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Article(id=1320440974719964114, tenantId=1146029695717560320, journalId=1319373162502258839, issueId=1320440935603880850, articleNumber=null, orderNo=null, doi=10.16016/j.2097-0927.202512075, pmid=null, cstr=null, oa=null, hot=null, price=null, onlineType=0, articleFormat=0, articleType=null, articleTypeStr=null, receivedDate=1765641600000, receivedDateStr=2025-12-14, revisedDate=1767888000000, revisedDateStr=2026-01-09, acceptedDate=null, acceptedDateStr=null, onlineDate=1792747260980, onlineDateStr=2026-10-23, pubDate=1773504000000, pubDateStr=2026-03-15, doiRegisterDate=null, doiRegisterDateStr=null, onlineIssueDate=1792747260980, onlineIssueDateStr=2026-10-23, onlineJustAcceptDate=null, onlineJustAcceptDateStr=null, onlineFirstDate=null, onlineFirstDateStr=null, sourceXml=null, magXml=null, createTime=1792747260980, creator=13701087609, updateTime=1792747260980, updator=13701087609, issue=Issue{id=1320440935603880850, tenantId=1146029695717560320, journalId=1319373162502258839, year='2026', volume='48', issue='5', pageStart='523', pageEnd='662', issueExtLink='null', onlineDate='null', pubDate='1773504000000', pubDateStr='2026-03-15', beforeIssueId=null, nextIssueId=null, price=null, status=1, issueComplete=1, articleOrder=1, issueType=-1, specialIssue=null, createTime=1792747251654, creator='13701087609', updateTime=1792749737175, updator='13701087609', preIssue=null, nextIssue=null, articleTotal=null, ext={EN=IssueExt(id=1320451360810713528, tenantId=1146029695717560320, journalId=1319373162502258839, issueId=1320440935603880850, language=EN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=), CN=IssueExt(id=1320451360810713529, tenantId=1146029695717560320, journalId=1319373162502258839, issueId=1320440935603880850, language=CN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=)}, issueFiles=null, downloadFileDto=null}, startPage=600, endPage=610, ext={EN=ArticleExt(id=1320440975164560339, articleId=1320440974719964114, tenantId=1146029695717560320, journalId=1319373162502258839, language=EN, title=Incidence of postoperative pneumonia as high as 28.0% significantly increases the risk of mortality after acute type A aortic dissection: a multi-hospital retrospective cohort study, columnId=1320435174995772212, journalTitle=Journal of Army Medical University, columnName=Clinical Medicine, runingTitle=null, highlight=null, articleAbstract=
Objective

To analyze the incidence and related risk factors of postoperative pneumonia(POP) in patients with acute type A aortic dissection(ATAAD) after surgery.

Methods

A multi-hospital retrospective cohort study was conducted, consecutively enrolling 493 ATAAD patients who underwent surgical treatment at the Second Affiliated Hospital of Army Medical University, Affiliated Hospital of Southwest Medical University, and Chongqing Emergency Medical Center between January 2018 and December 2022. Clinical data were collected, including general characteristics, preoperative comorbidities, surgical indicators, and postoperative monitoring parameters. The participants were divided into a POP group (n=138) and a control group (n=355) based on POP occurrence. Univariate analysis was used to screen the risk variables related to the occurrence of POP(P<0.15), followed by multivariate logistic regression using forward, backward, and enter methods to identify the independent risk factors. Receiver operating characteristic(ROC) curve analysis was used to assess the predictive efficacy of continuous variables and determine optimal cut-off values.

Results

Among the 493 patients, the incidence of POP was 28.0%(138/493). The POP group exhibited significantly prolonged postoperative mechanical ventilation time(92.6±68.5 vs 45.3±32.8 h, P<0.001), length of intensive care unit(ICU) stay(156.8±88.3 vs 102.5±65.7 h, P<0.001), and length of total hospitalization stay(27.3±14.6 vs 19.8±10.2 d, P<0.001), along with significantly higher in-hospital mortality(18.8% vs 7.9%, P<0.001) when compared with the control group. Multivariate logistic regression analysis identified preoperative chronic obstructive pulmonary disease(COPD)(OR=2.447, 95%CI: 1.191 to 5.026, P=0.015), history of aspiration pneumonia(OR=2.282, 95%CI: 0.992 to 5.246, P=0.052), mechanical ventilation duration ≥68 h(OR=3.619, 95%CI: 1.963 to 6.672, P<0.001), red blood cell transfusion volume≥10 U(OR=1.984, 95%CI: 1.113 to 3.536, P=0.020), intraoperative peak blood glucose ≥11 mmol/L(OR=2.134, 95%CI: 1.190 to 3.826, P=0.011), and postoperative 24 h total drainage ≥1 100 mL(OR=1.808, 95%CI: 1.032 to 3.169, P=0.039) as independent risk factors for POP in ATAAD patients. ROC curve analysis further validated the predictive efficacy of these continuous variables, with mechanical ventilation duration demonstrating an AUC value of 0.762(95%CI: 0.718 to 0.806), red blood cell transfusion a value of 0.682(95%CI: 0.632 to 0.732), intraoperative peak blood glucose a value of 0.658(95%CI: 0.606 to 0.710), and postoperative 24 h drainage a value of 0.642(95%CI: 0.589 to 0.695).

Conclusion

The incidence of POP in ATAAD patients is as high as 28.0%, significantly increasing the mortality and hospital stay. Individualized preventive strategies targeting preoperative COPD, aspiration pneumonia history, prolonged mechanical ventilation, massive red blood cell transfusion, intraoperative hyperglycemia, and early postoperative high-volume drainage may reduce the incidence of POP and improve the prognosis of patients.

, authors=Guiqiang HAO1, Wanqiu FAN1, Dukun ZUO1, Minlin CHEN1, Jian ZHAN2, Hong FU3, Guiying YANG1, Hong LI1, authorsList=Guiqiang HAO, Wanqiu FAN, Dukun ZUO, Minlin CHEN, Jian ZHAN, Hong FU, Guiying YANG, Hong LI, authorCompany=null, correspAuthors=Hong LI, authorNote=null, correspAuthorsNote=null, copyrightStatement=© 2026 Journal of Army Medical University, copyrightOwner=Editorial Office of Journal of Army Medical University, extLink=null, articleAbsUrl=null, sourceXml=null, magXml=null, pdfUrl=null, pdf=null, pdfFileSize=null, pdfExtLink=null, richHtmlUrl=null, mobilePdfUrl=null, reviewReport=null, pdfFirstPage=null, abstractGraph=null, abstractGraphContent=null, abstractVideo=null, citation=null, cebUrl=null, magXmlContent=null, mapNumber=null, fund=null), CN=ArticleExt(id=1320440977978938326, articleId=1320440974719964114, tenantId=1146029695717560320, journalId=1319373162502258839, language=CN, title=急性A型主动脉夹层术后肺炎发生率高达28.0%并显著增加死亡风险：一项多医院回顾性队列研究, columnId=1320435175822050102, journalTitle=陆军军医大学学报, columnName=论著·临床医学, runingTitle=null, highlight=null, articleAbstract=
目的

