在无体外循环情况下对高危患者进行手术的实习生：一种高危策略？
Trainees operating on high-risk patients without cardiopulmonary bypass: a high-risk strategy?
作者信息
Ascione Raimondo, Reeves Barnaby C, Pano Marco, Angelini Gianni D
机构信息
Bristol Heart Institute, University of Bristol, Bristol Roayl Infirmary, United Kingdom.
出版信息
Ann Thorac Surg. 2004 Jul;78(1):26-33. doi: 10.1016/j.athoracsur.2003.10.127.
BACKGROUND
The safety of teaching off-pump coronary artery bypass grafting to trainees is best tested in high-risk patients, who are more likely to experience significant morbidity after surgery. This study compared outcomes of off-pump coronary artery bypass grafting operations performed by consultants and trainees in high-risk patients.
METHODS
Data for consecutive patients undergoing off-pump coronary artery bypass grafting were collected prospectively. Patients satisfying at least one of the following criteria were classified as high-risk: age older than 75 years, ejection fraction less than 0.30, myocardial infarction in the previous month, current congestive heart failure, previous cerebrovascular accident, creatinine greater than 150 micromol/L, respiratory impairment, peripheral vascular disease, previous cardiac surgery, and left main stem stenosis greater than 50%. Early morbidity, 30-day mortality, and late survival were compared.
RESULTS
From April 1996 to December 2002, 686 high-risk patients underwent off-pump coronary artery bypass grafting revascularization. Operations by five consultants (416; 61%) and four trainees (239; 35%) were the focus of subsequent analyses. Nine visiting or research fellows performed the other 31 operations. Prognostic factors were more favorable in trainee-led operations. On average, consultants and trainees grafted the same number of vessels. There were 18 (4.3%) and 5 (1.9%) deaths within 30 days, and 14 (3.4%) and 5 (1.9%) myocardial infarctions in consultant and trainee groups, respectively. After adjusting for imbalances in prognostic factors, odd ratios for almost all adverse outcomes implied no increased risk with trainee operators, although patients operated on by trainees had longer postoperative stays and were more likely to have a red blood cell transfusion. Kaplan-Meier cumulative mortality estimates at 24-month follow-up were 10.5% (95% confidence interval, 7.7% to 14.2%) and 6.4% (95% confidence interval, 3.8% to 10.9%) in consultant and trainee groups, respectively (hazard ratio = 0.60 [95% confidence interval, 0.37 to 0.99]; p = 0.05).
CONCLUSIONS
Off-pump coronary artery bypass grafting surgery in high-risk patients can be safely performed by trainees.
背景
向受训人员传授非体外循环冠状动脉搭桥术的安全性，最好在高危患者中进行测试，这些患者术后更有可能出现严重的发病情况。本研究比较了高危患者中由顾问医生和受训人员进行的非体外循环冠状动脉搭桥手术的结果。
方法
前瞻性收集连续接受非体外循环冠状动脉搭桥手术患者的数据。满足以下至少一项标准的患者被归类为高危患者：年龄大于75岁、射血分数小于0.30、前一个月发生心肌梗死、目前患有充血性心力衰竭、既往有脑血管意外、肌酐大于150微摩尔/升、呼吸功能受损、外周血管疾病、既往心脏手术史以及左主干狭窄大于50%。比较早期发病率、30天死亡率和晚期生存率。
结果
从1996年4月至2002年12月，686例高危患者接受了非体外循环冠状动脉搭桥血运重建术。随后的分析重点是5位顾问医生（416例；61%）和4位受训人员（239例；35%）所做的手术。另外9位访问学者或研究员进行了其他31例手术。在由受训人员主导的手术中，预后因素更为有利。平均而言，顾问医生和受训人员吻合的血管数量相同。顾问医生组和受训人员组在30天内分别有18例（4.3%）和5例（1.9%）死亡，分别有14例（3.4%）和5例（1.9%）发生心肌梗死。在对预后因素的不平衡进行调整后，几乎所有不良结局的比值比表明，受训人员手术并没有增加风险，尽管接受受训人员手术的患者术后住院时间更长，更有可能接受红细胞输血。在24个月随访时，顾问医生组和受训人员组的Kaplan-Meier累积死亡率估计分别为10.5%（95%置信区间，7.7%至14.2%）和6.4%（95%置信区间，3.8%至10.9%）（风险比 = 0.60 [95%置信区间，0.37至0.99]；p = 0.05）。
结论
受训人员可以安全地对高危患者进行非体外循环冠状动脉搭桥手术。
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