重症监护病房中困难插管高危患者的早期识别：多中心队列研究中 MACOCHA 评分的制定与验证。

Early identification of patients at risk for difficult intubation in the intensive care unit: development and validation of the MACOCHA score in a multicenter cohort study.

机构信息

Intensive Care and Anesthesiology Department, University of Montpellier Saint Eloi Hospital, Montpellier, France.

出版信息

Am J Respir Crit Care Med. 2013 Apr 15;187(8):832-9. doi: 10.1164/rccm.201210-1851OC.

DOI:10.1164/rccm.201210-1851OC

PMID:23348979

Abstract

RATIONALE

Difficult intubation in the intensive care unit (ICU) is a challenging issue.

OBJECTIVES

To develop and validate a simplified score for identifying patients with difficult intubation in the ICU and to report related complications.

METHODS

Data collected in a prospective multicenter study from 1,000 consecutive intubations from 42 ICUs were used to develop a simplified score of difficult intubation, which was then validated externally in 400 consecutive intubation procedures from 18 other ICUs and internally by bootstrap on 1,000 iterations.

MEASUREMENTS AND MAIN RESULTS

In multivariate analysis, the main predictors of difficult intubation (incidence = 11.3%) were related to patient (Mallampati score III or IV, obstructive sleep apnea syndrome, reduced mobility of cervical spine, limited mouth opening); pathology (severe hypoxia, coma); and operator (nonanesthesiologist). From the β parameter, a seven-item simplified score (MACOCHA score) was built, with an area under the curve (AUC) of 0.89 (95% confidence interval [CI], 0.85-0.94). In the validation cohort (prevalence of difficult intubation = 8%), the AUC was 0.86 (95% CI, 0.76-0.96), with a sensitivity of 73%, a specificity of 89%, a negative predictive value of 98%, and a positive predictive value of 36%. After internal validation by bootstrap, the AUC was 0.89 (95% CI, 0.86-0.93). Severe life-threatening events (severe hypoxia, collapse, cardiac arrest, or death) occurred in 38% of the 1,000 cases. Patients with difficult intubation (n = 113) had significantly higher severe life-threatening complications than those who had a nondifficult intubation (51% vs. 36%; P < 0.0001).

CONCLUSIONS

Difficult intubation in the ICU is strongly associated with severe life-threatening complications. A simple score including seven clinical items discriminates difficult and nondifficult intubation in the ICU. Clinical trial registered with www.clinicaltrials.gov (NCT 01532063).

摘要

背景

在重症监护病房（ICU）中进行困难的气管插管是一个具有挑战性的问题。

目的

开发和验证一种简化的评分系统，用于识别 ICU 中具有困难插管的患者，并报告相关并发症。

方法

从 42 个 ICU 的 1000 例连续插管中前瞻性收集的数据用于开发一种简化的插管困难评分系统，然后在另外 18 个 ICU 的 400 例连续插管中进行外部验证，并通过 1000 次迭代进行 bootstrap 内部验证。

测量和主要结果

在多变量分析中，困难插管的主要预测因素（发生率=11.3%）与患者（Mallampati 评分 III 或 IV、阻塞性睡眠呼吸暂停综合征、颈椎活动度降低、张口受限）、病理学（严重缺氧、昏迷）和操作者（非麻醉师）有关。从β参数中构建了一个包含 7 项的简化评分（MACOCHA 评分），曲线下面积（AUC）为 0.89（95%置信区间[CI]，0.85-0.94）。在验证队列（困难插管发生率=8%）中，AUC 为 0.86（95%CI，0.76-0.96），灵敏度为 73%，特异性为 89%，阴性预测值为 98%，阳性预测值为 36%。通过 bootstrap 进行内部验证后，AUC 为 0.89（95%CI，0.86-0.93）。1000 例患者中发生了 38%的严重危及生命的事件（严重缺氧、崩溃、心脏骤停或死亡）。困难插管患者（n=113）的严重危及生命的并发症发生率明显高于非困难插管患者（51%比 36%；P<0.0001）。