分析急性A型主动脉夹层（acute type A aortic dissection， ATAAD）患者术后肺炎（postoperative pneumonia，POP）的发生率及相关危险因素。

方法

采用多医院回顾性队列研究设计，连续纳入2018年1月至2022年12月在陆军军医大学第二附属医院、西南医科大学附属医院、重庆市急救医疗中心麻醉科接受ATAAD手术治疗的493例患者。收集患者一般资料、术前合并症、手术相关指标、术后监测数据等。根据是否发生POP，将患者分为POP组（n=138）和对照组（n=355），比较2组各项指标。采用单因素分析筛选与POP发生相关的危险变量（P<0.15），进而通过前进法、后退法和Enter法进行多因素Logistic回归分析，确定独立危险因素。通过受试者工作特征（receiver operating characteristic，ROC）评估连续变量的预测效能并确定最佳截断值。

结果

493例患者中，POP发生率为28.0%（138/493）。与对照组相比，POP组患者的术后机械通气时间［（92.6±68.5） h vs （45.3±32.8） h， P<0.001］、重症监护病房（intensive care unit，ICU）停留时间［（156.8±88.3） h vs （102.5±65.7） h， P<0.001］、住院天数［（27.3±14.6） d vs （19.8±10.2） d， P<0.001］均显著延长，且院内死亡率显著升高（18.8% vs 7.9%， P<0.001）。多因素Logistic回归分析显示，术前合并慢性阻塞性肺疾病（chronic obstructive pulmonary disease， COPD）（OR=2.447， 95% CI： 1.191~5.026， P=0.015）、吸入性肺炎史（OR=2.282， 95%CI： 0.992~5.246， P=0.052）、机械通气时间≥68 h（OR=3.619， 95%CI： 1.963~6.672， P<0.001）、红细胞输注量≥10 U（OR=1.984，95%CI：1.113~3.536，P=0.020）、术中最高血糖≥11 mmol/L（OR=2.134， 95%CI： 1.190~3.826， P=0.011）以及术后24 h总引流量≥1 100 mL（OR=1.808， 95%CI： 1.032~3.169， P=0.039）是ATAAD患者POP的独立危险因素。ROC曲线分析进一步验证了上述连续变量预测POP的效能，其中机械通气时间预测POP的曲线下面积（area under curve， AUC）为0.762（95%CI：0.718~0.806），红细胞输注量的AUC为0.682（95%CI：0.632~0.732），术中最高血糖的AUC为0.658（95%CI：0.606~0.710），术后24 h总引流量的AUC为0.642（95%CI：0.589~0.695）。

结论

ATAAD患者POP发生率高达28.0%，显著增加其病死率和住院时间。针对术前合并COPD、吸入性肺炎史、长时间机械通气、大量红细胞输注管理、术中高血糖以及术后早期大量引流等危险因素制定个体化预防策略，有望降低POP发生率，改善患者预后。

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李洪，E-mail：
LI Hong， E-mail：
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Crit Care Med， 2010， 38（8Suppl）： S352-S362., articleTitle=Recognition and prevention of nosocomial pneumonia in the intensive care unit and infection control in mechanical ventilation, refAbstract=null)], funds=null, companyList=[AuthorCompany(id=1320440978448700375, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1320440974719964114, xref=1, ext=[AuthorCompanyExt(id=1320440978457088984, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1320440974719964114, companyId=1320440978448700375, language=EN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=1Department of Anesthesiology， Second Affiliated Hospital， Army Medical University（Third Military Medical University）， Chongqing), AuthorCompanyExt(id=1320440978465477593, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1320440974719964114, companyId=1320440978448700375, language=CN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=1陆军军医大学（第三军医大学）第二附属医院麻醉科，重庆)]), AuthorCompany(id=1320440978545169370, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1320440974719964114, xref=2, ext=[AuthorCompanyExt(id=1320440978553557979, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1320440974719964114, companyId=1320440978545169370, language=EN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=2Department of Anesthsiology， The Affiliated Hospital of Southwest Medical University， Luzhou， Sichuan), AuthorCompanyExt(id=1320440978566140892, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1320440974719964114, companyId=1320440978545169370, language=CN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=2西南医科大学附属医院麻醉科，四川 泸州)]), AuthorCompany(id=1320440978801021917, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1320440974719964114, xref=3, ext=[AuthorCompanyExt(id=1320440978813604830, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1320440974719964114, companyId=1320440978801021917, language=EN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=3Department of Anesthsiology， Chongqing Emergency Medical Center， Chongqing， China), AuthorCompanyExt(id=1320440978821993439, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1320440974719964114, companyId=1320440978801021917, language=CN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=3重庆市急救医疗中心麻醉科，重庆)])], figs=[ArticleFig(id=1320440992256348179, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1320440974719964114, language=EN, label=Figure 1, caption=ROC curves for each indicator in predicting POP, figureFileSmall=ZKYw4fS3jcrzisyQtGaN4g==, figureFileBig=u40k0Z8miEq7ln60Xce0zQ==, tableContent=null), ArticleFig(id=1320440992713527316, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1320440974719964114, language=CN, label=图1, caption=各指标预测POP的ROC曲线

POP： Postoperative pneumonia

, figureFileSmall=ZKYw4fS3jcrzisyQtGaN4g==, figureFileBig=u40k0Z8miEq7ln60Xce0zQ==, tableContent=null), ArticleFig(id=1320440993581748245, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1320440974719964114, language=EN, label=Table 1, caption=

Comparison of general data between groups ［n（%），x¯±s］

, figureFileSmall=null, figureFileBig=null, tableContent=
VariablePOP Group（n=138）Control Group（n=355）χ²/tP
Age/years51.8±11.550.2±10.91.4520.147
Male106（76.8）259（73.0）0.8760.349
BMI/（kg/m²）26.3±3.825.7±3.51.6580.098
ASA classification Ⅲ~Ⅳ102（73.9）224（63.1）5.3420.021
Preoperative diabetes38（27.5）62（17.5）6.5470.011
Preoperative COPD31（22.5）45（12.7）7.8920.005
History of aspiration pneumonia22（15.9）28（7.9）7.3480.007
Left ventricular ejection fraction55.7±9.358.1±7.8-2.8630.004
History of trauma18（13.0）35（9.9）1.1650.280
), ArticleFig(id=1320440993871155222, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1320440974719964114, language=CN, label=表1, caption=

2组患者一般资料比较［例（%），x¯±s］

, figureFileSmall=null, figureFileBig=null, tableContent=
VariablePOP Group（n=138）Control Group（n=355）χ²/tP
Age/years51.8±11.550.2±10.91.4520.147
Male106（76.8）259（73.0）0.8760.349
BMI/（kg/m²）26.3±3.825.7±3.51.6580.098
ASA classification Ⅲ~Ⅳ102（73.9）224（63.1）5.3420.021
Preoperative diabetes38（27.5）62（17.5）6.5470.011
Preoperative COPD31（22.5）45（12.7）7.8920.005
History of aspiration pneumonia22（15.9）28（7.9）7.3480.007
Left ventricular ejection fraction55.7±9.358.1±7.8-2.8630.004
History of trauma18（13.0）35（9.9）1.1650.280
), ArticleFig(id=1320440994319945751, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1320440974719964114, language=EN, label=Table 2, caption=

