Brazilian Journal of Anesthesiology
https://bjan-sba.org/article/doi/10.1590/S0034-70942008000200005
Brazilian Journal of Anesthesiology
Scientific Article

Hipoxemia após revascularização miocárdica: análise dos fatores de risco

Hypoxemia after myocardial revascularization: analysis of risk factors

Tais Felix Szeles; Eduardo Muracca Yoshinaga; Wellington Alencar; Marcio Brudniewski; Flávio Silva Ferreira; José Otavio Costa Auler Jr; Maria José Carvalho Carmona; Luiz Marcelo Sá Malbouisson

http://dx.doi.org/10.1590/S0034-70942008000200005 Braz J Anesthesiol, vol.58, n2, p.124-136, 2008
PDF Português
PDF English
Downloads: 0
Views: 665

Resumo

JUSTIFICATIVA E OBJETIVOS: Hipoxemia grave é uma complicação freqüente no pós-operatório imediato de revascularização do miocárdio (RM), promovendo aumento da duração da ventilação mecânica, da incidência de infecções pulmonares, dos custos e da mortalidade. O objetivo desse estudo foi identificar fatores preditivos de hipoxemia grave em pacientes submetidos à RM. MÉTODO: Foram estudados 481 pacientes adultos submetidos à RM eletiva entre outubro de 2003 e março de 2004. Considerou-se hipoxemia grave uma relação PaO2/FiO2 < 150 na admissão à UTI. A análise estatística foi realizada por meio de teste de Qui-quadrado, t de Student ou Wilcoxon, seguida de análise multivariada por meio de regressão logística (RL) para variáveis com valor p < 0,25 na análise univariada. Considerou-se valor de p > 0,2 para exclusão da variável do modelo de RL e p < 0,1 como sendo significativo. RESULTADOS: O tempo para extubação dos pacientes com hipoxemia grave foi maior que nos outros pacientes (p < 0,001). Na análise multivariada, as variáveis idade (p = 0,081), peso (p = 0,001), necessidade de CEC prolongada (p = 0,033) e disfunção ventricular esquerda (p = 0,082) foram identificadas como preditores independentes para hipoxemia grave. CONCLUSÕES: Pacientes com idade e peso elevados, disfunção ventricular esquerda e necessidade de CEC apresentaram risco aumentado para hipoxemia grave após RM. Nesses pacientes, o uso de estratégias ventilatórias perioperatória com pressões positivas expiratórias mais elevadas e manobra de recrutamento alveolar devem ser consideradas tendo como objetivo a prevenção da disfunção pulmonar pós-operatória.

Palavras-chave

CIRURGIA, Cardíaca, COMPLICAÇÕES: hipoxemia, RISCO

Abstract

BACKGROUND AND OBJECTIVES: Severe hypoxemia is complication frequently seen in the immediate postoperative period of myocardial revascularization (MR), increasing the duration of mechanical ventilation, the incidence of pulmonary infections, hospital costs, and mortality. The objective of this study was to identify predictive factors of severe hypoxemia in patients undergoing MR. METHODS: Four-hundred and eighty-one adult patients undergoing elective MR between October 2003 and March 2004 were enrolled in this study. Severe hypoxemia was defined as PaO2/FiO2 < 150 upon admission to the ICU. The Chi-square test, Student's t or Wilcoxon test, followed by multivariate analysis and logistic regression (LR) for parameters with p < 0.25 in the univariate analysis, were used for the statistical analysis. A p > 0.2 was required to exclude the parameter from the LR model, and a p < 0.1 was considered significant. RESULTS: Time for extubation was greater in patients with severe hypoxemia (p < 0.001). Multivariate analysis identified age (p = 0.081), weight (p = 0.001), need of prolonged CBP (p = 0.033), and left ventricular dysfunction (p = 0.082) as independent predictors of severe hypoxemia. CONCLUSIONS: Older and overweighted patients, those with left ventricular dysfunction, and those who needed CPB presented an increased risk of severe hypoxemia after MR. In those patients, the use of perioperative ventilatory strategies, with elevated positive expiratory pressures and alveolar recruitment maneuver should be considered to prevent postoperative pulmonary dysfunction.

Keywords

COMPLICATIONS, RISK, factors, SURGERY, Cardiac

References

Cheng DC, Karski J, Peniston C. A morbidity outcome in early versus conventional tracheal extubation after coronary artery bypass grafting: a prospective randomized controlled trial. J Thorac Cardiovasc Surg. 1996;112:755-764.

Cheng DC, Karski J, Peniston C. Early tracheal extubation after coronary artery bypass graft surgery reduces costs and improves resource use: A prospective, randomized, controlled trial. Anesthesiology. 1996;85:1300-1310.

Singh NP, Vargas FS, Cukier A. Arterial blood gases after coronary artery bypass surgery. Chest. 1992;102:1337-1341.

Yende S, Wunderink R. Causes of prolonged mechanical ventilation after coronary artery bypass surgery. Chest. 2002;122:245-252.

