手术时间与胸器官移植术后结果的关联。

Association of operative time of day with outcomes after thoracic organ transplant.

机构信息

Division of Cardiac Surgery, Johns Hopkins Medical Institutions, Baltimore, MD 21287, USA.

出版信息

JAMA. 2011 Jun 1;305(21):2193-9. doi: 10.1001/jama.2011.726.

DOI:10.1001/jama.2011.726

PMID:21632483

Abstract

CONTEXT

Recent emphasis on systems-based approaches to patient safety has led to several studies demonstrating worse outcomes associated with surgery at night.

OBJECTIVE

To evaluate whether operative time of day was associated with thoracic organ transplant outcomes, hypothesizing that it would not be associated with increased morbidity or mortality.

DESIGN, SETTING, AND PARTICIPANTS: We conducted a retrospective cohort study of adult heart and lung transplant recipients in the United Network for Organ Sharing database from January 2000 through June 2010. Primary stratification was by operative time of day (night, 7 PM-7 AM; day, 7 AM-7 PM).

MAIN OUTCOME MEASURES

Primary end points were short-term survival, assessed by the Kaplan-Meier method at 30, 90, and 365 days. Secondary end points encompassed common postoperative complications. Risk-adjusted multivariable Cox proportional hazards regression examined mortality.

RESULTS

A total of 27,118 patients were included in the study population. Of the 16,573 who underwent a heart transplant, 8346 (50.36%) did so during the day and 8227 (49.64%) during the night. Of the 10,545 who underwent a lung transplant, 5179 (49.11%) did so during the day and 5366 (50.89%) during the night. During a median follow-up of 32.2 months (interquartile range, 11.2-61.1 months), 8061 patients (28.99%) died. Survival was similar for organ transplants performed during the day and night. Survival rates at 30 days for heart transplants during the day were 95.0% vs 95.2% during the night (hazard ratio [HR], 1.05; 95% confidence interval, 0.83-1.32; P = .67) and for lung transplants during the day were 96.0% vs 95.5% during the night (HR, 1.22; 95% CI, 0.97-1.55; P = .09). At 90 days, survival rates for heart transplants were 92.6% during the day vs 92.7% during the night (HR, 1.05; 95% CI, 0.88-1.26; P = .59) and for lung transplants during the day were 92.7% vs 91.7% during the night (HR, 1.23; 95% CI, 1.04-1.47; P = .02). At 1 year, survival rates for heart transplants during the day were 88.0% vs 87.7% during the night (HR, 1.05; 95% CI, 0.91-1.21; P = .47) and for lung transplants during the day were 83.8% vs 82.6% during the night (HR, 1.08; 95% CI, 0.96-1.22; P = .19). Among lung transplant recipients, there was a slightly higher rate of airway dehiscence associated with nighttime transplants (57 of 5022 [1.1%] vs 87 of 5224 [1.7%], P = .02).

CONCLUSION

Among patients who underwent thoracic organ transplants, there was no significant association between operative time of day and survival up to 1 year after organ transplant.

摘要

背景

最近强调以系统为基础的方法来解决患者安全问题，这导致了几项研究表明，夜间手术与更差的结果相关。

目的

评估手术时间是否与胸器官移植结果相关，假设它与发病率或死亡率的增加无关。

设计、地点和参与者：我们对美国器官共享网络数据库中的成人心脏和肺移植受者进行了回顾性队列研究，时间从 2000 年 1 月至 2010 年 6 月。主要分层是根据手术时间（夜间，7 点至 7 点；白天，7 点至 7 点）。

主要结局测量

主要终点是通过 30、90 和 365 天的 Kaplan-Meier 方法评估短期生存率。次要终点包括常见的术后并发症。风险调整多变量 Cox 比例风险回归检查死亡率。

结果

共纳入 27118 例患者。在 16573 例接受心脏移植的患者中，8346 例（50.36%）在白天进行，8227 例（49.64%）在夜间进行。在 10545 例接受肺移植的患者中，5179 例（49.11%）在白天进行，5366 例（50.89%）在夜间进行。在中位随访 32.2 个月（四分位距，11.2-61.1 个月）期间，8061 例患者（28.99%）死亡。日间和夜间进行的器官移植的生存率相似。日间心脏移植 30 天的生存率为 95.0%，夜间为 95.2%（风险比[HR]，1.05；95%置信区间，0.83-1.32；P=0.67），日间肺移植为 96.0%，夜间为 95.5%（HR，1.22；95%置信区间，0.97-1.55；P=0.09）。在 90 天，日间心脏移植的生存率为 92.6%，夜间为 92.7%（HR，1.05；95%置信区间，0.88-1.26；P=0.59），日间肺移植为 92.7%，夜间为 91.7%（HR，1.23；95%置信区间，1.04-1.47；P=0.02）。在 1 年时，日间心脏移植的生存率为 88.0%，夜间为 87.7%（HR，1.05；95%置信区间，0.91-1.21；P=0.47），日间肺移植的生存率为 83.8%，夜间为 82.6%（HR，1.08；95%置信区间，0.96-1.22；P=0.19）。在肺移植受者中，夜间移植与气道裂开的发生率稍高（57/5022[1.1%]与 87/5224[1.7%]，P=0.02）。