Comparison of surgical and perioperative factors between groups ［n（%），x¯±s］

, figureFileSmall=null, figureFileBig=null, tableContent=
VariablePOP Group（n=138）Control Group（n=355）χ²/tP
Time from onset to surgery/h29.3±19.825.6±17.22.0150.045
Anesthesia time/h8.5±2.67.4±2.14.652<0.001
Emergency surgery98（71.0）218（61.4）4.2810.039
Aortic root replacement52（37.7）115（32.4）1.3420.247
Aortic arch replacement115（83.3）265（74.6）4.6580.031
Concomitant cardiac surgery56（40.6）108（30.4）5.0270.025
Red blood cell transfusion/U11.8±7.29.1±5.34.252<0.001
Fresh frozen plasma/mL1 625±9851 245±7384.368<0.001
Platelet transfusion/U2.6±1.72.0±1.43.825<0.001
Cryoprecipitate/U1.8±1.21.3±0.94.562<0.001
Albumin use118（85.5）248（69.9）13.758<0.001
), ArticleFig(id=1320440995750203416, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1320440974719964114, language=CN, label=表2, caption=

2组患者手术及围术期相关因素比较［例（%），x¯±s］

, figureFileSmall=null, figureFileBig=null, tableContent=
VariablePOP Group（n=138）Control Group（n=355）χ²/tP
Time from onset to surgery/h29.3±19.825.6±17.22.0150.045
Anesthesia time/h8.5±2.67.4±2.14.652<0.001
Emergency surgery98（71.0）218（61.4）4.2810.039
Aortic root replacement52（37.7）115（32.4）1.3420.247
Aortic arch replacement115（83.3）265（74.6）4.6580.031
Concomitant cardiac surgery56（40.6）108（30.4）5.0270.025
Red blood cell transfusion/U11.8±7.29.1±5.34.252<0.001
Fresh frozen plasma/mL1 625±9851 245±7384.368<0.001
Platelet transfusion/U2.6±1.72.0±1.43.825<0.001
Cryoprecipitate/U1.8±1.21.3±0.94.562<0.001
Albumin use118（85.5）248（69.9）13.758<0.001
), ArticleFig(id=1320440996064776217, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1320440974719964114, language=EN, label=Table 3, caption=

Comparison of postoperative indicators and clinical outcomes between groups ［n（%），x¯±s］

, figureFileSmall=null, figureFileBig=null, tableContent=
VariablePOP Group（n=138）Control Group（n=355）χ²/tP
Duration of mechanical ventilation/h92.6±68.545.3±32.88.452<0.001
Chest tube drainage in 24 h/mL658±342512±2854.652<0.001
Mediastinal drainage in 24 h/mL415±206328±1784.582<0.001
Pericardial drainage in 24 h/mL128±92105±732.7520.006
Total drainage in 24 h/mL1 201±562945±4864.852<0.001
Postoperative ICU stay/h156.8±88.3102.5±65.76.825<0.001
Length of hospital stay/d27.3±14.619.8±10.25.982<0.001
Spinal cord injury12（8.7）15（4.2）4.1250.042
Chylothorax18（13.0）22（6.2）6.5820.010
Deep vein thrombosis10（7.2）10（2.8）4.6580.031
Gastrointestinal bleeding13（9.4）16（4.5）4.3580.037
In-hospital mortality26（18.8）28（7.9）13.852<0.001
Hospitalization cost（10 000 CNY）38.5±12.832.6±9.55.125<0.001
), ArticleFig(id=1320440996450652186, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1320440974719964114, language=CN, label=表3, caption=

2组患者术后指标及临床结局比较［例（%），x¯±s］

, figureFileSmall=null, figureFileBig=null, tableContent=
VariablePOP Group（n=138）Control Group（n=355）χ²/tP
Duration of mechanical ventilation/h92.6±68.545.3±32.88.452<0.001
Chest tube drainage in 24 h/mL658±342512±2854.652<0.001
Mediastinal drainage in 24 h/mL415±206328±1784.582<0.001
Pericardial drainage in 24 h/mL128±92105±732.7520.006
Total drainage in 24 h/mL1 201±562945±4864.852<0.001
Postoperative ICU stay/h156.8±88.3102.5±65.76.825<0.001
Length of hospital stay/d27.3±14.619.8±10.25.982<0.001
Spinal cord injury12（8.7）15（4.2）4.1250.042
Chylothorax18（13.0）22（6.2）6.5820.010
Deep vein thrombosis10（7.2）10（2.8）4.6580.031
Gastrointestinal bleeding13（9.4）16（4.5）4.3580.037
In-hospital mortality26（18.8）28（7.9）13.852<0.001
Hospitalization cost（10 000 CNY）38.5±12.832.6±9.55.125<0.001
), ArticleFig(id=1320440996601647131, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1320440974719964114, language=EN, label=Table 4, caption=

Comparison of glycemic related indicators between groups (x¯±s)

, figureFileSmall=null, figureFileBig=null, tableContent=
Variable/（mmol/L）POP Group（n=138）Control Group（n=355）tP
Last preoperative blood glucose8.6±3.57.5±2.43.652<0.001
Intraoperative maximum blood glucose12.5±4.810.5±3.64.652<0.001
Postoperative day 1 blood glucose11.8±4.29.7±3.15.625<0.001
Postoperative day 2 blood glucose10.5±3.88.9±2.94.658<0.001
Postoperative day 3 blood glucose9.8±3.28.2±2.65.325<0.001
Postoperative maximum blood glucose13.8±5.311.5±4.14.852<0.001
), ArticleFig(id=1320440996735864860, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1320440974719964114, language=CN, label=表4, caption=

2组患者血糖相关指标比较（x¯±s)

, figureFileSmall=null, figureFileBig=null, tableContent=
Variable/（mmol/L）POP Group（n=138）Control Group（n=355）tP
Last preoperative blood glucose8.6±3.57.5±2.43.652<0.001
Intraoperative maximum blood glucose12.5±4.810.5±3.64.652<0.001
Postoperative day 1 blood glucose11.8±4.29.7±3.15.625<0.001
Postoperative day 2 blood glucose10.5±3.88.9±2.94.658<0.001
Postoperative day 3 blood glucose9.8±3.28.2±2.65.325<0.001
Postoperative maximum blood glucose13.8±5.311.5±4.14.852<0.001
), ArticleFig(id=1320440996924608541, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1320440974719964114, language=EN, label=Table 5, caption=