Brooks-Brunn JA. Postoperative atelectasis and pneumonia. Heart Lung. 1995;24:94-115.

Rothen HU, Sporre B, Engberg G. Atelectasis and pulmonary shunting during induction of general anaesthesia: can they be avoided?. Acta Anaesthesiol Scand. 1996;40:524-529.

Hachenberg T, Tenling A, Nystrom SO. Ventilation-perfusion inequality in patients undergoing cardiac surgery. Anesthesiology. 1994;80:509-519.

Tenling A, Hachenberg T, Tyden H. Atelectasis and gas exchange after cardiac surgery. Anesthesiology. 1998;89:371-378.

Magnusson L, Zemgulis V, Wicky S. Atelectasis is a major cause of hypoxemia and shunt after cardiopulmonary bypass: an experimental study. Anesthesiology. 1997;87:1153-1163.

Wheeler WE, Rubis LJ, Jones CW. Etiology and prevention of topical cardiac hypothermia-induced phrenic nerve injury and left lower lobe atelectasis during cardiac surgery. Chest. 1985;88:680-683.

Asimakopoulos G, Smith PL, Ratnatunga CP. Lung injury and acute respiratory distress syndrome after cardiopulmonary bypass. Ann Thorac Surg. 1999;68:1107-1115.

Auler-Junior JO, Saldiva PH. Pulmonary structure and extravascular lung water after cardiopulmonary bypass. Braz J Med Biol Res. 1986;19:707-714.

Weiss YG, Merin G, Koganov E. Postcardiopulmonary bypass hypoxemia: a prospective study on incidence, risk factors, and clinical significance. J Cardiothorac Vasc Anesth. 2000;14:506-513.

Hachenberg T, Brussel T, Roos N. Gas exchange impairment and pulmonary densities after cardiac surgery. Acta Anaesthesiol Scand. 1992;36:800-805.

Canver CC, Chanda J. Intraoperative and postoperative risk factors for respiratory failure after coronary bypass. Ann Thorac Surg. 2003;75:853-858.

Andrejaitiene J, Sirvinskas E, Bolys R. The influence of cardiopulmonary bypass on respiratory dysfunction in early postoperative period. Medicina. 2004;40(^s1):7-12.

Tonz M, Mihaljevic T, von Segesser LK. Acute lung injury during cardiopulmonary bypass: Are the neutrophils responsible?. Chest. 1995;108:1551-1556.

Wasowicz M, Sobczynski P, Drwila R. Air-blood barrier injury during cardiac operations with the use of cardiopulmonary bypass (CPB): An old story? A morphological study. Scand Cardiovasc J. 2003;37:216-221.

Nozawa E, Kobayashi E, Matsumoto ME. Assessment of factors that influence weaning from long-term mechanical ventilation after cardiac surgery. Arq Bras Cardiol. 2003;80:301-310.

London MJ, Shroyer AL, Coll JR. Early extubation following cardiac surgery in a veterans population. Anesthesiology. 1998;88:1447-1458.

Branca P, McGaw P, Light R. Factors associated with prolonged mechanical ventilation following coronary artery bypass surgery. Chest. 2001;119:537-546.

Rady MY, Ryan T, Starr NJ. Early onset of acute pulmonary dysfunction after cardiovascular surgery: risk factors and clinical outcome. Crit Care Med. 1997;25:1831-9.

Spivack SD, Shinozaki T, Albertini JJ. Preoperative prediction of postoperative respiratory outcome: Coronary artery bypass grafting. Chest. 1996;109:1222-1230.

Albert RK, Hubmayr RD. The prone position eliminates compression of the lungs by the heart. Am J Respir Crit Care Med. 2000;161:1660-1665.

Malbouisson LM, Busch CJ, Puybasset L. Role of the heart in the loss of aeration characterizing lower lobes in acute respiratory distress syndrome: CT Scan ARDS Study Group. Am J Respir Crit Care Med. 2000;161:2005-2012.

Wong DT, Cheng DC, Kustra R. - Risk factors of delayed extubation, prolonged length of stay in the intensive care unit, and mortality in patients undergoing coronary artery bypass graft with fast-track cardiac anesthesia: a new cardiac risk score. Anesthesiology. 1999;91:936-944.

Weissman C. Pulmonary function during the perioperative period. Isr Med Assoc J. 2000;2:868-74.

Froese AB, Bryan AC. Effects of anesthesia and paralysis on diaphragmatic mechanics in man. Anesthesiology. 1974;41:242-254.

Daganou M, Dimopoulou I, Michalopoulos N. Respiratory complications after coronary artery bypass surgery with unilateral or bilateral internal mammary artery grafting. Chest. 1998;113:1285-1289.

5dd6c7350e8825834113f286 rba Articles
Links & Downloads
2352-2291 (Electronic) 0104-0014 (Printed)
Braz J Anesthesiol ©2024 All rights reserved.

Braz J Anesthesiol

Share this page
Page Sections