高危手术后接受长时间机械通气的老年患者的病程及预后

Trajectories and Prognosis of Older Patients Who Have Prolonged Mechanical Ventilation After High-Risk Surgery.

作者信息

Nabozny Michael J, Barnato Amber E, Rathouz Paul J, Havlena Jeffrey A, Kind Amy J, Ehlenbach William J, Zhao Qianqian, Ronk Katie, Smith Maureen A, Greenberg Caprice C, Schwarze Margaret L

机构信息

1Wisconsin Surgical Outcomes Research Program, Department of Surgery, University of Wisconsin, Madison, WI. 2Department of Medicine, University of Pittsburgh, Pittsburgh, PA. 3Department of Biostatistics and Medical Informatics, University of Wisconsin, Madison, WI. 4Department of Medicine, University of Wisconsin, Madison, WI. 5VA Geriatrics Research Education and Clinical Center, William S. Middleton VA Hospital, Madison, WI. 6Department of Population Health Sciences, University of Wisconsin, Madison, WI. 7Department of Family Medicine, University of Wisconsin, Madison, WI. 8Department of Medical History and Bioethics, University of Wisconsin, Madison, WI.

出版信息

Crit Care Med. 2016 Jun;44(6):1091-7. doi: 10.1097/CCM.0000000000001618.

DOI:10.1097/CCM.0000000000001618

PMID:26841105

原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC4868766/

Abstract

OBJECTIVES

Surgical patients often receive routine postoperative mechanical ventilation with excellent outcomes. However, older patients who receive prolonged mechanical ventilation may have a significantly different long-term trajectory not fully captured in 30-day postoperative metrics. The objective of this study is to describe patterns of mortality and hospitalization for Medicare beneficiaries 66 years old and older who have major surgery with and without prolonged mechanical ventilation.

DESIGN

Retrospective cohort study.

SETTING

Hospitals throughout the United States.

PATIENTS

Five percent random national sample of elderly Medicare beneficiaries (age ≥ 66 yr) who underwent 1 of 227 operations previously defined as high risk during an inpatient stay at an acute care hospital between January 1, 2005, and November 30, 2009.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We identified 117,917 episodes for older patients who had high-risk surgery; 4% received prolonged mechanical ventilation during the hospitalization. Patients who received prolonged mechanical ventilation had higher 1-year mortality rate than patients who did not have prolonged ventilation (64% [95% CI, 62-65%] vs 17% [95% CI, 16.4-16.9%]). Thirty-day survivors who received prolonged mechanical ventilation had a 1-year mortality rate of 47% (95% CI, 45-48%). Thirty-day survivors who did not receive prolonged ventilation were more likely to be discharged home than patients who received prolonged ventilation 71% versus 10%. Patients who received prolonged ventilation and were not discharged by postoperative day 30 had a substantially increased 1-year mortality (adjusted hazard ratio, 4.39 [95% CI, 3.29-5.85]) compared with patients discharged home by day 30. Hospitalized 30-day survivors who received prolonged mechanical ventilation and died within 6 months of their index procedure spent the majority of their remaining days hospitalized.

CONCLUSIONS

Older patients who require prolonged mechanical ventilation after high-risk surgery and survive 30 days have a significant 1-year risk of mortality and high burdens of treatment. This difficult trajectory should be considered in surgical decision making and has important implications for surgeons, intensivists, and patients.

摘要

目的

外科手术患者术后常接受常规机械通气，且预后良好。然而，接受长时间机械通气的老年患者可能有显著不同的长期病程，这在术后30天的指标中并未完全体现。本研究的目的是描述66岁及以上接受大手术且有或无长时间机械通气的医疗保险受益人的死亡率和住院模式。

设计

回顾性队列研究。

地点

美国各地的医院。

患者

从2005年1月1日至2009年11月30日期间在急性护理医院住院期间接受过227种先前定义为高风险手术之一的老年医疗保险受益人（年龄≥66岁）的5%全国随机样本。

干预措施

无。

测量指标及主要结果

我们确定了117,917例接受高风险手术的老年患者病例；4%的患者在住院期间接受了长时间机械通气。接受长时间机械通气的患者1年死亡率高于未接受长时间机械通气的患者（64%[95%CI，62 - 65%]对17%[95%CI，16.4 - 16.9%]）。接受长时间机械通气的30天幸存者1年死亡率为47%（95%CI，45 - 48%）。未接受长时间机械通气的30天幸存者比接受长时间机械通气的患者更有可能出院回家（71%对10%）。与术后30天出院的患者相比，术后30天未出院且接受长时间通气的患者1年死亡率大幅增加（调整后风险比，4.39[95%CI，3.29 - 5.85]）。接受长时间机械通气且在索引手术6个月内死亡的30天住院幸存者，其剩余大部分时间都在住院。