Potential risk factors associated with POP in univariate analysis ［n（%），x¯±s］

, figureFileSmall=null, figureFileBig=null, tableContent=
VariablePOP group（n=138）Control group（n=355）χ²/tP
Preoperative comorbidities and baseline status
Preoperative diabetes38（27.5）62（17.5）6.5470.011
Preoperative COPD31（22.5）45（12.7）7.8920.005
History of aspiration pneumonia22（15.9）28（7.9）7.3480.007
Left ventricular ejection fraction55.7±9.358.1±7.8-2.8630.004
Surgical factors
Time from onset to surgery/h29.3±19.825.6±17.22.0150.045
Emergency surgery98（71.0）218（61.4）4.2810.039
Aortic arch replacement115（83.3）265（74.6）4.6580.031
Concomitant cardiac surgery56（40.6）108（30.4）5.0270.025
Anesthesia time/h8.5±2.67.4±2.14.652<0.001
Red blood cell transfusion/U11.8±7.29.1±5.34.252<0.001
Fresh frozen plasma transfusion/mL1 625±9851 245±7384.368<0.001
Platelet transfusion/U2.6±1.72.0±1.43.825<0.001
Cryoprecipitate transfusion/U1.8±1.21.3±0.94.562<0.001
Albumin use118（85.5）248（69.9）13.758<0.001
Postoperative indicators
Duration of mechanical ventilation/h92.6±68.545.3±32.88.452<0.001
Total drainage in 24 h/mL1 201±562945±4864.852<0.001
Glycemic parameters
Last preoperative blood glucose/（mmol/L）8.6±3.57.5±2.43.652<0.001
Intraoperative maximum blood glucose/（mmol/L）12.5±4.810.5±3.64.652<0.001
Postoperative maximum blood glucose/（mmol/L）13.8±5.311.5±4.14.852<0.001
), ArticleFig(id=1320440997130129438, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1320440974719964114, language=CN, label=表5, caption=

单因素分析中与POP相关的潜在危险因素［例（%），x¯±s］

, figureFileSmall=null, figureFileBig=null, tableContent=
VariablePOP group（n=138）Control group（n=355）χ²/tP
Preoperative comorbidities and baseline status
Preoperative diabetes38（27.5）62（17.5）6.5470.011
Preoperative COPD31（22.5）45（12.7）7.8920.005
History of aspiration pneumonia22（15.9）28（7.9）7.3480.007
Left ventricular ejection fraction55.7±9.358.1±7.8-2.8630.004
Surgical factors
Time from onset to surgery/h29.3±19.825.6±17.22.0150.045
Emergency surgery98（71.0）218（61.4）4.2810.039
Aortic arch replacement115（83.3）265（74.6）4.6580.031
Concomitant cardiac surgery56（40.6）108（30.4）5.0270.025
Anesthesia time/h8.5±2.67.4±2.14.652<0.001
Red blood cell transfusion/U11.8±7.29.1±5.34.252<0.001
Fresh frozen plasma transfusion/mL1 625±9851 245±7384.368<0.001
Platelet transfusion/U2.6±1.72.0±1.43.825<0.001
Cryoprecipitate transfusion/U1.8±1.21.3±0.94.562<0.001
Albumin use118（85.5）248（69.9）13.758<0.001
Postoperative indicators
Duration of mechanical ventilation/h92.6±68.545.3±32.88.452<0.001
Total drainage in 24 h/mL1 201±562945±4864.852<0.001
Glycemic parameters
Last preoperative blood glucose/（mmol/L）8.6±3.57.5±2.43.652<0.001
Intraoperative maximum blood glucose/（mmol/L）12.5±4.810.5±3.64.652<0.001
Postoperative maximum blood glucose/（mmol/L）13.8±5.311.5±4.14.852<0.001
), ArticleFig(id=1320440997516005408, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1320440974719964114, language=EN, label=Table 6, caption=

Multivariate Logistic regression analysis of risk factors for POP

, figureFileSmall=null, figureFileBig=null, tableContent=
VariableForward method
OR（95%CI）		PBackward method
OR（95%CI）		Enter method
OR（95%CI）
Preoperative COPD2.447（1.191~5.026）0.0152.398（1.165~4.938）2.421（1.176~4.987）
History of aspiration pneumonia2.282（0.992~5.246）0.0522.245（0.976~5.165）2.263（0.984~5.206）
Duration of mechanical ventilation ≥68 h3.619（1.963~6.672）<0.0013.587（1.942~6.625）3.603（1.953~6.648）
Red blood cell transfusion ≥10 U1.984（1.113~3.536）0.0201.952（1.095~3.482）1.968（1.104~3.509）
Intraoperative maximum blood glucose ≥11 mmol/L2.134（1.190~3.826）0.0112.109（1.175~3.785）2.121（1.182~3.805）
Total drainage in 24h ≥1 100 mL1.808（1.032~3.169）0.0391.785（1.018~3.132）1.796（1.025~3.150）
), ArticleFig(id=1320440997759275041, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1320440974719964114, language=CN, label=表6, caption=

POP危险因素的多因素Logistic回归分析

, figureFileSmall=null, figureFileBig=null, tableContent=
VariableForward method
OR（95%CI）		PBackward method
OR（95%CI）		Enter method
OR（95%CI）
Preoperative COPD2.447（1.191~5.026）0.0152.398（1.165~4.938）2.421（1.176~4.987）
History of aspiration pneumonia2.282（0.992~5.246）0.0522.245（0.976~5.165）2.263（0.984~5.206）
Duration of mechanical ventilation ≥68 h3.619（1.963~6.672）<0.0013.587（1.942~6.625）3.603（1.953~6.648）
Red blood cell transfusion ≥10 U1.984（1.113~3.536）0.0201.952（1.095~3.482）1.968（1.104~3.509）
Intraoperative maximum blood glucose ≥11 mmol/L2.134（1.190~3.826）0.0112.109（1.175~3.785）2.121（1.182~3.805）
Total drainage in 24h ≥1 100 mL1.808（1.032~3.169）0.0391.785（1.018~3.132）1.796（1.025~3.150）
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急性A型主动脉夹层术后肺炎发生率高达28.0%并显著增加死亡风险：一项多医院回顾性队列研究
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郝贵强 1 , 范婉秋 1 , 左都坤 1 , 陈敏琳 1 , 詹剑 2 , 傅洪 3 , 杨贵英 1 , 李洪 1
陆军军医大学学报 | 论著·临床医学 2026,48(5): 600-610
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陆军军医大学学报 |论著·临床医学 2026 , 48 (5) : 600 -610
急性A型主动脉夹层术后肺炎发生率高达28.0%并显著增加死亡风险：一项多医院回顾性队列研究
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郝贵强1, 范婉秋1, 左都坤1, 陈敏琳1, 詹剑2, 傅洪3, 杨贵英1, 李洪1
作者信息
  • 1陆军军医大学（第三军医大学）第二附属医院麻醉科，重庆
  • 2西南医科大学附属医院麻醉科，四川 泸州
  • 3重庆市急救医疗中心麻醉科，重庆
通讯作者:
李洪，E-mail：
LI Hong， E-mail：
Incidence of postoperative pneumonia as high as 28.0% significantly increases the risk of mortality after acute type A aortic dissection: a multi-hospital retrospective cohort study
Guiqiang HAO1, Wanqiu FAN1, Dukun ZUO1, Minlin CHEN1, Jian ZHAN2, Hong FU3, Guiying YANG1, Hong LI1
Affiliations
  • 1Department of Anesthesiology， Second Affiliated Hospital， Army Medical University（Third Military Medical University）， Chongqing
  • 2Department of Anesthsiology， The Affiliated Hospital of Southwest Medical University， Luzhou， Sichuan
  • 3Department of Anesthsiology， Chongqing Emergency Medical Center， Chongqing， China
出版时间: 2026-03-15 doi: 10.16016/j.2097-0927.202512075
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摘要
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目的

