脫離幫浦的CABG縮短住院天數但可能增加感染風險


  Jan. 18, 2005(鳳凰城)-根據一項發表於第34屆美國重症醫學會重症照護會議中的回顧分析試驗結果,脫離幫浦的冠狀動脈繞道手術(CABG)手術可以縮短住院時間,但是可能增加中隔感染風險。
  
  匹茲堡大學副教授John A. Kellum醫師,同時也是這項試驗的資深研究人員向Medscape表示,傳統CABG手術可能會誘發強烈的發炎反應,而且增加的反應可能實際上對感染是有保護作用的;他的團隊發現,接受傳統CABG手術病患的細胞激素,相較於接受脫離幫浦CABG的病患,有顯著的差異。
  
  在這項試驗中,相較於接受傳統CABG病患的2.3%,接受脫離幫浦CABG手術病患的感染率大約上升了5倍,其感染率為10.2%(P<.03)。
  
  Kellum醫師與其同事回顧性分析131位接受傳統CABG手術、以及78位脫離幫浦CABG手術病患的住院時間長短、中風、感染與死亡率;所有的手術流程都在同一家社區醫院進行。
  
  脫離幫浦手術確實顯著地增加住院時間,接受脫離幫浦CABG手術病患的住院時間平均少了一天(3.24天),相較於接受傳統手術的4.56天(P<.001);Kellum醫師表示,為什麼這個族群住院天數較少,但是感染率較高呢?感染的數字實際上是很低的,所以感染數字對住院天數沒有什麼貢獻。
  
  Kellum醫師表示,他與他的同事們將這個試驗設計成要找出脫離幫浦CABG手術,是否與中風事件數目的下降有關;結果發現證據是支持我們的假設,也就是接受脫離幫浦試驗的病患並沒有發生中風的病例,而接受傳統CABG手術病患的中風發生率為7.6%;這樣的差距達到統計上差異(P<.03)。
  
  此外,接受脫離幫浦手術的病患沒有死亡的病例,而接受傳統手術病患的死亡率為1.5%,不過,這樣的差距並沒有達到統計上的差異。
  
  不同的手術團隊之間所進行的手術並沒有顯著差異,而且這兩組病患在人口統計學上也是相符的;接受傳統CABG手術病患的平均年齡為68歲,而接受脫離幫浦CABG手術病患的平均年齡為67歲;這兩組病患的平均繞道血管數目為3條;這兩組病患之間風險因子的盛行率,包括糖尿病、高血壓、高血脂、肥胖、吸菸、腎臟功能不全、與家族史都是相符的。
  
  聖路易斯華盛頓大學醫學院外科與麻醉學副教授Craig M. Coopersmith醫師,同時也是SCCM會議計畫委員會副主席向Medscape表示,這項有關於接受脫離幫浦CABG手術病患的感染率較高的試驗是引人注意的,這樣試驗結果產生了發炎角色的假說;這是刺激的,但是因為這是來自於單一中心的回顧性分析,因此我們無法下任何結論。
  
  儘管如此,沒有參與這項試驗的Coopersmith醫師表示,回答這個問題最好的方式是進行有關於這項課題的前瞻性試驗,在感染與中風之間是否有交易存在呢?如果存活率沒有顯著差異的話,那大部分人的選擇可能會是冒感染的風險,而不是中風。

Off-Pump CABG Shortens Length<

By Peggy Peck
Medscape Medical News

Jan. 18, 2005 (Phoenix) — Off-pump coronary artery bypass graft (CABG) surgery can shorten hospitalization time, but may increase the risk of mediastinal infection, according to the results of a retrospective study reported here at the 34th Critical Care Congress of the Society of Critical Care Medicine (SCCM).

John A. Kellum, MD, an associate professor at the University of Pittsburgh and senior author of the study, told Medscape that "it may be possible that the traditional CABG surgery triggers a greater inflammatory response and that increased response may actually be protective in terms of infection." Additional work by his group found a significant difference in cytokine levels in traditional CABG surgery patients compared with those who undergo off-pump surgery, he said.

In this study, there was roughly a fivefold increase in infection among patients who had off-pump surgery — a 10.2% infection rate — compared with the 2.3% infection rate in patients who had traditional CABG surgery (P < .03).

Dr. Kellum and colleagues retrospectively analyzed length of stay, stroke, infection, and mortality in 131 patients who underwent on-pump CABG surgery and 78 patients who underwent off-pump CABG surgery. All procedures were done at the same community hospital.

Off-pump surgery did significantly decrease length of stay, which averaged more than a day shorter (3.24 days) compared 4.56 days for on-pump surgery (P < .001). Asked why length of stay was shorter in a cohort with more infections, Dr. Kellum said, "The absolute number of infections was actually very low so the number of infections didn't contribute to [length of stay]."

Dr. Kellum said that he and his colleagues designed the study to determine if off-pump surgery was associated with fewer strokes. "The findings support our hypothesis: there were no strokes in the off-pump patients and a 7.6% stroke rate among patients in the on-pump CABG group," he said. That difference was significant (P < .03).

There were no deaths in the off-pump group, while the mortality rate in the on-pump arm was 1.5%, but this was not a statistically significant difference.

There were no significant differences between the surgical teams performing the procedures, and the patients in both groups were demographically well matched. The average age of patients was 68 years in the on-pump group and 67 years in the off-pump group. The mean number of grafts was three in both groups. The patients were also well-matched for incidence of risk factors, including diabetes, hypertension, hyperlipidemia, obesity, smoking, renal insufficiency, and family history.

Craig M. Coopersmith, MD, an associate professor of surgery and anesthesia at Washington University School of Medicine in St. Louis and cochairman of the SCCM Congress program committee, told Medscape that while the finding about increased infection rates among off-pump surgery patients is interesting, the study "can do no more than generate a hypothesis about the role of inflammation. It is provocative, but since it is a retrospective study from one center, we can't draw any conclusions."

Nonetheless, Dr. Coopersmith, who was not involved in the study, said that it would be useful to have a "study that prospectively answers the question: is there a trade-off between strokes and infections? If there is no difference in mortality, most people given the choice would probably chance an infection rather than a stroke."

SCCM 34th Critical Care Congress: Abstract 156. Presented Jan. 17, 2005.

Reviewed by Gary D. Vogin, MD

    
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