE在胎儿娩出后5 min较麻醉前显著增高，而轻中度PH组改善不明显；CCE可作为间接评估重度PH产妇围术期心功能的敏感指标。

• 【Abstract】Objective    To analyze the perinatal outcome and hemodynamic characteristics in parturients with pulmonary hypertension（PH）. Methods    A total of 44 parturients with PH undergoing cesarean section from January 2016 to December 2017 in Beijing Anzhen Hospital, Capital Medical University were enrolled. According to preoperative results of transthoracic echocardiography, the parturients were divided into mild to moderate PH group(n=24) and severe PH group(n=20). Cesarean section was performed with continuous epidural anesthesia. Basic information including age, New York Heart Association(NYHA) cardiac functional grade and comorbidities, hemodynamic indexes before anesthesia and 5 min after delivery［diastolic pressure, systolic pressure, heart rate, heavy pulse pressure, systemic vascular resistance index (SVRI), cardiac circulation efficiency（CCE）, cardiac output index, stroke volume index, stroke volume variation, ventricular pressure change rate, pulse pressure variation, systemic vascular resistance, cardiac output volume, stroke volume］, clinical outcome indicators including intensive care unit(ICU) stay time, total hospitalization time and occurrence of complications were analyzed.ResultsIn the mild to moderate PH group there were 7 cases of NYHA grade Ⅰ, 14 cases of grade Ⅱ, 3 cases of grade Ⅲ and 0 case of grade Ⅳ. In the severe PH group there was 0 case of grade Ⅰ, 4 cases of grade Ⅱ, 12 cases of grade Ⅲ and 4 cases of grade Ⅳ. NYHA grading results in the mild to moderate PH group was superior to those in the severe PH group（P<0.001). At 5 min after delivery, SVRI significantly decreased［(1 622±593)dyn/（sec·cm2） vs （2 041±863）dyn/（sec·cm2） before anesthesia］ and CCE significantly increased［20.0(13.7,32.3)% vs 3.9(-0.8,23.9)% before anesthesia］ in the severe PH group（both P＜0.05）. Pulse pressure variation in the severe PH group was significantly lower than that in the mild to moderate PH group before anesthesia and 5 min after delivery［10（4,11）% vs 15（5,24）%, 9（5,10）% vs 16（6,19）%］(both P<0.05). Total hospitalization time and ICU stay time in the severe PH group were significantly longer than those in the mild to moderate PH group［(11.6±4.0)d vs (7.4±2.4)d, (60±42)h vs (22±16)h］(both P<0.05). In the severe PH group, 1 parturient died of heart failure at 3 d after delivery, 1 parturient developed respiratory failure, and 2 fetuses died. Conclusions    This study demonstrates a high prevalence of severe cardiac damage affecting parturients with severe PH, which leads to long duration of postpartum ICU care and hospital stay. CCE significantly increases at 5 min after cesarean section for severe PH but shows no obvious change in mild to moderate PH, suggesting that CCE might be a sensitive index for the assessment of perinatal cardiac function in severe PH parturients.