分析急性A型主动脉夹层（acute type A aortic dissection， ATAAD）患者术后肺炎（postoperative pneumonia，POP）的发生率及相关危险因素。

方法

采用多医院回顾性队列研究设计，连续纳入2018年1月至2022年12月在陆军军医大学第二附属医院、西南医科大学附属医院、重庆市急救医疗中心麻醉科接受ATAAD手术治疗的493例患者。收集患者一般资料、术前合并症、手术相关指标、术后监测数据等。根据是否发生POP，将患者分为POP组（n=138）和对照组（n=355），比较2组各项指标。采用单因素分析筛选与POP发生相关的危险变量（P<0.15），进而通过前进法、后退法和Enter法进行多因素Logistic回归分析，确定独立危险因素。通过受试者工作特征（receiver operating characteristic，ROC）评估连续变量的预测效能并确定最佳截断值。

结果

493例患者中，POP发生率为28.0%（138/493）。与对照组相比，POP组患者的术后机械通气时间［（92.6±68.5） h vs （45.3±32.8） h， P<0.001］、重症监护病房（intensive care unit，ICU）停留时间［（156.8±88.3） h vs （102.5±65.7） h， P<0.001］、住院天数［（27.3±14.6） d vs （19.8±10.2） d， P<0.001］均显著延长，且院内死亡率显著升高（18.8% vs 7.9%， P<0.001）。多因素Logistic回归分析显示，术前合并慢性阻塞性肺疾病（chronic obstructive pulmonary disease， COPD）（OR=2.447， 95% CI： 1.191~5.026， P=0.015）、吸入性肺炎史（OR=2.282， 95%CI： 0.992~5.246， P=0.052）、机械通气时间≥68 h（OR=3.619， 95%CI： 1.963~6.672， P<0.001）、红细胞输注量≥10 U（OR=1.984，95%CI：1.113~3.536，P=0.020）、术中最高血糖≥11 mmol/L（OR=2.134， 95%CI： 1.190~3.826， P=0.011）以及术后24 h总引流量≥1 100 mL（OR=1.808， 95%CI： 1.032~3.169， P=0.039）是ATAAD患者POP的独立危险因素。ROC曲线分析进一步验证了上述连续变量预测POP的效能，其中机械通气时间预测POP的曲线下面积（area under curve， AUC）为0.762（95%CI：0.718~0.806），红细胞输注量的AUC为0.682（95%CI：0.632~0.732），术中最高血糖的AUC为0.658（95%CI：0.606~0.710），术后24 h总引流量的AUC为0.642（95%CI：0.589~0.695）。

结论

ATAAD患者POP发生率高达28.0%，显著增加其病死率和住院时间。针对术前合并COPD、吸入性肺炎史、长时间机械通气、大量红细胞输注管理、术中高血糖以及术后早期大量引流等危险因素制定个体化预防策略，有望降低POP发生率，改善患者预后。

主动脉夹层  /  肺炎  /  术后并发症  /  发生率  /  风险因素
Objective

To analyze the incidence and related risk factors of postoperative pneumonia(POP) in patients with acute type A aortic dissection(ATAAD) after surgery.

Methods

A multi-hospital retrospective cohort study was conducted, consecutively enrolling 493 ATAAD patients who underwent surgical treatment at the Second Affiliated Hospital of Army Medical University, Affiliated Hospital of Southwest Medical University, and Chongqing Emergency Medical Center between January 2018 and December 2022. Clinical data were collected, including general characteristics, preoperative comorbidities, surgical indicators, and postoperative monitoring parameters. The participants were divided into a POP group (n=138) and a control group (n=355) based on POP occurrence. Univariate analysis was used to screen the risk variables related to the occurrence of POP(P<0.15), followed by multivariate logistic regression using forward, backward, and enter methods to identify the independent risk factors. Receiver operating characteristic(ROC) curve analysis was used to assess the predictive efficacy of continuous variables and determine optimal cut-off values.

Results

Among the 493 patients, the incidence of POP was 28.0%(138/493). The POP group exhibited significantly prolonged postoperative mechanical ventilation time(92.6±68.5 vs 45.3±32.8 h, P<0.001), length of intensive care unit(ICU) stay(156.8±88.3 vs 102.5±65.7 h, P<0.001), and length of total hospitalization stay(27.3±14.6 vs 19.8±10.2 d, P<0.001), along with significantly higher in-hospital mortality(18.8% vs 7.9%, P<0.001) when compared with the control group. Multivariate logistic regression analysis identified preoperative chronic obstructive pulmonary disease(COPD)(OR=2.447, 95%CI: 1.191 to 5.026, P=0.015), history of aspiration pneumonia(OR=2.282, 95%CI: 0.992 to 5.246, P=0.052), mechanical ventilation duration ≥68 h(OR=3.619, 95%CI: 1.963 to 6.672, P<0.001), red blood cell transfusion volume≥10 U(OR=1.984, 95%CI: 1.113 to 3.536, P=0.020), intraoperative peak blood glucose ≥11 mmol/L(OR=2.134, 95%CI: 1.190 to 3.826, P=0.011), and postoperative 24 h total drainage ≥1 100 mL(OR=1.808, 95%CI: 1.032 to 3.169, P=0.039) as independent risk factors for POP in ATAAD patients. ROC curve analysis further validated the predictive efficacy of these continuous variables, with mechanical ventilation duration demonstrating an AUC value of 0.762(95%CI: 0.718 to 0.806), red blood cell transfusion a value of 0.682(95%CI: 0.632 to 0.732), intraoperative peak blood glucose a value of 0.658(95%CI: 0.606 to 0.710), and postoperative 24 h drainage a value of 0.642(95%CI: 0.589 to 0.695).

Conclusion

The incidence of POP in ATAAD patients is as high as 28.0%, significantly increasing the mortality and hospital stay. Individualized preventive strategies targeting preoperative COPD, aspiration pneumonia history, prolonged mechanical ventilation, massive red blood cell transfusion, intraoperative hyperglycemia, and early postoperative high-volume drainage may reduce the incidence of POP and improve the prognosis of patients.

