重症阻塞性睡眠呼吸暂停低通气综合征患者死亡原因分析
摘要
目的 阻塞性睡眠呼吸暂停低通气综合征(OSAHS)是具有潜在危险的常见病症,用外科手术解除上气道结构性异常是目前治疗OSAHS的常用方法,但在其检查治疗的各个时期均易发生危及生命的严重并发症,我们收集6家医院OSAHS患者死亡病例的资料,探讨OSAHS检查治疗时发生患者死亡的原因及防治对策。
方法 对1991年至2004年6家医院在检查治疗中死亡的6例OSAHS患者的病例资料进行回顾性分析,患者年龄42~59岁,对死亡原因进行总结讨论。
结果 5例手术死亡患者中肥胖4例;合并高血压、心脏病、糖尿病1例,合并高血压、心脏病1例;肺功能异常或影像有改变2例;1例无合并症病史。其中3例患者未行多导睡眠图(PSG)监测,2例呼吸暂停低通气指数(AHI)分别为56次/h和82次/h。1例在PSG监测时发生意外死亡。死亡原因分别为:手术开始前诱导麻醉后行气管插管困难,致呼吸道梗阻、呼吸心跳骤停后死亡2例;局麻下行悬雍垂腭咽成形术(UPPP)后,咳嗽后出血,待行全麻止血手术,使用肌松剂后反复气管插管不成功,因缺氧时间过长造成脑水肿,长期昏迷死亡1例;1例术前肺功能检查发现气道阻力过高,提示小气道病变,全麻UPPP术后患者清醒状态下拔除气管插管后出现躁动、口唇紫绀,重新插管,呼吸机给氧,血压测不出,心音不清,心电图示室颤,心跳呼吸骤停,抢救无效死亡;l例术前查体发现心肺等器官存在潜在性病变,全麻气管插管后气管切开行UPPP术后,患者清醒状态下更换气管套管时出现血压波动、心率紊乱、血压下降,心率减慢,心跳停止,抢救无效死亡;1例患有高血压、冠心病、糖尿病、肥胖病,心电图示心功能三级,呈呼吸性酸中毒状态患者,行PSG监测反复呼吸暂停,1小时后发生呼吸心跳停止,行紧急气管插管、心肺复苏抢救,心跳恢复,但呼吸无恢复,依赖呼吸机呼吸,最终家属放弃抢救,因呼吸循环衰竭死亡。
结论 OSAHS是一种常见病和多发病,可以累及全身多个系统、多个脏器,是对人体健康造成严重危害的临床综合征。围手术期的各个时期都可能发生意外死亡,其原因可能与心源性猝死、心肌梗死、脑卒中、心律失常或呼吸道梗阻有关,这些都大大增加了治疗管理的难度。我们认为OSAHS术后即刻的并发症与OSAHS的严重程度明显相关,对于重症伴有明显器官系统并发症的患者,纠正全身状态,改善患者术前状况,再择期行手术治疗,是减少围手术期严重并发症的重要措施。一定要详细全面地查体,对重症患者应在改善其心肺功能及全身情况后再手术,必要的CPAP治疗或气管切开,麻醉前的气道评估,气管插管困难时的紧急环甲膜切开,手术后的ICU监护或普通病房的监护,均为不可或缺的环节,严格细致地做好围术期每一环节的预案和准备工作,才能减少防止严重并发症的发生。
【关键词】睡眠呼吸暂停,阻塞性;手术中并发症;手术后并发症;死亡原因
An analysis of the cause and countermeasure of death of patients with severe obstructive sleep apnea hypopnea syndrome
ZHANG Qing-quan,WANG Qiang,CAI Xiao-lan,LI Hai-yan,LIU Hongying.
Department of Otorhinolaryngology and Neck Surgery,YuhuangdingHospital,Yamai,Shandong264000,China
Correspondence author:ZHANG Qing-quan,Email:ytebhzqq@163.com
【Abstract】-ive Obstructive sleep apnea hypopnea syndrome (OSAHS) is a potentially dangerous common disease, and surgeries to change the upper airway structural abnormalities are common methods of treatment of OSAHS, but in each period of the examination and treatment patients are prone to serious complications of life, we have collected the data of patients with OSAHS who died before or after surgies from some hospitals, to discuss the causes and countermeasures of death of patients with severe OSAHS undergoing tests or treatment. Methods A retrospective study of the data of 6 patients with severe OSAHS who died undergoing tests or treatment from 1991 to 2004 in 6 hospitals was conducted. Results Among the 6 patients, overly fat were found in 2 cases, hypertension in 2 cases. cardiac diseases in 2 cases, abnormal pulmonary function or chest X-ray in 2 Cases, diabetes in 2 cases, while 2 cases had no above positive finding. Three patients did not have polysomnography(PSG).One patient died during PSG test. Two patients’apnea hypopnea index(AHI)were 56 times/h and 82 times/h respectively. The causes of death were as follows, two patients died of airway obstruction and unsuccessful tracheal intubation before uvulopalatopharyngoplasty (UPPP)operation. One died of encephaledema in long-term coma due to airway obstruction, long time poor oxygenation and unsuccessful tracheal intubation with muscle relaxants before hemostasis procedure for treating postoperative hemorrhage. One patient whose preoperative pulmonary function showed increased airway resistance died of cardiac and respiratory arrest after tracheal extubation when UPPP surgery finished. One who Was found to have potential cardiac and pulmonary disorder died of cardiac arrest when doctors were replacing his tracheal intubation with a cannula, before the tube replacing procedure the patient Was conscious. One who had hypertension, coronary heart disease, diabetes mellitus and acidosis suffering from respiratory acidosis with his electrocardiogram showing a level—three heart function died of cardiac arrest with repeated apnea during PSG monitoring. Conclusions OSAHS is a common and frequently-occurring disease, which can involve multiple body systems, multiple organ clinical syndromes, and causing serious harm to human health. Perioperative accidental death may be associated with sudden cardiac death, myocardial infarction, stroke, cardiac arrhythmia, or pulmonary embolism. These have greatly increased the difficulty of treatment and management. Some experts believe that the OSAHS immediate postoperative complications and OSAHS severity are significantly related to the patients’ severity. Improving body condition and status of patients before elective surgical treatment is an important measure of to reduce perioperative serious complications. Numerous studies show that OSAHS with high degree of vigilance OSAHS patients may be fatal serious complications, emphasizing the indications for surgical treatment of patients with OSAHS. Detailed and comprehensive examination of critically ill patients should be conducted. Surgeons should improve patients’ heart and lung function and general condition before surgery, the necessary CPAP therapy or tracheostomy, airway assessment before anesthesia, endotracheal intubation difficulties the emergency thyrocricoid of incision, post-operative ICU care or general ward care, are integral part of meticulous job and every aspect of perioperative plans and preparations should be done in order to reduce or prevent the occurrence of serious complications.
【Key words】Sleep apnea, Obstructive;Intraoperative complication;Postoperative complication;Cause of death