aortic dissection  /  pneumonia  /  postoperative complications  /  incidence  /  risk factors
郝贵强, 范婉秋, 左都坤, 陈敏琳, 詹剑, 傅洪, 杨贵英, 李洪. 急性A型主动脉夹层术后肺炎发生率高达28.0%并显著增加死亡风险：一项多医院回顾性队列研究. 陆军军医大学学报, 2026 , 48 (5) : 600 -610 . DOI: 10.16016/j.2097-0927.202512075
Guiqiang HAO, Wanqiu FAN, Dukun ZUO, Minlin CHEN, Jian ZHAN, Hong FU, Guiying YANG, Hong LI. Incidence of postoperative pneumonia as high as 28.0% significantly increases the risk of mortality after acute type A aortic dissection: a multi-hospital retrospective cohort study[J]. Journal of Army Medical University, 2026 , 48 (5) : 600 -610 . DOI: 10.16016/j.2097-0927.202512075
正文
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急性A型主动脉夹层（acute type A aortic dissection，ATAAD）是一种危及生命的心血管急症，其特点为主动脉内膜撕裂，血液进入主动脉壁中层，形成真假腔，累及升主动脉部分。根据国际主动脉夹层注册研究（International Registry of Acute Aortic Dissection，IRAD）数据，未经手术治疗的ATAAD患者48 h死亡率约为23.7%［1］。目前，紧急手术仍是ATAAD治疗的金标准。然而，尽管手术技术和围术期管理不断进步，ATAAD术后并发症发生率仍居高不下，其中术后肺炎（postoperative pneumonia，POP）是最常见的术后并发症之一，发生率约为25.0%［2-3］。
ATAAD手术具有特殊性，包括深低温停循环（deep hypothermic circulatory arrest，DHCA）、长时间体外循环（cardiopulmonary bypass，CPB）、术中大量输血及液体复苏等，这些因素都可能增加术后肺部并发症风险［4］。研究表明，POP不仅显著延长患者机械通气时间、重症监护病房（intensive care unit，ICU）停留时间及住院天数，还增加医疗成本，甚至显著增加患者院内死亡风险［5-6］。
尽管近年来国内外对心脏手术后肺炎的研究较多，但针对ATAAD这一特殊人群的研究相对缺乏，且各研究结论存在一定差异［2，7］。虽然慢性阻塞性肺疾病（chronic obstructive pulmonary disease，COPD）、高血糖、输血等因素在常规心脏手术中已被确认为危险因素，但这些因素在ATAAD患者中的具体作用及影响程度尚需进一步验证。鉴于ATAAD术后肺炎的高发生率及严重后果，明确其危险因素对指导临床预防和治疗具有重要意义。
因此，本研究旨在分析ATAAD患者术后肺炎的发生率及相关危险因素，从而为制定这些患者的个体化预防策略提供依据。
1　对象与方法
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1.1　研究设计与研究对象
本研究采用多医院回顾性队列研究设计方案，纳入2018年1月至2022年12月在陆军军医大学第二附属医院、西南医科大学附属医院、重庆市急救医疗中心麻醉科接受ATAAD手术治疗的患者。3家医院分别纳入205例（41.6%）、168例（34.1%）和120例（24.3%），共计493例。根据是否发生POP，将患者分为POP组（n=138）与对照组（n=355）。本研究分别经陆军军医大学第二附属医院伦理委员会（2024-研第257-01）、西南医科大学附属医院伦理委员会（KY2025714）、重庆市急救医疗中心伦理委员会［2026年伦审第（11号）］批准，由于研究为回顾性分析，免除知情同意。
1.2　诊断标准
ATAAD诊断标准参照《2014年欧洲心脏病学会主动脉疾病诊断和治疗指南》［8］。所有患者均经计算机断层扫描血管造影（computed tomography angiography，CTA）确诊为ATAAD。
POP诊断标准根据美国疾病控制与预防中心（Centers for Disease Control and Prevention，CDC）医院获得性肺炎诊断标准及中国《医院感染诊断标准》，定义为术后新发肺部感染，需同时满足以下条件：①术后新出现或原有肺部浸润影加重；②至少具备以下临床表现之一：发热（>38 ℃）、白细胞计数增高（>10×109/L）或降低（<4×109/L）、新发脓性痰液；③微生物学检查阳性：痰培养、支气管肺泡灌洗液培养或血培养阳性。所有肺炎诊断均由2名高年资感染科医师独立判断，意见不一致时由第3位专家决定。
“吸入性肺炎史”的诊断基于以下标准：患者既往有明确的吸入事件（如呕吐物、食物或液体误吸）史，并有医疗记录证实的临床症状（咳嗽、呼吸困难、发热）和影像学证据（胸部X线或CT显示肺部浸润影，通常为双肺下叶或右肺为主的斑片状、片状阴影），同时排除其他原因引起的肺炎。
1.3　纳入与排除标准
纳入标准：①年龄≥18岁；②发病至手术时间≤14 d；③行ATAAD手术治疗。
排除标准：①术前已确诊肺炎或其他活动性感染；②术前已气管插管；③围术期（术后48 h内）死亡；④围术期资料不完整。
1.4　资料收集
收集患者一般资料，包括年龄、性别、体质量指数（body mass index，BMI）、美国麻醉医师学会（American Society of Anesthesiologists， ASA）身体状况分级、吸入性肺炎史、左心室射血分数、创伤史、术前合并症（糖尿病、COPD）。手术相关指标（发病到手术时间、麻醉时间、是否为急诊手术、手术类型、是否伴随其他心脏手术、红细胞输注、血浆输注、血小板输注、冷沉淀输注、白蛋白使用等）。术后监测指标（机械通气时间、ICU停留时间、住院时间）。术后引流（术后24 h胸腔、纵隔、心包及总引流量）。临床结局（院内死亡、其他并发症、住院费用等）。血糖水平（术前最后一次血糖、术中最高血糖、术后第1、2、3天血糖、术后最高血糖）。其中，“术后24 h总引流量”是指患者术后第1个24 h内胸腔引流管、纵隔引流管及心包引流管的引流液总量。引流量由ICU护理团队每小时记录1次，通过标准化引流瓶进行精确测量，每班交接时进行核对确认，以确保数据的准确性和可靠性。“术中最高血糖”由麻醉医师每隔30~60 min进行1次动脉血或指尖血糖监测，并记录整个手术期间测得的最高血糖值。对于糖尿病或高血糖患者，监测频率可增至每30分钟1次，对血糖超过10 mmol/L的患者予以胰岛素治疗。“院内全因死亡率”定义为患者从入院至出院期间因任何原因导致的死亡。
通过提取病历记录收集患者主要结局指标与次要结局指标。主要结局指标为POP的发生率，次要结局包含机械通气时间、ICU停留时间、住院时间以及院内全因死亡率。
1.5　质量控制
为确保多医院数据的标准化和一致性，研究前制定了统一的数据收集表格和评估标准，并由专门培训的研究人员在各医院采用相同方法收集数据。所有实验室检查均采用各医院标准化方法进行，3家医院定期进行室间质控，确保检测结果的可比性。患者诊断和手术方案由各医院主任级医师制定，手术操作和围术期管理遵循相同的临床路径。所有数据由2名研究人员独立收集并交叉核对，确保准确性。
1.6　围术期处理流程
所有患者入院后立即完成胸腹主动脉CTA检查，并行经胸超声心动图（transthoracic echocardiography，TTE）评估心功能及心包积液情况。术前准备包括建立有效静脉通路、动脉监测、控制血压、必要时行冠状动脉造影及床旁心肺功能评估。手术采用中位胸骨劈开，根据病变范围选择不同术式，包括Bentall手术、Sun’s手术、全弓置换术。所有患者均在体外循环下进行手术，采用深低温循环停止技术，脑灌注方式根据弓部累及情况选择单侧顺行脑灌注或双侧顺行脑灌注。术后转入心脏外科ICU，遵循标准化ICU管理流程，包括血流动力学监测、呼吸机辅助通气管理、镇静镇痛策略、早期拔管计划、血糖管理、营养支持及早期康复。
1.7　统计学分析
采用SPSS 26.0软件进行统计分析。计量资料根据正态性检验结果，符合正态分布的以x¯±s表示，组间比较采用独立样本t检验；不符合正态分布的以［M（P25，P75）］表示，组间比较采用Mann-Whitney U检验。计数资料以例（%）表示，组间比较采用χ²检验或Fisher精确概率法。
将单因素分析中P<0.15的变量纳入多因素Logistic回归分析［9-11］。多因素分析采用前进法、后退法和Enter法3种方式构建模型并比较结果稳定性，最终报告模型的优势比（odds ratio，OR）及95%置信区间（confidence interval，CI）。
对多因素分析中有统计学意义的连续变量，进行受试者工作特征（receiver operating characteristic，ROC）曲线分析，确定最佳截断值，计算曲线下面积（area under curve，AUC）、敏感度和特异度。同时，为验证分类后的模型效能，本研究将连续变量直接纳入模型进行ROC分析，比较两种方法的AUC差异。所有检验均为双侧检验，P<0.05视为差异有统计学意义。
2　结果
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2.1　ATAAD手术POP患者术前合并症负担更重、心功能更差
POP组患者ASA分级为Ⅲ~Ⅳ级比例显著高于对照组（73.9% vs 63.1%，P=0.021），提示术前状态较差可能增加术后肺炎风险。2组在BMI方面差异无统计学意义（26.3±3.8 vs 25.7±3.5，P=0.098），但POP组略高于对照组。术前合并症方面，POP组糖尿病（27.5% vs 17.5%，P=0.011）、COPD（22.5% vs 12.7%，P=0.005）及吸入性肺炎史（15.9% vs 7.9%，P=0.007）发生率均显著高于对照组，而左心室射血分数则显著低于对照组（55.7%±9.3% vs 58.1%±7.8%，P=0.004）。2组在年龄、性别及创伤史方面差异无统计学意义。见表1。
2.2　ATAAD手术POP患者手术创伤更重、输血更多
相比于对照组，POP组患者手术复杂性更高、手术时间更长、急诊手术比例更高、输血需求更大（P均<0.05），见表2。
2.3　ATAAD手术POP患者术后恢复显著延迟，院内死亡率显著升高
POP组患者术后机械通气时间［（92.6±68.5） h vs （45.3±32.8）h，P<0.001］、ICU停留时间［（156.8±88.3） h vs （102.5±65.7） h，P<0.001］、住院天数［（27.3±14.6） d vs （19.8±10.2） d，P<0.001］均明显长于对照组，院内死亡率显著升高（18.8% vs 7.9%，P<0.001），见表3。
2.4　ATAAD手术POP患者围术期各时点血糖水平均显著升高
POP组患者围术期血糖水平均显著高于对照组（P<0.001），见表4。
2.5　单因素分析筛选出多个与POP相关的潜在危险因素
将2组间比较P<0.15的变量纳入单因素分析，结果显示：术前合并糖尿病、术前合并COPD、吸入性肺炎史、左心室射血分数、发病到手术时间、急诊手术、主动脉弓置换、伴随心脏手术、麻醉时间、红细胞输注、血浆输注、血小板输注、冷沉淀输注、白蛋白使用、机械通气时间、术后24 h总引流量、术前最后血糖、术中最高血糖、术后最高血糖等因素与POP发生相关（P<0.15），见表5。
2.6　多因素分析证实COPD、吸入性肺炎史等六项因素为POP的独立危险因素
将单因素分析中P<0.15的变量分别采用前进法、后退法和Enter法进行多因素Logistic回归分析，以验证模型的稳健性。3种方法的结果高度一致，最终纳入的变量相同。前进法结果显示：术前合并COPD（OR=2.447，95%CI：1.191~5.026）、吸入性肺炎史（OR=2.282，95%CI：0.992~5.246）、机械通气时间≥68 h（OR=3.619，95%CI：1.963~6.672）、红细胞输注≥10 U（OR=1.984，95%CI：1.113~3.536）、术中最高血糖≥11 mmol/L（OR=2.134，95%CI：1.190~3.826）、术后24 h总引流量≥1 100 mL（OR=1.808，95%CI：1.032~3.169）是ATAAD患者POP的独立危险因素。后退法和Enter法得到的OR值及95%CI与前进法结果差异小于5.0%，表示模型具有良好的稳定性，见表6。
2.7　ROC曲线验证各独立危险因素的预测效能并确定临床最佳截断值
连续变量模型的AUC为0.792（95%CI：0.752~0.833），略高于分类变量模型的AUC 0.775（95%CI：0.733~0.818），但差异无统计学意义（Z=1.26，P=0.208）。
通过对多因素分析中的连续变量进行ROC曲线分析，评估其预测POP的效能。机械通气时间预测POP的AUC为0.762（95%CI：0.718~0.806），最佳截断值为68 h，敏感度为71.0%，特异度为72.4%。红细胞输注量的AUC为0.682（95%CI：0.632~0.732），最佳截断值为10 U，敏感度为65.2%，特异度为63.7%。术中最高血糖的AUC为0.658（95%CI：0.606~0.710），最佳截断值为11 mmol/L，敏感度为62.3%，特异度为61.4%。术后24 h总引流量的AUC为0.642（95%CI：0.589~0.695），最佳截断值为1 100 mL，敏感度为60.1%，特异度为59.7%。见图1。
3　讨论
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3.1　ATAAD术后POP发生率高达28.0%，是导致患者预后不良的关键因素
本研究结果显示，ATAAD患者POP的发生率为28.0%，与既往文献报道的25.18%~36.94%相符［2-3，12-13］。POP不仅延长了患者的机械通气时间和ICU停留时间，还明显增加了住院天数和住院费用。更为严重的是，POP组患者院内死亡率达18.8%，远高于对照组的7.9%（P<0.001）。这一结果与多项研究一致［14-15］，表明POP是影响ATAAD患者预后的重要因素。POP导致预后不良的机制可能与以下因素相关：①肺部感染加重全身炎症反应，导致多器官功能障碍；②抗生素治疗增加肾功能损伤风险；③延长机械通气时间增加呼吸机相关并发症；④延长ICU停留时间增加继发感染和导管相关感染风险［3，15］。
3.2　术前基础肺疾病（COPD、吸入性肺炎史）显著增加ATAAD患者POP风险
本研究发现，术前合并COPD和既往吸入性肺炎史是ATAAD患者POP发生的独立危险因素，这与既往关于心脏手术后肺炎的研究结果相符［16］。COPD患者由于气道防御功能受损、肺泡结构改变和分泌物潴留等原因，术后易发生肺部感染［17］。吸入性肺炎史提示患者可能存在潜在的吞咽功能障碍或胃食管反流，增加术后误吸风险［18］。
另外，尽管单因素分析显示术前糖尿病与POP相关，但多因素分析未能证实其为独立危险因素，这可能与术中、术后血糖水平的影响更为直接有关。此外，糖尿病患者常合并COPD等其他疾病，这些因素间可能存在交互作用。本研究中，糖尿病与COPD共存患者的肺炎发生率（38.2%）高于单纯糖尿病（24.5%）或单纯COPD患者（29.7%），这表明共病可能通过免疫功能抑制、血管微循环障碍等机制增加肺炎风险［19］。
左心室射血分数降低也与术后肺炎风险增加相关。这可能是因为心功能不全患者容易出现肺淤血，影响肺部氧合和清除分泌物的能力，同时增加术后机械通气依赖和再插管风险［20］。本研究中，POP组患者左心室射血分数明显低于对照组，这提示术前心功能评估和优化对减少POP发生具有重要意义。
3.3　大量输血与术后大量引流是POP的重要危险因素
本研究结果表明，主动脉弓置换、长时间麻醉、术中大量输血及术后24 h总引流量增加是术后肺炎的危险因素。其中，红细胞输注量≥10 U和术后24 h总引流量≥1 100 mL是独立危险因素。
大量红细胞输注可能通过多种机制增加肺炎风险：①输血相关急性肺损伤（transfusion-related acute lung injury，TRALI）；②输血相关免疫调节（transfusion-related immunomodulation，TRIM）导致免疫抑制；③大量输血产品中的白细胞和生物活性物质触发炎症反应；④输血增加肺水肿风险［21-24］。而术后大量引流提示手术创伤严重或凝血功能异常，患者可能需要更多输血和液体复苏，增加肺水肿和肺损伤风险，同时也可能延长机械通气时间［25］。
主动脉弓置换涉及深低温循环停止和选择性脑灌注，手术时间长，操作复杂，体外循环时间延长，这些因素均可增加全身炎症反应和肺损伤［26］。本研究中，POP组主动脉弓置换比例和麻醉时间均高于对照组，提示复杂手术和长时间麻醉是POP发生的重要影响因素。
3.4　围术期高血糖状态显著增加POP风险
本研究分析了围术期血糖水平与ATAAD术后肺炎的关系，结果显示术中最高血糖≥11 mmol/L是术后肺炎的独立危险因素。高血糖状态可通过多种病理生理机制增加感染风险：①抑制中性粒细胞趋化和吞噬功能；②影响补体活性；③损害抗体结合；④促进细菌生长；⑤影响伤口愈合；⑥增加氧化应激反应；⑦导致内皮功能障碍和微血管损伤；⑧促进炎症因子如肿瘤坏死因子-α（tumor necrosis factor-α，TNF-α）、白介素6（interleukin-6，IL-6）等释放；⑨抑制T淋巴细胞功能和抗原呈递［27-28］。
心脏大血管手术尤其是ATAAD紧急手术常伴有应激性高血糖，体外循环和深低温也会引起胰岛素抵抗，进一步加剧血糖波动。本研究中，POP组患者从术前到术后的血糖水平始终高于对照组，表明围术期血糖管理可能是预防术后肺炎的关键环节。ROC曲线分析显示，术中最高血糖预测术后肺炎的AUC为0.658，最佳截断值为11 mmol/L，这为临床血糖管理提供了目标值。
3.5　机械通气时间≥68 h是预测POP的最强独立因素
本研究发现，机械通气时间≥68 h是术后肺炎最强的独立预测因素，其ROC曲线下面积达0.762，敏感度和特异度分别为71.0%和72.4%。该截断值高于一般心脏手术研究报道的48 h［29-30］，这可能反映了ATAAD手术的特殊性和复杂性。与常规冠状动脉旁路移植术或瓣膜手术相比，ATAAD手术创伤更大，体外循环时间更长，出血风险更高，可能需要更长的机械通气时间进行术后稳定。
长时间机械通气增加肺炎风险的机制包括：①气管插管破坏上呼吸道防御屏障；②气管内导管为细菌定植提供通道；③正压通气影响肺部血液灌注和黏液廓清；④机械通气相关肺损伤（ventilator-induced lung injury，VILI）；⑤长期卧床引起分泌物潴留［31］。
机械通气时间与肺炎之间可能存在双向因果关系：一方面，长时间机械通气会增加肺炎风险；另一方面，肺炎本身也会延长机械通气时间。因此，早期识别高风险患者并采取积极预防措施至关重要。根据本研究结果，68 h可作为临床预警的时间节点，对于机械通气时间接近或超过此阈值的患者，应加强肺部评估和预防措施。
3.6　基于危险因素的个体化综合预防策略是降低ATAAD术后POP的关键
基于本研究结果，提出以下预防ATAAD术后肺炎的策略：①术前充分评估COPD、吸入性肺炎史等高危因素，优化呼吸功能；②严格控制围术期血糖，尤其是将术中血糖维持在11 mmol/L以下；③合理输血策略，尽量避免不必要的红细胞输注；④加强手术技术和止血措施，减少术后出血和引流量；⑤采用肺保护性通气策略，如低潮气量、适当呼气末正气通气（positive end expiratory pressure，PEEP）；⑥实施早期唤醒和拔管计划，缩短机械通气时间；⑦加强口腔护理和体位管理，预防误吸；⑧早期活动和肺康复训练。
对于高危患者，可考虑使用选择性消化道去污染（selective digestive decontamination，SDD）、预防性抗生素调整、免疫营养支持等个体化预防措施。同时，建立术后肺炎风险评分系统，对高危患者实施强化预防策略。
3.7　研究局限性和展望
本研究存在以下局限性：①虽为多医院研究，但仍属于同一医疗系统内的3家医院，患者人群和诊疗方案相对同质化；②回顾性研究设计使部分数据收集受限，如病原学分型和耐药性分析；③围术期抗生素使用策略在不同医院可能存在细微差异；④部分患者术前紧急状态下未能完成全面肺功能评估；⑤随访期限较短，无法评估POP对中远期预后的影响。
既往文献在心脏手术后肺炎方面已有大量研究，如AILAWADI等［30］针对5 158名成人心脏手术患者的多中心研究和KILIC等［19］纳入6 222名患者接受心脏手术的成年人推导并验证心脏手术后肺炎的风险评分的研究，都为认识心脏手术后肺炎的流行病学特征和危险因素提供了重要依据。然而，这些研究大多以常规心脏手术为主，ATAAD患者比例很小，未能针对这一特殊人群的特点进行专门分析。此外，多数研究未深入探讨血糖控制、输血管理等可调节因素的临界值，限制了其临床指导价值。本研究在既往工作基础上，重点关注ATAAD这一特殊高风险人群，并通过ROC分析确定关键危险因素的最佳截断值，为临床实践提供了更具针对性的参考。
未来研究应着重于：①扩大样本量并纳入不同地区医疗中心的患者；②深入分析病原菌谱分布及其与预后的关系；③前瞻性评估预防措施的临床有效性；④结合临床和基础研究，探讨ATAAD患者POP的发病机制；⑤建立并验证适用于ATAAD患者的POP预测模型。

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2026年第48卷第5期
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doi: 10.16016/j.2097-0927.202512075
  • 接收时间：2025-12-14
  • 首发时间：2026-10-23
  • 出版时间：2026-03-15
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  • 收稿日期：2025-12-14
  • 修回日期：2026-01-09
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    1陆军军医大学（第三军医大学）第二附属医院麻醉科，重庆
    2西南医科大学附属医院麻醉科，四川 泸州
    3重庆市急救医疗中心麻醉科，重庆

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